There were some headlines recently about how people were using their Personal Health Budgets. Concerns were raised about whether items like games consoles, a summer house and satnavs were the best use of public money, with the inevitable calls for resources instead to be focused on traditional ways of doing things – beds, staff, medical equipment.
A positive aspect of the debate was it provided an opportunity for people who have Personal Health Budgets and the professionals who support them to explain why they’re so important in meeting their care and support needs. Kevin Shergold, for example, highlighted:
The PHB has given us freedom to live our lives as we choose – in a way that’s sensible and cost effective. Developing a severe disability might seem hopeless, but I want people to know that it’s possible to live a good, full, interesting life when you have the right support and choice.
This gets to what I think is a vital but often unasked question: what is the point of public services and so the money that funds them?
The vast majority of people with lived experience and who have used care and support services say that they want a life, not a service. Their focus isn’t on getting a few more hours of home care here or seeing an occupational therapist there; it’s about living as full and enriching a life as possible.
Norman Kirk – a New Zealand Prime Minister in the 1970s – described it this way:
People don’t want much. They just want someone to love, somewhere to live, somewhere to work and something to hope for.
He could well have added “something to do”, because wanting to be physically active or play sport is often reported by all people, including disabled people, as a key source of general wellbeing.
The point of public services and the money that funds them, therefore, covers being a means to support wellbeing and achieve what people want to do in their lives – including being active and playing sport. We have already heard from a number of people through the Get Yourself Active project that using their personal budget in this way has changed things for the better.
This means there are three main reasons why I feel Get Yourself Active is such an important contribution:
It helps to support people who use care and support services and the professionals who work in them to recognise the value of physical activity and sport
It provides a much-needed wider focus on how Personal Budgets can be used to directly support such activity, and not just focus on traditional ways of meeting people’s needs
And, by the way, it helps councils and their partners meet the general wellbeing requirements of the Care Act.
If this leads to more stories about how Personal Budgets are being used to fund exercise classes, gym memberships or being involved sporting activity, I for one won’t be disappointed. It will mean that public services are doing their job well.
Most discussion about health and social care is about how much money there is(n’t) in the system. Relatively little attention is given to how the money in health and social care flows through that system.
This post shares some extended thoughts on what we know about the payment system in health, how this has been applied to mental health and how, despite potential perils, we can use current and future payment system changes and extensions into social care to support personalisation.
It is a bit dense in places, but it hopefully gives a useful grounding in the payment system for those who’d like to know a bit more about it and the opportunities (and difficulties) it presents. The post is broken up into 3 parts: (1) How the health payment system works; (2) How the health payment system has been extended into mental health; and (3) The perils and opportunities of moving a health payment system into social care.
I. The health payment system
To understand how a system works a good rule of thumb is to follow the money. In large parts of the health service this is pretty easy to do because of the payment/tariff system (which used to be known as “Payment by Results”).
The core building blocks of the payment system are currencies and tariffs. The currency defines the unit of healthcare for which a payment is made (i.e. the ‘what’, such as a hip replacement or cataract operation) and the tariff defines ‘how much’ for each currency (i.e. what will be paid).
Thus, for any person receiving any treatment in certain settings, the following basic process is followed:
Treatment is coded using separate classification systems for diagnoses and interventions
Grouping of treatment – a Healthcare Resource Grouping (HRG) is allocated based on clinical codes and other patient data
Tariff – The tariff price depends on HRG and type of admission, and there are a variety of tariff adjustments made
Payment – standard monthly payments are made in advance, based on activity plan. Actual activity transmitted from provider to commissioners adjusts these payments up or down
In its introduction to the payment system (from 2013) the Department of Health produced this useful diagram to explain the broad principles of how the payment system applied to Mrs Smith having twins, Mr Jones having an emergency hip replacement and how much their treatment costs.
To get to this point the payment system in health has evolved a lot since it was first introduced in 2003/4. That year this type of payment system made up around £100m of health spending (some 0.2% of relevant commissioner allocations); by 2011/12 it made up £28.9bn of health spending (32.4% of relevant commissioner allocations).
II. Extending the health payment system into mental health
What if, though, we apply similar principles to areas where definitions or boundaries aren’t so easy to come across: mental health and social care?
