## Moving Towards A More Personalised Nhs

The emphasis that putting patients in control has in the NHS Five Year Forward View demonstrates that this is an idea whose time has come. Put into practice, this shift in policy has the potential to radically change the way that the NHS works and fundamentally to alter the relationship between service users and health and care services.  In implementing this agenda, there will be much to draw on from the experience of local government in personalising adult social care services.

## Overview

Putting people more firmly in control of their own care and forging a new relationship with patients and communities come through as strong messages in the recently published NHS Five Year Forward View. As well as being seen as vital for improving the experience and outcomes of service users, personalisation is part of a wider agenda to change the relationship between citizens and the state and to transform public services, drawing on the energy and values of the people who use them.

Person centred care is a core component in health and care integration and is crucial to efforts to shift the balance of activity away from more expensive acute and long term residential care towards primary and community services and a greater emphasis on supporting selfmanagement, particularly for people with long term conditions. This is particularly important in the context of rising demand and increasing costs pressures set against fixed and diminishing NHS and adult social care budgets, for example:

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The cost of providing adult care services in London is expected to grow by £1.14 billion between 2016 and 2020.1
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NHS England's Five Year Forward View warns that, without new ways of operating and sustained improvements in NHS productivity, there will be a £30 billion hole in the NHS budget by 2020/21.2
Adult social care is somewhat ahead of the NHS in terms of personalisation with an evolution in this sector having taken place over the last few decades transforming the nature of provision to offer people genuine choice and control. The experience of the NHS in this area is more recent.  However, over the last few years there have been signs that this is changing, with initiatives such as the Year of Care, which showed the importance of care planning for people with long term conditions, and the personal health budgets pilot being particularly important.

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Even more recently, person centred care planning and support for self-management have been made important components of the CCG and local government-led Better Care Fund plans.  And the Integrated Personal Commissioning Initiative, launched by NHS England in September 2014, will take this a step further by allowing service users in the pilot areas even greater control over the support they receive to meet their health and care needs.

Local 
government has 
many years of 
experience in 
personalising 
adult social care 
services

However, for the ambitions about patient and service user involvement and control to be fully realised, there will need to be significant and sustained change across all levels of the NHS.

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## Analysis

Providing personalised adult social care services Local government has many years of experience in personalising adult social care services. 

Councils have been able to provide direct cash payments to working age disabled adults from 1996 and, since 2003, local authorities have had a duty to provide direct payments to individuals who requested and were able to manage them.  
The 2007 Putting People First concordat made an important commitment that person centred care planning and self directed support would become mainstream practice. This way of working emphasises the need to put the service user at the centre - identifying their needs, offering information, advice and advocacy and enabling people to make real choices about how, when and where they are supported to live their lives. Personal budgets have been an important, but by no means the only, element of this. Take-up of personal budgets in all their forms has increased considerably, with the latest figures from the National ADASS Personalisation Survey report 20143 showing that:

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In 2013/14, around 70 per cent of spending on adult social care community services was via personal budgets.
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Four out of five adult social care users now has a personal budget.
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Over a quarter (29 per cent) of service users now receive their personal budget in the form of direct payment.
The survey also reports some regional variation in the take-up of personal budgets with this lowest in the South West (72 per cent) and highest in the North East (90 per cent). London stands somewhere in the middle, with an 82 per cent take up. The Care Act (2014) has also placed new duties on local authorities to promote individual well-being, to prevent the need for care and support, to promote the integration of care and support services and the provision of integration and advice. The experience of providing personal budgets in adult social care has demonstrated the importance of ensuring that people have the right advice and support, of developing and shaping the market to ensure that people have genuine choice and of working with user led organisations. There are also challenges presented in providing personal budgets, for example ensuring that safeguarding issues are dealt with, and dealing with the size of the budgets that people are given and the level of choice that this gives them in reality.  It will be valuable to apply this learning to the personalisation of services within the NHS and to the roll out of integrated health and care budgets.

Personalisation in health care In 2007, the Year of Care Initiative was launched aiming to introduce more widely the principles of care planning and support for self-management to support people with long term 
"

The number of 
people who can 
benefit from a 
personal health 
budget has now 
been extended

conditions. This initiative was built on the recognition that for people with a chronic condition, the amount of time they spend discussing their care with a health professional represents a tiny proportion of the time they spend looking after themselves and making decisions for themselves. The initiative therefore emphasised the importance of enabling people to identify their own goals, the actions they wanted to take to reach these and any support they might need along the way.  It has thus paved the way for other policy developments and changes to practice in this area.

