Public services: only a means to living full and active lives


I’m involved with the Get Yourself Active campaign and recently wrote a blogpost for it, which is reproduced below. There’s also a fantastic post by Anne Beales of Together UK (on small steps and grand plans) and from Leanne Wightman (who is doing a great job of running the whole project) on the opportunity of Get Yourself Active. You can follow Get Yourself Active via @GetYrselfActive

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:

  1.  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
  2.  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
  3. 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.



Personal Health Budgets and the placebo effect

An idle thought following on from my last post about the evidence base and Personal Health Budgets: what if there’s a placebo effect associated with Personal Health Budgets?

As far as I understand it (as someone who is neither medically trained nor well-versed in the associated literature) there is good evidence that the placebo effect exists: when a patient takes medication or does something they perceive will help their condition to improve, it does (in either their perception or actuality), even if the medication or thing done has no proven effects.

Thus, irrespective of the evidence base of Personal Health Budgets, if people believe having a Personal Health Budget will make them better or contribute to making them better, will the mechanism of a PHB contribute to making them better?

(Note: just to be clear, I find the current evidence base regarding Personal Health Budgets, captured primarily in the PHB Evaluation, persuasive of the benefits of PHBs.)

How many countries are there? On evidence and PHBs

Image via
Image via

How many countries are there?

This seems like a straightforward question to answer, doesn’t it? Most primary school children could give you an answer, and even if they couldn’t they could quickly look it up in an Atlas.

But perhaps it’s not as simple a question to answer as we think. Scotland and Wales are countries, aren’t they(?), and yet they don’t appear on the list of countries recognised by the United Nations: the UN reckons there are 193 countries, including “the United Kingdom”. My Times World Atlas from 1986 says there were 173 countries. And football’s governing body, FIFA, currently has a list of 209 countries with football rankings.

So, in order to know how many countries there are we need to ask ourselves at least two prior questions: (1) What do we mean by a “country”?; and (2) Who are we asking?

Maybe the question is a bit complicated, so let’s ask ourselves an easier question by going up a level: how many continents on the world are there?

Erm, well. National Geographic reports: “By convention there are seven continents… [but] some geographers list only six [and] in some parts of the world students learn there are just five continents.” Which means the answer again depends on asking other questions, including: (1) What do we mean by a “continent”?; and (2) Who are we asking?

This “facts” business is tricky, isn’t it?

I share this by way of thinking about what we mean by “evidence” in the context of “evidence-based policy” and the recent example of Personal Health Budgets.

A significant announcement by Simon Stevens, the Chief Executive of NHS England, about Personal Health Budgets gave rise to some teeth-gnashing earlier this month.

The gnashing focused on the evidence base that underpins the effectiveness of Personal Health Budgets. Some folks, especially the well-known Ben Goldacre of Bad Science fame, are not convinced by the current status of the PHBs evidence. They think there should be at least a Randomised Control Trial (RCT) to test whether Personal Health Budgets work. Others, including advocates of personalisation in public services more generally, noted both the results of the existing evaluation of the Personal Health Budgets pilot and the value of all types of evidence, especially including the views of patients/users themselves.

Both groups therefore lay claim to “evidence-based policy”, which leads me to two reflections:

  1. It’s hardly an original thought (indeed, there are entire disciplines dedicated to such questions) but we must remember there is value associated with all different types of evidence and research methods. The value derived, and of the associated evidence arrived at, depends on what types of answers you’re hoping to uncover, how questions are framed and what pre-questions and/or assumptions underpin the framing of those questions. Different people have different thresholds for evidence and research methods, quite aside from the fact that one type of evidence or research method that’s a gold standard in one discipline could be next to useless in another.

For me, this is the equivalent of the first pre-question we came to in considering countries and continents: What do we mean by “evidence”?

  1. Let’s not even get into the “policy” bit of “evidence-based policy”. For example, when has policy ever been based on evidence anyway? Does policy making happen in a rational, evidence-led vacuum that is protected from the whims of politicians and public opinion which, heaven forfend, may not be evidence based? Notwithstanding questions of what we mean by evidence, it’s safe to say that not all policy is based on what evidence there is. This is therefore the equivalent of the second pre-question we came to in considering countries and continents: Who are we asking what we mean by “evidence”?

The up-shot of this in the context of the evidence base for Personal Health Budgets is that Ben Goldacre and advocates of personalisation are both right, and they’re both wrong. There cannot be a definitive answer to the question of whether Personal Health Budgets are effective until some other, perhaps unanswerable questions, are considered.


Snippets from a study on #personalisation

Yesterday, I cross-posted a blogpost on learning from Personal Budgets for Personal Health Budgets. The learning comes from general experience, as well as from the results of a 3-year study I’ve been involved with looking at the long-term impact of Personal Budgets on users.

I opened my post as follows:

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: