Despite significant progress over time, we still know very little about what works to improve people’s health in some areas of healthcare – but we suspect that some things need to be very tailored to the specific needs of the individual.
In mental health services, for example, many people are admitted to in-patient settings each year, and far too many seem to end up in the mental health system for life in a revolving door of re-admissions. Yet recovery from mental ill health feels instinctively as if it must be a very personal process, and that different things might help different people.
Take Joe (not his real name), who was living in a mental health rehabilitation hostel and taking medication that stabilised his schizophrenia. But the hostel was funded by taking all his housing and disability benefits off him, leaving him with his weekly “personal expenses allowance” (or “pocket money” as residents call it) of around £23 a week.
Alongside his accommodation in the hostel, Joe wanted to join a gym to lose weight (as significant weight gain was a side effect of his medication and had really dented his confidence and started to damage his health). He also wanted to continue training as a bricklayer at an adult education class and buy a bus pass to travel to these activities, but also to get out and about and meet more friends (possibly even a partner one day).
In Joe’s view, he was stuck in the mental health system not because of his mental ill health, but because it isn’t possible to do all that on £23 per week, and because the system couldn’t free up enough money to give him a genuine shot at recovery.
It’s common sense
The idea of a personal health budget is to allow people like Joe to have greater choice and control over the money that funds their care is spent. This common sense and everyday innovation wasn’t possible when, as a trainee social worker, I met Joe. But with the advent of personal budgets in social care and personal health budgets in the NHS, it is now.
In social care, this involves a social worker being clear with a patient from day one about how much is available to spend on meeting their needs, and then allowing the person much greater choice and flexibility over how this money is spent.
This means people can be more innovative in how they go about meeting their needs, and that they can tailor support to their individual circumstances. Ultimately it means decisions that really matter to people are made as close as possible to the person they affect – ideally by the person themselves (or, if not possible, by someone who knows them well and cares about them).
So far so good. But in a new policy paper, we argue that barriers to this way of working are being created in part by the traditional focus of the NHS on quantitative and medically-orientated notions of valid evidence.
For us, the question isn’t “do personal health budgets work?” – but rather, who decides what success should look like in the first place and what outcomes service users and staff working together more creatively might not have been able to achieve with mass purchased or produced services.
What works is what matters
When it comes to personal health budgets there has been a lot of attention devoted to what people use the money for, like the stroke patient who bought a drum kit or an overweight person who reportedly used their personal budget to buy a dog. There are no guidelines on the cost-effectiveness of dogs, but it does seem like a simple way of getting someone to walk more and could work better than more traditional weight loss programmes.
The point is that the focus has to be on the outcomes achieved, rather than on the process itself.
Another example is a woman with a serious mental health condition who used to make frequent ambulance call outs and visits to Accident and Emergency. She used her personal health budget to buy art materials, which provided sufficient distraction when she heard voices to prevent more emergency visits. In another case, several people used singing classes as an alternative to pulmonary rehabilitation to stabilise their breathing and provide a greater sense of well-being than the traditional service.
In all these examples, the focus is not on what is purchased but on whether or not it is a good way of meeting the desired end. For Joe, these approaches arguably came too late. But other people using health and social services could benefit significantly if only we can expand our definition of what constitutes valid evidence and shift our thinking from services to results.