Personal budgets and PbR offer integration stepping stones

The increasing call for integration of health and social care delivery in mental health services brings together the personalisation agenda with the implementation of mental health payment by results.

Much of current professional comment places the approach as an anathema in relation to the principles and values of personalisation.

However if its implementation can provide the framework for personal health budgets, could it also be a mechanism for the transformation of mental health services to achieve personalisation for both social care and health?

Getting personal

The message of personalisation is focused on giving service users choice and control and a changed relationship with those providing mental health and social care services.

This is often epitomised in social care by the use of personal budgets, where the individual is allocated an amount of money and makes the decisions about what it is spent on in order to meet their needs.

Currently within mental health services the use of personal health budgets is rare but it could provide an excellent opportunity for personalisation and a true integration of services. 

Here in Cambridgeshire we are just beginning the conversation with service users about what choice and personalisation really could mean.

The historic block contract and lack of transparency and outcomes in mental healthcare has made access to any detailed conversation and debate about change prohibitive to many, including service users and health and social care commissioners.

‘The use of personal health budgets is rare within mental health services but it could be an excellent opportunity to truly integrate services’

Regardless of whether a national tariff and full implementation of the system happens or not, the process of understanding patterns of need, what is offered to meet those needs, its cost and having processes in place to begin to focus on outcomes, is in itself beneficial.   

Much has been commented on regarding the barriers, or more strongly the impossibilities of personalisation in the context of the payment by result system. However, it is missing the potential stepping stones that the system can offer health providers and commissioners to move closer to an infrastructure and culture that enables personalisation. 

When the system has been developed well and embraced as a powerful enabler of transformational change, it makes it possible to use as a nationally standardised framework for assessing need and allocating a budget against that need.

Opportunity for outcomes

It also includes review periods and a focus on outcomes. This opens up an opportunity to introduce a point of choice in health where an individual can choose to use their care cluster funding as a personal budget.

If mental health services truly wish to provide care and interventions that are person centred, offer choice and are recovery focused, more flexible – and sometimes difficult – conversations are needed.

Health colleagues often find talking money incompatible with the values of providing universal services. Inevitably money does impact on the service the person receives and this is rarely explicitly acknowledged in the care planning process. 

‘Offering the solutions valued by the individual are often missed because they fall outside the conventional services system of care and treatment’

With the introduction of payment by results comes the unavoidable assumptions that there has been open collaboration with service users during the implementation phase, and a connection made between the individual, their needs and the cost of care. 

Managing to hold respectful care planning conversations with the individual in tandem with openness about budgets and cost has been central to the process of personalisation through personal budgets in social care since its inception. As has using community resources to meet need.

Offering the solutions valued by the individual are often missed because they fall outside the conventional services system of care and treatment.

These are the solutions which have been so evident in the personal health budget successes demonstrated in the pilot sites.

The pros and cons

An often raised challenge is the difference between health and social care. At the point when an individual receives services these differences are often meaningless and indistinguishable. But at the professional and organisational level these differences are experienced culturally and practically on a daily basis.  

We need to look at how we can use the opportunities we have, as well as the knowledge and experience that already exists regardless of the professional and organisational differences. In this way the individual can experience truly integrated care, personalisation and choice through an integrated health and social care personal budget – all made possible by the stepping stone and opportunities thrown up by the implementation process of payment by results.

The challenge to the inherited mental health systems and services today is the logistics of managing large organisations safely and efficiently, whilst delivering personalised care to each individual using the service.

‘Mental health is not an area of need that can be objectively tested and evaluated’

People have a vast range of needs, with a range of complexity and social factors, many of which are subjectively judged by both the individual and the professional. Mental health is not an area of need that can be objectively tested and evaluated. 

The shift to new systems of service delivery is needed if personalised care is to be achieved. When done well personal budgets provide individualised, flexible and inclusive solutions; inclusive, as the purchase of psychological interventions can sit alongside the purchase of less conventional, but as effective, options.

It may be worth considering that if we want to do things differently it may feel uncomfortable and difficult. If we think only of the occasions where it will not work we can prevent progress for those for whom it would have worked.

It can be important when making judgements to know the difference between what cannot be done and what is failing because it is not done well.

Kim Woodbridge-Dodd is head of the Mental Health Cambridgeshire County Council and a doctoral student at the University of Northampton