Patients who are “more able” than others may derive greater benefits from receiving personal health budgets, and it could be hard to stop wealthier recipients who “know how to play the system” from topping-up their care plans with their own money, a new report warns.

“Self-selecting (white middle class)” people would be more likely to access personal health budgets, and in particular be happier utilising the option which gives them a cash payment to buy services, researchers from the University of Kent have been told by personal health budget leads at Primary Care Trusts (PCTs) involved in pilots for the scheme, which began in England last year.

In an interim report produced for the Department of Health to examine early experiences with the pilots, the researchers note that this new way of delivering health care represents a major cultural shift within the NHS. It is believed that personal health budgets can make the Service more responsive to individuals’ needs, leading to better targeting of resources and less waste and duplication and, therefore, to improvements in both value for money and patient outcomes and satisfaction. They can also encourage clinicians and care co-ordinators to have better-informed discussions with individuals, they say.

However, personal health budgets also present potential risks and disadvantages, the study finds. For example, people may use them to secure services or equipment that they personally value but that may not best serve their health. Budgets could also disproportionately benefit people from particular socioeconomic, age or ethnic groups in a way that undermines the equity principles of the NHS; some interviewees wondered how “more affluent” individuals who "know how to play the system" could be prevented from topping-up their budgets from their own resources to purchase additional services.

Moreover, helping the “less competent” to get the same outcomes as those who are better able to navigate the system has implications for costs and the workloads of health care professionals, while groups such as older people and the very ill might be reluctant to take up a personal health budget, feeling that the responsibility would to be “too much” for them, they add.

Factors identified through the interviews as important for facilitating the implementation of personal health budgets include: - having the PCT finance department on board during the pilot; - engaging NHS leaders, middle managers, clinicians, health professionals, providers and patients to manage the cultural shift; and - workforce training, which is seen as essential.

Among the challenges to implementation reported by interviewees are: - knowing where the boundaries are, in terms of what could be included in the budget; - encouraging representatives in the PCT to let go of current control and see individuals as being the best judge of what services they need; and - engaging middle managers in the pilot.

- The three types of personal health budgets being considered by the Department of Health are: - a notional budget held by a commissioner, in which individuals are aware of the treatment options with a budget constraint and the financial implications of their choices; - a budget managed on behalf of the patient by a third party such as an organisation or Trust; and - direct payment, in which the patient receives a cash payment to buy services.