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Professor Lord Darzi's review of the NHS in 2008^[1] introduced the idea of personal health budgets in the English National Health Service. From October 2014 patients were given the 'fundamental right' to personal health budgets, at Norman Lamb's insistence.^[2] NHS England’s Five Year Forward View called for a ‘major expansion’ of the scheme.

In Scotland a similar idea is called Self-directed Support, and was the subject of the Social Care (Self-directed Support) (Scotland) Act 2013 but only applies to social care.

Practical arrangements

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A personal budget may be used by a patient to buy services not normally available on the NHS, or to pay for services like nursing care which are provided by the NHS, but giving them more autonomy in deciding where, how and when they are provided. This can enable people with long term care needs to go on holiday, for example.

There may be

A notional budget where the NHS actually manages the money
A third-party arrangement: an organisation legally independent of the patient and the NHS manages the money
A direct payment: money is transferred directly to the patient, and they buy the goods and services agreed in their care plan

The Royal College of General Practitioners produced guidance for its members on the use of Personal health budgets in 2012.^[3] PHBs have been mainly used for people with continuing health needs. The RCGP explained that "At the heart of a personal health budget is a care or support plan – an agreement between the local NHS and the individual that sets out the person’s health needs, the amount of money available to meet those needs and how this money will be spent."

By 2015-16 expenditure on PHBs was estimated at £123 million per year, just over 0.1% of NHS spending. The number of people with a budget was 4,800, so the average package costs £25,600. PHBs have been targeted on people with most significant needs, generally people on continuing care packages.^[4]

Advocates

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Personal budgets have been widely adopted in social care and have been championed by, among others, Liz Kendall, who advocated extending the idea into health services. Simon Duffy, who was the chief executive of the influential social enterprise company In Control, was one of the creators of Self Directed Support which piloted the idea with people with learning disabilities. According to him "If you don't tell people what the budget is, as a local authority you are forced into a position of planning for them in order to ration, but if you give them a budget, doing the rationing up front, you liberate people and their families to do their own planning, and liberate service providers to do creative planning. Philosophically, this is a shift towards clarity about rights and duties."^[5] His ideas were formulated in the Deinstitutionalisation

The idea is to give people in England with long-term conditions more control and choice over their healthcare and support.^[6]

The Metropolitan Borough of Barnsley is piloting both individual social care budgets and the Right to Control scheme to provide integrated personal budgets across different services. Martin Farran, the council’s executive director of adults and community services is keen to extend personalisation into health, particularly mental health. He says this would "free up a lot of resources for better outcomes and at a lower cost.”^[7]

Criticism

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A survey by Pulse in September 2015, based on Freedom of Information requests to Clinical Commissioning Groups was headlined "Revealed: NHS funding splashed on holidays, games consoles and summer houses" and generated considerable publicity. An angry 81-year-old widow in Gateshead complained that the NHS “can afford to pay for horse riding lessons but can’t get me to hospital.”^[8]

According to Pulse the scheme has been used to buy unevidenced treatments while long-established services are no longer provided.^[9] Duffy said PHBs made up a tiny percentage of NHS spending which was assessed and approved by health professionals. "You cannot simply turn up to your GP and ask for a summer house."

Holland

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A similar scheme, (persoonsgebonden budget, known as PGB) was introduced in the Netherlands in 1997. Because the number of personal budget holders increased tenfold between 2002 and 2010, and expenditure increased on average by 23% a year, restrictions were introduced. From 2014, only people who would otherwise have to move to a nursing or residential home could keep their budget or apply for one to enable them to continue living at home. There were reports of fraud and improper behaviour by brokers who handled money on behalf of vulnerable people who were not able to manage the budget themselves.^[10] The Health Foundation produced a report on the Dutch experience in 2011, which was quite positive.^[11]