Ever since social care commissioners found that they could give people their own budgets to spend on services through 'direct payments', there have been calls for healthcare to follow suit. But is this a realistic idea for committing health spend?
Lance Gardner, the projects director at North East Lincolnshire PCT and a former nurse, thinks it is.
He is in charge of setting up a pilot to investigate whether it can be done through practice-based commissioning (PBC).
Patients with chronic diseases will sit with a case manager and examine their care plan and spend for the previous year to determine if they can improve upon it for the next year.
The PCT has backed this plan after discovering that it could save up to 40 per cent of costs (GP, 26 May).
Hospitals have found that they have more certainty about their future workload and practices have less to do.
Patients have expressed a liking for it because they are more in control of their own care, said Mr Gardner.
He stressed that the project was still in its very early stages, so there could be no evaluation of its success.
But the theory behind it appealed to former NHS chief executive Sir Nigel Crisp, who said in July 2005 that the government was considering individual budgets to balance up Payment by Results and hospitals that were attempting to hang on to patients.
However, the White Paper 'Your Health, Your Care, Your Say' ditched the proposal, stating that it would 'compromise the founding principle of the NHS, that care should be free at the point of need.
'Social care operates on a different basis and has always included means testing and the principles of self- and co-payment for services,' the document stated.
Dr Graham Archard, vice-chairman of the RCGP, thought it unlikely that the government would proclaim that everyone could have their own budgets.
Chronic disease care
'It's more likely that individual practices will be recommended to look at models of delivering chronic disease care, one of which could be individual budgets,' he said.
Dr Archard said it would then be clearer which methods were likely to work nationally, and practices could be encouraged to take them up through elements such as the quality framework.
There are problems with giving patients their budgets, he said, such as what happens when patients want to spend their budget inappropriately, or when patients want to contribute to their budget to have additional private services.
Dr James Kingsland, chairman of the National Association of Primary Care, was wary of the idea of individual budgets although he admitted it would provide greater choice and make patients more aware of the limits of NHS resources.
End of registered lists
'My main concern is that this might well be the next stage if PBC doesn't work. If we fail to deliver, patients could have their own records kept on smart cards and be custodians of their own budget, and then we lose registered lists.'
However, Sandra Rote, lead nurse for the NHS Alliance, said she thought that it was a 'brilliant idea'.
'There is so much evidence that shows that patients who feel in control of their condition have better outcomes.'
She pointed out that these patients would need a lot of support and proper governance procedures before it could possibly be thought about on a national scale.
'We need to think about what happens if a patient overspends, and there will need to be some kind of advocacy service for them. Community matrons could take on some of this, but that could see their role change,' she said.
Jo Webber, deputy director of policy at the NHS Confederation and a former nurse, pointed out that without a change in legislation, patients would only ever be able to have indicative budgets in healthcare.
'What I think would be really interesting, is if we could find a way of combining a patient's direct payments in social care with a patient's indicative budget in healthcare, and think of it as one pot of money for designing a care pathway,' she said.
'A lot of the problems might come when you are working out how much each element will eventually cost.
'If we're going to make this market work, you have to make sure you can split the budget down into parts and be confident that when you put them together differently, it is still a realistic indicator.'
'If we moved in this direction, then we would need to think about the role and training of the community matron as to whether they are providers of care, a hybrid of provider and commissioner or a commissioner of care only,' she said.
Lucy Botting, chairwoman of the RCN's district nurse forum, was convinced the move to patient budgets would become more widespread.
'The White Paper is about empowering patients and making people more accountable for their illness. Individual budgets are the way forward,' she said.