How will personal health budgets affect GPs?

With 5m patients likely to hold personal health budgets from 2018, David Millett looks at how the reform will affect GPs and the wider NHS

Consultation: personal health budget concerns for GPs (photo: JH Lancy)
Consultation: personal health budget concerns for GPs (photo: JH Lancy)

From April this year, GPs will have to be prepared for some of their patients to begin managing their own health budgets, as NHS England expects CCGs to 'lead a major expansion in the offer and delivery of personal health budgets' this financial year.

NHS England estimates that  up to 5m patients in England could have their own personal health budget by 2018, allowing them to manage their own care and help decide which treatments they receive..

The move promises to hand patients more control and to blend health and social care funding - a key step towards 'a truly person-centred NHS', according to Think Local Act Personal, a partnership of local and central government, charities and NHS organisations.

NHS England chief executive Simon Stevens said last July: 'Patients, service users and carers have the biggest interest in getting things right, but they can only do so if we give them real power to shape their own care.'

But how will putting patients in the hot seat affect the care provided by their GP?

GP workload

As patients gain more choice, GPs should expect a rise in workload, says GPC deputy chairman Dr Richard Vautrey.

'GPs are well used to providing information to patients about different services that are available,' he says.

'The problem is if individual patients start to be targeted by other service providers, because that could make it very difficult for the GP to know the quality of service individual providers are offering and whether patients will be better served by accepting those invitations.

'It could make it much more difficult to be able to provide the right advice to patients.'

GPs could also face more patients seeking advice, he adds. 'As we see when a patient is not satisfied with the service they get from a hospital, it's GPs they come back to and ask for a second opinion. So the risk is that when a patient finds they have spent their budget, or are not satisfied with how they spent it, they'll come back to their GP and ask for help.'

GPs have historically opposed roll-out of the scheme. The RCGP and the BMA called for personal health budgets to be delayed in 2012, after most doctors said they had not been well informed about the process.

Many GPs remain concerned about what could happen if a patient spends their entire budget but requires essential further care.

University of Liverpool researchers warn that once patients use up their budget, they could have to foot the bill personally for further care.

In a paper published in the International Journal of Health Services, public health expert Dr Alex Scott-Samuel argues that personal health budgets are a step towards NHS privatisation, although NHS England says these concerns are unfounded.

Personal budgets - topped up by the patient's own bank account or insurance - will become the norm, he warns.

'Personal health budgets are being introduced at a time when rapid privatisation of the English NHS is taking place and restrictions are being placed on people's access to healthcare,' he says. 'As a result, many view their introduction as a diversionary gimmick designed to help pave the way for the conversion of the NHS into the insurance-based system.'

An NHS England spokesman said: 'Free healthcare at the point of delivery is enshrined in the NHS Constitution, and there is no intention to undermine this absolute principle.'

But Dr Vautrey agrees that the scheme could potentially lead to greater marketisation and privatisation of health services.

'Companies will undoubtedly start approaching individual patients and encouraging them to spend money with them,' he says, adding that this could see essential services being dropped as patients increasingly opt for different treatments, making existing services less viable.

Patients can elect to receive their health budget, financed by their CCG and NHS England, in one of three forms, according to the NHS confederation. It could be a notional budget, where no actual money changes hands, a real budget held by a third party, or a direct payment made to the patient.

There are fears patients could be pressured into spending this on non-evidence based or bogus treatments that may not be the best, or most cost-effective, option.

Personal budget pilots

In pilot schemes for personal budgets, which ran from 2009 across 70 PCTs, some patients used their health budget to fund personal trainers, manicures, driving lessons and theatre tickets.

Perhaps tellingly, the DH found it necessary to put a ban on the money being spent on gambling, debt repayments, alcohol and tobacco.

An unnamed GP responding to an NHS Confederation poll on personal budgets said: 'We are still accountable for public money and therefore if you're going to ask for something non-evidence based, it's not going to be reasonable. There is financial constraint.'

Barbara Young, chief executive of Diabetes UK, has also raised concerns about how effective personal budgets will be for patients with diabetes, who will be eligible to opt into the scheme from April.

Baroness Young said diabetes was complicated and unpredictable, while research showed that personal health budgets worked best for patients who had stable, predictable conditions.

'Personal health budgets are not suited for clinical diabetes care delivery and may impact negatively on quality of care and lead to fragmentation of service,' she warned.

But only time will tell how personal budgets affect patient care - or indeed whether they mark the beginning of the end for the NHS.

Mr Stevens says giving patients more control will see the NHS 'move beyond just asking "What's the matter with you?" to "What matters to you?"'.

Patients who took part in pilots, however, are largely in favour of personal budgets, according to a 2013 survey by Think Local Act Personal.

About three-quarters (73%) of patients who had their own budget said it helped improve their independence and 69% said it had a positive impact on their health.

Pilots also found no negative impact on clinical outcomes for those enrolled in the scheme, improvements in quality of life and psychological wellbeing, and a reduction in unplanned admissions.

But Dr Vautrey warns: 'There are real risks that we will open a Pandora's box that we'll regret, as a result of going down this route.'

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