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The Department of Health introduced its personal health budgets pilot programme in 2009. Around 70 PCTs chose to take part in the programme and to offer personal budgets to adults with a range of health conditions. The pilot programme evaluation found that people who received a personal budget experienced a significant improvement in their care-related quality of life and in their psychological wellbeing. Interestingly, the health status of participants stayed the same, however the evaluation did find that inpatient costs for people with a personal budget fell, suggesting that they had fewer or less intensive hospital stays. The number of people who can benefit from a personal health budget has now been extended. In November 2012, Minister of State, Norman Lamb, announced the national roll out of personal health budgets. From April 2014 people eligible for NHS Continuing Health Care have been entitled to ask for a personal budget and from October 2014 it became a right for people in this group to have such a budget.  
Next steps It is acknowledged in the NHS Forward View that "sometimes the health service has been prone to operating a 'factory' model of care and repair".   It is also now widely recognised and noted that the NHS has moved away from providing episodic care to spending 70 per centof its budget on looking after people with long term conditions.  This, along with other factors, will necessitate a change in the way that the NHS operates. The report sets out important changes in relation to empowering patients:

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Improving the information that people have access to.
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Supporting people to manage their own health, such as through self-management educational courses and encouraging independent peer to peer communities to emerge.
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Increasing the direct control that people have over the care that is provided to them, including choice over where and how they receive care and the introduction of integrated personal commissioning.
There are already initiatives in place in relation to each of the above, however work will be required to accelerate progress on these at scale and at pace. One example of this is the Integrated Personal Commissioning programme (IPC), launched in September 2014, based around two key elements: First, a care model based on person centred care and care planning, and the expectation of the offer of control over at least part of their integrated personal health and care budget, for people who will benefit. Second, a capitated payment approach where the selected sites will develop and test a "blended" funding model that brings together all the NHS and local authority funding for a defined population. This will require local areas to develop and test new financial models bringing together all the costs of providing primary, mental, community, acute and social care for individuals, representing a shift away from traditional mechanisms for paying providers.

This initiative is targeted at a relatively small group of people in the first instance.  To have a significant impact, in time, its scope will need to be widened to encompass a wider group of people with health and social care needs. However, while important in their own right, it is evident that initiatives such as IPC will need to be rolled-out much more widely and to reach far more people for truly personalised care to become part and parcel of how the NHS works. It will also be important to remember that not everyone with a long term condition has social care needs and not everyone who uses adult social care requires on-going and regular health care input.  Therefore the importance of rolling out personal health budgets and extending still further the uptake of personal budgets in adult social care will continue.

## Commentary

The imperatives for putting patients and service users in control emanate from both a moral case - relating to a right to personal autonomy and self- determination - and a financial case - the NHS needs to find more efficient ways of working that harness the skills and input of people who use NHS services. However, the learning from local government in moving towards personalisation in adult social care shows that it takes time to get this right.  The adult social services experience points to the importance of ensuring that service users have the right support to take advantage of the control they have been given, of ensuring that the market is sufficiently well developed to provide for genuine choice and of the valuable role played by third sector and user led organisations in bringing service users together, in advocacy and in providing peer support. The Integrated Personal Care Initiative is just one example of how greater personalisation is being taken forward.  However, with there only expected to be around 10 demonstrator sites nationally, in the short term at least this initiative will not have a direct impact on the majority of areas either nationally or in London.  Nevertheless it is worth watching closely, not least for the trialling of capitated payment models  on a larger scale than previously. Done effectively, this has the potential to lead to an even greater shift towards supporting self- care and primary and community level interventions, away from more costly hospital based interventions, especially unplanned acute care.

More broadly, as this agenda of empowering patients and putting service users in control develops within the NHS, local government has a great deal to offer - not least as experts in providing personalised adult social care services, and in engaging with their citizens and as partners in delivering integrated, personalised care on the ground.    
Author: Judith Hendley, Head of Health and Adult Social Services (T: 020 7934 9972) Click here to send a comment or query to the author

## Links:

NHS Five Year Forward View

## This Member Briefing Has Been Circulated To:

Portfolio holders and those members who requested policy briefings in the following categories: Health and Adult Services