Policy background for integrating personal budgets for people with mental health problems

Here we look at three policy areas that are central to the emergence and implementation of integrated personal budgets in mental health: recovery, integration and personalisation.

Recovery

In mental health, ‘recovery’ means the process through which people find ways of living meaningful lives with or without ongoing symptoms or occasional periods of distress. Integrated personal budgets should aim to give people the flexibility and choice to purchase what they feel will support their recovery.

Three key recovery principles have been identified in consultation with users: [6]

• the continuing presence of hope that it is possible to pursue one’s personal goals and ambitions
• the need to maintain a sense of control over one’s life and one’s symptoms
• the importance of having the opportunity to build a life beyond illness.

Recovery has the potential to transform services and people’s experiences of them, as well as enabling people to lead more independent and meaningful lives. A number of ‘recovery colleges’ have been established across England, which offer courses on living with mental health problems, designed jointly by people with experience of mental illness and mental health professionals. For more information, see Practice example 5: Recovery colleges.

This approach is gaining momentum across mental health services and fits well with integrated care and personalisation. Indeed, recovery could form the basis for integration between health and social care in mental health, as it could unite services and staff around positive core principles.

Integration

Integration across health and social care has long been sought as a solution to delivering coordinated and comprehensive care to people, particularly those with complex needs. By managing the whole of a pathway of care, it should be easier to anticipate or avoid problems, avoid duplication of assessments and care, and provide care closer to home, while improving patient experience and health outcomes. [7]

Integration requires a spirit of collaboration between health and social care. [8] Where this integration exists, it will result in support plans for users that are:

• seamless – in that there is no obvious divide between health and social care support
• holistic – in that support plans will cover all key areas of a person’s day-to-day life
• empowering – in that users will have control of their support plan and be able to choose and direct the various elements of their support plan.

Many people with mental health problems have both health and social care needs, meaning that they call on at least two different systems (others include housing, leisure services and employment support services). The benefits of integrated care in mental health are that systems will take into account people’s whole lives, rather than separating their needs into different support systems.

However, the challenges to integrating services continue to obstruct the integration of care for the individual. The barriers are significant: health and social care services are provided through different funding streams, and while health care is free at the point of delivery, social care is subject to means-testing and eligibility criteria. [9]

The value of integration at the level of the individual is that creating an integrated personal budget helps them to experience joined-up care rather than having to wait for structural integration to be agreed. The process of bringing health and social care personal budgets together at a grass-roots level can provide a model for what could occur further up within the organisations involved. The individual becomes the point of integration between health and social care. [10]

Personalisation

Personalisation means thinking about care and support services in an entirely new way. It means starting with the person as an individual with strengths, preferences and aspirations, and putting them at the centre of the process of identifying their needs and making choices about how and when they are supported to live their lives. It requires a significant transformation of all adult social care services, including mental health, so that all systems, processes, staff and services are geared up to put people first.

The traditional service-led approach has often meant that people have not received the right help at the right time and have been unable to shape the kind of support they need. Personalisation is about giving people more choice and control over their lives.

Personalisation means addressing the needs and aspirations of whole communities to ensure that everyone has access to the right information, advice and advocacy to make informed choices about the support they need. It means ensuring that people can access transport, leisure and education, housing, health and opportunities for employment, regardless of age or disability.

Personalisation challenges the traditional notion that staff and managers know what is best about the care and support a person should receive. The challenge is for staff to improve how they share their expertise and respect the experience and expertise of users, their families and friends, who are often in the best position to identify both problems and solutions. Personalisation for community mental health services means:

• making sure that people with mental health problems can take as much control as possible over their support arrangements, to pursue their recovery and social inclusion on their own terms
• committing to developing a more equal and creative relationship between users and practitioners
• having relationship-based rather than process-driven ways of working
• dealing effectively with the challenges of risk management, fluctuating conditions and public stigma, to make sure that people with mental health problems benefit equally from more choice and control
• adapting job roles, the organisation of teams and the allocation of resources over time to make sure that services can meet people’s needs and aspirations in more personalised ways.

Personal budgets are widely recognised as an important mechanism for delivering personalised services. The basis of personal budgets in both health and social care is that an individual has a budget with which they can purchase the support and care they need to live as full and independent a life as possible. Personal budgets began in social care but have more recently been extended into health care with the development of personal health budgets.

Mental health, culture and personalisation

The evidence from personal budgets in social care suggests that people with mental health problems can benefit significantly from having increased choice and control over their care, because their needs tend to cross boundaries between health and social care. [11] However, the uptake of personal budgets has been lowest among people with mental health problems, partly due to the effects of a risk-averse culture.

For personalisation to work in mental health, a fundamental change in culture is necessary: from a service-based approach to a person-centred approach to care. Personalisation implies a paradigm shift in thinking at personal, political and developmental levels. [12], [13]

This change in culture is a potential challenge to mental health services still reliant on a medical model and a clinical approach to mental health care and support. The aim of integrated budgets is to enable individuals to choose what they would like to spend the money on, even if their choices may not be seen to fit with the medical model.