On a new journey

Around 20 years ago, personalisation was said to be the future of commissioning and the NHS responded by offering greater patient choice in where and when to be treated, as well as experimenting with personal health budgets. 

These measures were launched in a time of relative plenty, but responding to individual needs has perhaps been lost as the service has sought efficiency savings. Consolidating services on fewer sites, for example, arguably limits choice. Even so, NHS leaders still regard tailoring care to individual needs as important and believe that in many cases providing budgets to individuals to commission their own care can lead to better outcomes and less money spent overall.

As ever with the NHS, the terminology around personal budgets can be confusing, as funding can come from clinical commissioning groups, local authorities or both. NHS England offers these definitions:

• Personal health budgets The NHS wholly funds the budget 
• Personal budgets The local authority wholly funds the budget 
• Integrated personal budgets The budget includes funding from both the local authority and the NHS 
• IPC (integrated personal commissioning) personal budgets Umbrella term describing personal budgets, where funding could be from a local authority, the NHS, or both. 

For children and young people with education, health and care plans, a personal budget can include funding for special educational, health and social care provision. 

IPC was launched in 2015 and there are 18 demonstrator and early adopter sites, involving clinical commissioning groups, local authorities and, in some cases, providers. Integrated personal budgets are due to become mainstream models of care by 2020. They are not supported with new money, but aim to free up funding from existing contracts. For example, a person who has paraplegia may develop sores. The dressings need to be changed daily by a district nurse, which often makes them late for work. Instead, they could use their personal health budget to train their personal assistants to change the dressings.

In October 2014, those eligible for NHS continuing healthcare (CHC) or children and young people’s continuing care were given a legal right to have a personal health budget, unless there are exceptional circumstances. However, the demonstrators are widening the scope to include other people with complex physical and mental health needs and long-term conditions. 

NHS England estimates that IPC could be the mainstream model of community-based care for 5% of the population – up to 3 million people – and it is striving to increase the numbers with integrated personal budgets. Next steps on the NHS five-year forward view said IPC should be extended to reach more than 300,000 people by the end of 2018/19 and substantially scaled up thereafter. 

It added that the provision of personal health budgets should be expanded to cover
20,000 people by 2017/18 and double that number in 2018/19. According to the NHS England Mandate, commissioners should make progress on giving personal health budgets to 50,000-100,000 people by 2020/21. 

The new CCG  improvement and assessment framework includes a personal health budget metric, with quarterly reporting and benchmarking. Sustainability and transformation partnerships (STPs) must include expansion plans for personal health and IPC budgets in their plans.

Better signposting

NHS England’s Personalised Care Group senior strategic finance lead Sarah Day says IPC is not just about personal budgets. For most people, the initial interaction with IPC will give them signposts to community groups to help meet their needs. At the next level, more complex needs will be met through the personalised care and support planning process, which allows them to have a conversation with commissioners and clinicians about their needs and what is important to them. 

‘This leads to a better understanding of that person and can lead to signposting to different services,’ she says. ‘It won’t necessarily result in a personal budget, though some will be eligible for a personal health budget or a social care direct payment. A small number will require an integrated budget, combining health and social care funding, and potentially funding from education for younger people.’

There is guidance on direct payments, setting out what they can and can’t be spent on – so an A&E attendance wouldn’t be included. 

However, within these boundaries, there is some flexibility over how the money is spent, Ms Day says. ‘It’s down to local discretion. Where it’s spent more creatively, there tends to be more benefit for the person as they have greater choice and control over decisions on their health and social care needs.’

While greater system-wide integration is necessary in terms of providing seamless services and reducing bureaucracy, Ms Day says it can limit choice and personalisation. 

Ms Day explains that IPC can be seen as a counterweight to the development of STPs and accountable care organisations and systems – providing a necessary option for those with complex needs.

‘A budget may not necessarily cover someone’s whole care plan. It has to make sense for the person and the system. For example, if the system is already commissioning something that completely fits with what the person wants, you wouldn’t give them a budget to buy that service,’ Ms Day says.

The IPC work at Herts Valleys CCG and East and North Hertfordshire CCG initially focuses on older people with multiple long-term conditions who live in their own homes. The CCGs, working with Hertfordshire County Council, are early adopters of IPC, joining in the second wave (December 2016). 

Though the work is concentrated in the two localities, the patient cohort was chosen as it aligned with the local Herts and West Essex STP priorities. It is also a local priority as primary care and acute hospital costs are higher in this group than any other.

Jo Reeder, the integrated personal commissioning programme lead, explains that they deliberately chose a group of people outside of CHC. ‘In Hertfordshire, personal health budgets are very much mainstream in adult CHC, so we decided with the IPC programme to focus on people with primary health needs who don’t meet CHC criteria but are living at home with high levels of frailty.’