In mental health, a lot of effort has already been made in this direction. All of the various mental health problems that people can have are divided up into 21 ‘clusters’ – a way of grouping people with mental health problems according to their needs, based on descriptions of characteristics of people who are assumed to have similar mental health support needs, and the level of resource needed to meet these needs. In mental health, these ‘clusters’ are the currency (i.e. the ‘what’, or the equivalent of hip replacements etc.).
If this were to follow the twins / hip replacement example, we would then allocate an amount of money to the treatment of someone in a particular cluster and all would, we hope, be sorted. In mental health, though, there are a whole range of other factors that affect what is or isn’t included in someone’s treatment. These factors include (but are not limited to):
Mental health episodes are more difficult to define and diagnoses are less clear-cut
There is less clinical consensus on optimal care pathways, making cost variations more pronounced. Even if there was a consensus on pathways, mental health support is not consistently available across the country, including where some types of support simply aren’t available
Interrelationships with physical health are complex, with mental health problems having a substantial impact on health conditions
Mental health problems typically imposes costs and benefits in non-health sectors
There are shortcomings in both the availability and quality of activity data for mental health, which make very difficult the development of robust remuneration
The evidence base for mental health interventions is far less developed than for traditional health interventions
The money that meets different elements of the support comes from different sources, most notably health and social care pots of money.
What this list of factors means is that the pathway and the payment are much harder to determine in mental health.
Efforts have been underway since 2010/11 to both define the typical pathways associated with each cluster and the prices that might be attached to them. Progress is very mixed, though: clustering people with mental health problems is required by central government, but payment isn’t yet compulsory – local areas can develop their own ways of arranging payment. Furthermore, the extent to which the new payment system in mental health has changed the nature of activity and the differences it has made in people’s lives is a moot point. A recent survey by the Healthcare Financial Management Association (HFMA) (pdf) shared the views of health finance managers on progress regarding the mental health payment system. Findings included:
84% reported commissioner understanding of the mental health payment system to be very poor, poor or fair
60% reported cluster-based activity as having “no” financial impact
70% reported that they still operated under a block contract with commissioners with a shadow tariff.
III. The opportunities and perils of moving a health payment system into social care
As it is in mental health, so the picture would be (even) more complicated in social care.
It isn’t yet the case that formal segmentation of the care population (to create ‘currencies’ and ‘clusters’), associated care pathways and prices have been developed. What we are starting to see, though, is a more concerted effort to define what we might typically expect from a social care pathway; this is mainly been driven through the NICE Collaborating Centre for Social Care (guidelines are being produced, for example, on the topics of home care and reablement). The drive to integration will also bring social care far more, perhaps fundamentally, under the aegis of agencies like Monitor and NHS England, who are jointly responsible for the payment system in health. CQC is, of course, already a joint regulatory body that operates across both health and social care.
In my personal view, and drawing on the experience in mental health, there are both perils and opportunities of bringing a health-type payment system into social care.
The biggest peril is that social care could be the less richer for such a payment system. This lost richness would be made up of a more medical focus in social care, painting a more black and white picture of people than the complexity and range of social care represents. Health is making attempts to shift away from this viewpoint (see, for example, the Coalition for Collaborative Care, Co4CC), but the experience in mental health suggests the practice of anything other than medical thinking related to payment systems is very hard to do.
There are, though, 4 positive opportunities we can take from any current or future attempts to develop currencies and payments in social care.
Such a payment system begins to bridge the gaps (professional, language etc.) people from different professional backgrounds bring. Health and social care professionals start from very different technical positions, though aren’t different in what they seek to do for and with the people they support. Thinking about pathways and payments and trying to put them in place enables people across the piece to come together for a common goal, starting from where they currently respectively are
Building standard national mechanisms won’t, I think, work. But providing a strong requirement to develop a local model, backed up by excellent guidance, support, encouragement and sharing of learning can help areas to create strong local health and social care economies through their common work to develop (if not produce) pathways and payments
Attempts to build the picture will show where evidence is most needed in social care (and health). I am by no means advocating the unrealistic position that we should only spend money on models/interventions/supports backed up by ‘gold-standard’ evidence; but I am saying that knowing where more appropriate evidence is needed will help us to ensure more of what is available through social care is as effective as it can be in supporting people
Perhaps the most exciting opportunity is that developing payments systems like this does much of the heavy lifting in identifying how much money is associated with the care and support of an individual. Even more exciting is the idea that such information would incorporate both health and social care provision. Once the amount is known it is then easier for an individual to take that resource as a Personal Budget / Personal Health Budget, with all the benefits we know are associated with this. After such work, the natural foundations for things like Integrated Personal Commissioning are then in place.
