This practical guidance from the committee on community care aims to support doctors working in all parts of health and social care to understand the implications of personal health budgets (PHBs) for their own practice. This guidance applies to England only.
What is the background to the policy?
It is an extension of the department of health's 'personalisation of healthcare' policy.
A key policy driver of the personal health budget initiative, is the government and NHS England's desire to improve how patients and carers are involved in decisions about their own care, and become increasingly able to manage their own health decisions and needs.
Patients should have greater choice, flexibility and control over their care, treatment and support and, in handing responsibility to patients for the budget that funds their care, it is believed that patients will be empowered.
"Personal health budgets are about a shift in power and decision making, and sharing risk and responsibility within a clear partnership relationship."
An associated aspect of the personalisation and empowerment agenda, which is of particular interest to doctors, is the new balance of responsibility between clinician and patient. Part of the policy narrative is that patients should get 'real choice' in their care, and be able to come to decisions themselves.
The suggestion is that healthcare professionals will be asked to hold back on their traditional role of problem solver and enable patients to make their own decisions.
Some doctors may feel unsure about their role in this newly defined relationship, as may some patients; this guidance aims to explore and resolve some of the questions doctors may have.
What is the BMA's position on personal health budgets?
Whilst supportive of patients having more control over their care, the evidence shows that although quality of life may improve, personal health budgets do not directly result in better clinical outcomes for patients.
The BMA is also concerned that NHS funds, which are already stretched to the limit, are being spent on non-traditional treatments and non-NHS services that may not be clinically effective, which the health service can ill afford.
There is also the potential for inequity for patients, with those in receipt of personal health budgets being able to access treatments that others may not. Until these issues can be resolved satisfactorily, the BMA will remain unconvinced of the benefit of personal health budgets.
More information on the BMA's position and work done by the BMA
Practical guidance for doctors with patients holding personal health budgets
Which of my patients are eligible for a personal health budget?
Patients holding a personal health budget can use their allocated funding to pay for any goods or services, not limited simply to the NHS, that have been agreed with their local NHS team as being worthwhile in helping them achieve their agreed health goals.
The NHS Mandate for 2015-16 sets out that personal health budgets should be available in England for all those with long term health conditions who could benefit, from 2015 (para 2.6). From April 2015, this includes mental health patients. Those eligible for NHS continuing healthcare have been able to access personal health budgets since October 2014.
What can I do if I have concerns about the ethics of the personal health budget approach?
The BMA believes the personal health budget initiative opens up many questions about equity and fairness, and about good use of public funding.
Patients with personal health budgets will arguably be able to access treatments and assistance that other patients with similar difficulties may not. Money traditionally kept within the NHS system to pay for services will be moving into the private sector.
If you share these concerns, or have others, you can raise them with your CCG and/or your Health and Wellbeing Board. If you would also be willing to share them with the BMA for use on an anonymised basis in our lobbying, please get in touch at [email protected].
To help ensure the personal health budget works well for my patient, what should I be aware of from the pilots?
The overriding message from the evaluation of the pilots is that support and information sharing in the early stages of planning and agreeing a personal health budget is crucial.
Patients and the NHS team need to "know the deal" and the local framework of rules that govern personal health budgets. Patients particularly need to know what can be achieved through a personal health budget and what cannot so that expectations are clear.
Advising your patients
How can I help my patient decide if a personal health budget is right for them?
Not every patient who is eligible will know about personal health budgets or understand their benefits and drawbacks. As doctors are well aware, each patient is different, with different strengths, needs and values. Some may need more help in decision-making than others.
To help you best advise your patient:
- Become familiar with what personal health budgets are and which of your patients could be eligible
- If necessary, help eligible patients to understand the often complex information about personal health budgets to enable them to make the right decision
If it isn't practical to do this yourself, you can advise your patient to speak to a personal health budget broker, or another knowledgeable member of the NHS team involved in their care
- Check what has been agreed locally about the differing roles of individuals in the team of staff supporting patients with personal health budgets
This will ensure you are clear what the limits of your own role are, and those of others, which will help you and your patient
- Become familiar with alternative options to help patients access more personalised care
Doctors will already aspire to ensure patient empowerment, outside of any discussion about health budgets
- Be clear that social care personal budgets are a different thing altogether.
What is my role as a doctor in the process?
A patient with a personal health budget will be supported by a local team of NHS staff who will work in partnership to ensure the package of care agreed is delivered against the patient's agreed health needs. It is important that all roles are clearly defined within the team, and the time commitment required to support patients is clearly specified and understood.
For example, it may be agreed that advising patients on their options with personal health budgets may not be practical for a GP, and so other forms of support may need to be identified.
NHS England argues in its guidance that in some cases, the generally accepted role of health professionals to resolve their patient's problem can keep patients in a passive role, and prevent them from gaining the self-confidence to take responsibility for their own health.
NHS England believes the key to ensuring the personal health budget process is successful is to bring about a shift in the relationship "towards a more equal, partnership approach" where "practitioners need to develop their listening and facilitation skills, enabling people to find their own solutions."
However, it should be recognised that some doctors may feel uncomfortable with this approach, and its implications for the management of risk. Concerns like these should be discussed with your CCG and/or your Health and Wellbeing Board.
What’s the next step?
Once a patient has decided they would like to pursue holding a personal health budgets, they should be referred to a broker for personal health budgets. If agreed, a personal health care plan is drafted and at this stage input from the patient's GP and other doctors is required.
"People may want to use their budgets for treatments where there is no clinical evidence to support their use. This should not automatically prevent approval as, despite not being supported by clinical trials, a selected treatment may work for an individual."
"We will need to consider appropriate treatments or services on a case-by-case basis, thinking holistically about the individual and what may or may not work for them. Allow people to try things, setting clear review dates to help assess whether something is working."
As a clinician, any concerns you have will be taken into account in discussions between the broker and the patient, and the personal health budget plan amended as necessary. We recommend you ask to be regularly updated on the patient's progress, if you otherwise would not be seeing them yourself.
What if I don't believe something in the care plan will improve my patient's health outcome?
In some cases, patients may wish to use their budget to pay for something which is not evidence-based. The RCGP's advice is to note that there is a difference between approving an element of a care plan that you know is unsafe, and approving a non-traditional service or treatment that has no clinical evidence to say it will help but which you know is not harmful.
Can the budget run out?
The budget allocated to an individual must cover the entirety of the costs required to deliver the care plan agreed. The care plan can be changed at any time to take account of changes in health need.