Reflections of the Mental Health Demonstrator Programme by Vidhya Alakeson

January 12, 2018

In December 2013, CCGs and trusts in 14 places across the country came together to begin implementing personal health budgets in mental health.  In March this year, the same people met for the last time to review progress.  In the intervening time, a number of people's lives have changed for the better as a result of getting a personal health budget.

A man from Devon with a history of overdosing now uses his personal health budget to go on long coach journeys when things start to get too much and avoid ending up in hospital. A young woman from Stockport with a history of self harm and emergency hospital visits has stopped turning up at A&E without even spending her budget. Being listened to as part of the planning process - one would suspect for the first time - was enough to make a change in her life. Another woman has used her personal health budget to go on walking holidays at difficult times of the year and found the distraction far more effective than expensive NHS respite care. For all the stories of success, however, few places implemented more than a handful of personal health budgets during the 15 months of the programme, far fewer than we had expected. Is that success or failure?


When we set up the mental health demonstrator programme, the expectation was that local areas would implement 50 to 100 personal health budgets for individuals with mental health problems. Our thinking was simple: the national personal health budget pilot had run for three years and described in detail how to implement personal health budgets. A number of places had already blazed a trail in mental health and an array of tips and toolkits was available, making it easy for anyone else to get going quickly. We were being too simplistic. Yes, there is much more information available about personal health budgets, how they work and the basic steps to implement them than in 2009 when the pilot began. But putting personal health budgets in place is not just a technical task; it is a cultural one.


Implementing personal health budgets does not involve an incremental change in how NHS services are delivered. Personal health budgets are closer to a revolution, turning the established power structures on their head. Fear and resistance are, therefore, inevitable, from staff as well as those who use services. People have to be won over locally and that takes time and effort. Southwark, for example, wants to offer personal health budgets to individuals wishing to move out of residential care. As a first step, they worked through a user-led organisation, Experts by Experience, to engage potential budget holders and staff in residential homes to share knowledge and gain basic acceptance for personal health budgets. It is not a question of success or failure. Regardless of how many tools there are to hand, the culture change that has to accompany the implementation of personal health budgets cannot be easily sped up.


The other area where things proved to be far more difficult than anticipated was on the finances. The financial question we wanted to answer was how to sustain large numbers of personal health budgets without spending more money. However, it all proved a bit chicken and egg. Without large numbers of budgets in place, it was difficult to adapt existing finances to discover how to sustain large numbers of budgets. This is where the new Integrated Personal Commissioning programme comes in. It is tackling the financing question head on as a core requirement. However, the risk of focusing on technical solutions is that the culture change that must underpin them gets forgotten. Technical solutions without a real shift in choice and control to individuals will create personal health budgets in name only. We have seen this in social care where a focus on the technicalities of resource allocation systems led to people having personal budgets but not seeing their lives change in meaningful ways.


Looking back, when we started the demonstrator programme, we forgot the old tale of the hare and the tortoise. While it is tempting to drive forward at speed, slower implementation that allows the culture change to keep pace ensures a longer and stronger future for personal health budgets.


Vidhya Alakeson