These are 4 reasons I could get behind.
Reforms in health and social care aren’t always renowned for their subtlety. What I’ve therefore endeavoured to do in this post is show how there are always opportunities in reforms – in this case, the payment system, with its currencies and tariffs – that can be used to support a whole range of ends. Here, following the money provides a chance to bring health and social care people together and do much of the heavy lifting that personalisation through, for example personalised payment mechanisms, requires. Though this isn’t without its perils, as the experience in mental health shows, the opportunities aren’t too bad either.
As a reminder: the reason for this was because I think it’s useful to know the degree to which something is innovative or whether it is, for example, something that actually replicates practice in another area; or is something that is supposed to be done anyway; or perhaps something using a different mechanism to what is found in other places.
The suggested innovation scale has three axes: Scale (i.e. size), Known and Sector.
To help bring it to life, below are three examples of “innovation” and where I think they might lie respectively within the innovation scale.
Example 1: Using Twitter
This example is included to help orientate people within the innovation scale. Twitter, as a communications tool within public services, is used nearly everywhere (Scale), Known to virtually everyone and is used across all Sectors. Thus, to speak of Twitter as “innovative” in public services would seem, and is, a bit of a nonsense.
Example 2: Personal Budgets
Personal Budgets are very well Known about, especially in adult social care, and the principle of them is starting to be seen in other Sectors of public service, notably health and employment. Nevertheless, the Scale at which Personal Budgets exist still isn’t especially large. In this sense, then, Personal Budgets aren’t innovative; equally, something is happening such that they aren’t being adopted to the extent that it is hoped they would be.
Example 3: Alliance contracting
Alliance contracting is something that is relatively new in public services. It is only happening in a couple of places (Scale) and is relatively unKnown. What’s more, it’s primarily happening only in adult social care Sector at the moment. Thus, according to the suggested innovation scale, alliance contracting is innovative.
These examples hopefully give a flavour of how the innovation scale may be useful. In the next (and final) post on innovation, I’ll share an overall way of thinking about degrees and innovation and how it relates to other forms of change in public service reform.
In 2011/12, the total spend on Direct Payments for Mental Health was £30.5m. This was 0.56% of all mental health spend.
Of the total mental health spend, over 80% (83.3%, in fact) is spent in the NHS. However, when someone with a mental health condition is given money to spend to meet their mental health outcomes, over 80% (84.5%, in fact) is spent on non-statutory providers.
That is, when there is no choice for mental health services users, over 80% of mental health spend is in the NHS. When there is choice, over 80% of mental health spend is outside the NHS.
Recall that pre-payment cards (also called prepaid cards) are like debit cards, where funds are loaded into an account linked to the card and then spent by the card holder until the balance reaches zero. They can be used to make purchases, set up direct debits or standing orders, and sometimes withdraw cash at ATMs.
There has been an increased usage of pre-payment cards by local authorities, especially in the area of administering Direct Payments in social care, and the Demos report makes recommendations about them being considered for wider use, for example in benefits administration and other forms of public payments.
The topic of pre-payment cards is an emotive one, since it symbolises the concept of the state potentially or actually prescribing what Direct Payments or benefits can be spent on. This is fascinating in itself because, as the report highlights, pre-payment cards are essentially a question of the “nitty-gritty of implementation”.
Of course, I have views on pre-payment cards and whether they should be used. This comes from being pretty heavily involved in two areas of work – Direct Payments implementation and making the Right to Control a reality – and especially from the perspective of service users. I’m painfully familiar with the both the advantages and disadvantages that can arise in making payments to people or trying to integrate several types of payment. As I told the judge, I now know more about the appearances of money laundering than I probably should do.
The wider point to make, though, is that Demos should be congratulated for at least bringing the topic out into the open. Pre-payments cards are a growing phenomenon and there is a need for an open debate on their merits and demerits, rather than their use growing in the absence of a debate.