The team is concentrating on preventing GP and A&E visits, through personalised care and support planning. Much of the initial work has been on giving the workforce a greater understanding of the different roles across the community and working through the STP to sign up local providers. 

This was vital, Ms Reeder says, but they are moving on to examine the costs of individual services and the detail of contracts – for example, when they expire or can be varied to release funding for individual budgets.

‘We need to improve people’s lives and demonstrate we can save money. If we can save resources and also improve people’s lives, that’s not a language people are going to ignore. We can save on GP time particularly, and reduce A&E attendance, so there will be financial savings, though it’s not our primary driver.’

The costing work is being helped by a linked dataset that provides cost information across primary, community and secondary care, as well as social care in the East and North Hertfordshire CCG area. ‘We can look at information on, for example, older people diagnosed with multiple long-term conditions and start to see who are the top 10 in terms of the biggest cost to the system,’ says Ms Reeder. 

‘This helps us target preventative care, making a difference to the individuals and reducing primary care contacts, emergency care and inpatient days. The dataset is not perfect, but it’s the way forward to look at cost information across multiple organisations.’

Mandate targets

Nationally, there is some way to go on reaching the Mandate targets – by the end of June this year, there were almost 12,000 people with personal health or integrated personal budgets. However, NHS England’s Ms Day says commissioners are on the right trajectory to achieve the targets. 

She adds that moving people to personal budgets was always likely to be a phased process as a lot of the funding is locked up in existing contracts. As these are renewed, funding can be freed up for personal budgets where they are required, although variations are also possible during the contract term.

‘Some IPC sites are working closely with providers to understand where opportunities exist, particularly for groups that are not well served. Others have been looking at groups of people on long waiting lists because of vacancies in provider organisations – exploring if they can free up some of the vacancy funding to give people budgets to do something different. In many ways, IPC is supporting the system to address existing problems.’

Value for money is almost a secondary concern in the move to personalisation, but it can produce savings. 

‘IPC is important due to the fact that people with the most complex needs are often passed around different services, which is not great for them or the system,’ says Ms Day. ‘There’s a lot of potential duplication and wastage from that, but with IPC, people are receiving more appropriate care so they turn up for it – there are some financial benefits from a system perspective.’

Personal health budgets were piloted between 2009 and 2012 and a Department of Health evaluation at the end of that period concluded that it had improved care-related quality of life, and was more cost-effective. The evaluation showed that indirect costs, such as hospital admissions, for those receiving CHC reduced by approximately £4,000 per person,

Since then, the use of personal health budgets has expanded and NHS England is updating the Department analysis of cost-effectiveness and outcomes. Although still in the early stages, and the sample is small and self-selecting, the signs are good. 

Ms Day says: ‘We found that in continuing healthcare for personal health budgets, there was a 17% direct cost saving for the same level of need – that’s the difference between a traditional package of care and a PHB and allows for the fact that we assumed there would be an increase in admin costs. It’s early days, but the CCGs that provided information made savings in the range of 0.5% to 36%. ‘We haven’t yet looked again at indirect costs and related outcomes, but we are pretty confident from previous work that outcomes will have improved.’

Herts progress

It’s also early days for IPC in Hertfordshire, but the area introduced personal health budgets for CHC two years ago. ‘We’ve found this to be 10%-15% cheaper than if we commissioned directly,’ Ms Reeder says. The figure allows around 5% for higher administration costs, she adds.

The team is also working with the county council on sharing its back-office function to save on overheads. Local authorities have been making direct payments for social care for some time and several demonstrator CCGs are working with their local authorities to take advantage of this expertise.

Although IPC does not necessarily mean a payment into a patient’s bank account (see box previous page), finance managers may be concerned about whether it is spent appropriately and achieves value for money. On the other hand, there are fears that heavy-handed oversight could put off some candidates for IPC.

Ms Day insists that audit and monitoring should be proportionate. ‘It’s public money, so we have to make sure it’s used effectively and the cost is appropriate. There’s a requirement to monitor direct payments at three months and at a minimum every year to make sure people are okay with it. A CCG might look at a CHC budget of £50,000 once a year, but want to look at a £500 personal health budget every month.

‘It’s really important to take a proportionate approach and have a good care and support plan that makes it clear to both sides what the money’s for,’ she says. 

She suggests that commissioners could hold financial and clinical reviews in parallel. ‘The financial analysis can inform the clinical one and vice versa – if people are not spending the money, what are they doing? Are they causing issues for their health or were they given too much money? 

‘A clinical review might show that they’ve spent three months in hospital, so the finance people need to understand it’s not been spent because of that. Needs can also fluctuate, particularly in mental health.’

IPC is clearly in its infancy, but both commissioners and providers must be ready for it to gear up and become a mainstream option for patients with complex and long-term needs. Evaluations of personal health budgets have shown the personalised route to be more cost-effective, but, perhaps more importantly, it gives patients a voice in getting the services they need.