It would be great if a space could be created in which this debate can take place that brings together users, public bodies, government and those providing pre-payment cards.
Personalisation – and Personal Budgets in particular – are making a positive difference in the lives of lots of different people of different ages and impairment groups.
I did so deliberately: personalisation seems to have been getting quite a rough deal over the last 18 months, especially since its benefits aren’t being felt equally by all groups and seems to mean less is being spent on people. Personally, I think such views conflate a number of issues, including implementation, budgetary pressures and a lack of appropriate support.
If I had to summarise my feelings, I’d say the following: there is a legitimate debate to be had about how best to ensure personalisation is implemented such that it benefits everyone equally; in my view, that’s a different debate to one that challenges personalisation per se.
Still, it’s not good enough to have these debates in the abstract, or to talk about disrupting or innovating a system to within an inch of its life without really understanding what’s going on, and the 3-year study is one attempt to explore the issues fully over a period of time (rather than a snapshot)
The full report and 5 briefings will be available soon. In the meantime, below are 3 videos which capture the stories of 3 people and the impact Personal Budgets have had for them, now they’ve been receiving them for a long period of time.
You can also see these videos with subtitles and more background / description here:
This week, ahead of the publication of a joint 3-year longitudinal study with OPM and Essex County Council evaluating the impact of Personal Budgets, I sketched out 7 very practical lessons that the current Personal Health Budgets work can take from the social care arena. This is cross-posted from OPM’s blog here.
Personalisation – and Personal Budgets in particular – are making a positive difference in the lives of lots of different people of different ages and impairment groups.
This finding comes from 3 years of work ecdp, OPM and Essex County Council have done in Essex, following 29 people on Personal Budgets, the first “longitudinal” study of its kind.
Older people, people with learning disabilities and people with physical and/or sensory impairments have all reported positive outcomes from using a Personal Budget, such as:
Improved quality of care through increased choice and control. This included more choice and control over the providers used to deliver services, and more consistent, flexible or personalised care
Improved wellbeing and the ability to live a fuller life
Increased independence and dignity for service users
Increased confidence, self-esteem and sense of empowerment.
Of course the road to successful outcomes through personalisation and Personal Budgets has not always been smooth. But in recording the lessons learnt – including the occasions when things didn’t quite work and key recommendations for making these processes run more smoothly – the final report tells us how to continue to make personalisation and Personal Budgets as good as they can be.
The challenge of personalisation and Personal Budgets in social care has been considerable. It will be even more of a challenge to introduce Personal Health Budgets in the health service. It’s a challenge I have every confidence will be met though, and that will therefore make a considerable difference in the choice and control people have over their healthcare.
To help things along, here are the 7 very practical suggestions taken from the 3-year study that it would be worth those working on Personal Health Budgets keeping in mind.
It’s very unlikely someone will choose to have a Personal Health Budget if they don’t know about their existence. Make sure you let them know.
It is not possible to exercise choice and control if someone doesn’t know what options they have with their Personal Health Budget. Make sure you let them know their options.
It is entirely possible to forget to tell someone how much money they have available in their Personal Health Budget. Don’t forget to tell them.
It is entirely possible that someone can get good advice and guidance about Personal Health Budgets from health professionals. But it’s just as possible they can get that advice and guidance from someone independent. Make sure they have this option if they want it.
It is possible you’ll think a website will provide someone with all the information they need about Personal Health Budgets. It really, really, really won’t. Face-to-face contact, peer support, sources of information in the local community (such as voluntary sector organisations): these should all also be part of the information mix.
It is possible that holding a budget to meet healthcare needs is second nature to some people. But most likely, for the majority, it won’t be, particularly if they consider employing their own staff. Ensure support options for managing money and employing people are in place.
Finally, it is inevitable that assessing someone’s needs, establishing the level of financial resources this correlates to, describing the options they have available, planning and summarising how to meet these needs, signing it all off and putting the new system into place – is a complex process with many, many complicating factors. If people know it’s going to be a complex process, they’ll probably understand. Manage people’s expectations about how long the process will take, be honest about some of the common pitfalls and reassure them it will be worth it in the end (because, as we’ve seen, it most likely will be).
After talking about the Strengthening DPULOs Programme (on which more here) and hearing from one of the Ambassadors for the programme (you can find out who they are here), I talked briefly about the difference that DPULOs can and do make.
In social care, for example, I noted that were DPULOs provide support services, they can make a significant difference to the choice and control disabled people (and service users more generally) can have over their support.
To take one area: in Essex there is an independent support planning service which is run by and for disabled people. As a result of the different approach, 100% of the people who use this service end up with some form of cash payment – essentially giving them more choice and control. This compares to around 20% for the local council.
Similarly, across Essex, Thurrock and Cambridgeshire, an average of 92% of people who use an independent and peer-led information, advice and guidance service to find out about the social care process end up with a Direct Payment. This compares to global figures in social care of approximately 10% of users on a Direct Payment.
Even if it’s not quite comparing apples with apples, those are pretty significant differences that indicate the underlying difference DPULOs uniquely provide in enabling people to have more choice and control.
As well as thinking about the role that DPULOs can play in addressing disability hate crime (covered in a separate talk to Leicester CIL earlier this week), I also looked forward to two areas I think greater involvement of DPULOs could make a difference.
The first is Access to Work.
This was recently called the government’s “best kept secret”. I think there is a significant role that DPULOs can play in bridging the gap between Job Centre Plus, employers and potential employees in letting them all know about Access to Work: how to find out about it, how to get it, what to do with it.
The benefits from this won’t just be for disabled people or businesses, either: for every £1 invested in Access to Work, the government gets nearly £1.50 in tax and National Insurance contributions.
At a time when the economy needs to grow, this seems like a pretty good thing to do.
The second area is HealthWatch.
One of the areas that is potentially strong in the current NHS reforms is HealthWatch – the bit that is going to ensure the representation of the voice of service users and patients in the new system.
There’s an argument to say that Local Involvement Networks haven’t fulfilled the overall potential they had to hold health and social care to account. I’d argue that this was partly because it was the wrong types of organisations who were trying to run LINks. As far as I know, only two DPULOs were formally LINks bodies. If we can ensure that more DPULOs take on this function as HealthWatch, I have no doubt it will make the health and social care system better.
After outlining the difference I think DPULOs can make in just one or two particular areas (their effects, of course, aren’t just limited to these) I finished my talk with WECIL with a question to its members, which I’d like to offer more widely to readers and interested parties here: as the Strengthening DPULOs Programme continues to develop and make the case for DPULOs to decision makers and stakeholders, what messages do you think they should know about regarding DPULOs?
(Note: This is my personal website, so these represent personal views)
Some leading charities yesterday issued a warning about Personal Budgets, claiming that they could be a means by which Local Authorities are hoping to save money.
This has really riled me.
The social care system is under immense pressure at the moment: huge current demand, massive future demand, huge funding pressures anyway, and significant cuts about to make themselves known (if they haven’t already).
And, in amongst this, the personalisation of adult social care amounts to one of the biggest public service reforms of the last decade.
This personalisation has taken many forms, but one key form has been the introduction of what are known as “Personal Budgets”. Under this reform and put very simply, instead of the Council using its budget to pay for services that people can then take or leave, an individual is allocated an amount of money that will meet the needs the Council has assessed the individual as having. The person can then use this money as they wish to meet their needs.
It’s not an understatement to say that this revolutionises the way social care is provided. At the simplest level, it means that an individual has far more choice and control over their social care than the Council arranging it on their behalf. Undoubtedly, there are challenges with Personal Budgets on a number of levels, not least of which is ensuring that everyone of every impairment type can benefit from them. But in principle, I fully support them.
So when well-known disability and care organisations suggest that Personal Budgets are a means by which Councils are trying to make cuts, it bothers me.
Of course, I live in the real world. I understand the huge pressures that the social care system faces, and I know that Councils may put balancing their own budgets before meeting the needs of individuals.
But the key point is this: the financial pressures that Councils face are the same pressures they’d have faced whether personalisation happened or not.
My question to the organisations who have issued their warning – and who are part of a large number of familiar organisations almost constantly issuing press releases and statements on the topic of social care, as if they were disinterested representatives of service users – is this: would they rather the cuts to social care happened in an unreformed social care system, or in one that places choice and control at its very heart?