Going It Alone or Playing to the Crowd? A Critique of Individual Budgets and the Personalisation of Health Care in the English National Health Service

Abstract

The introduction of individual budgets into English health care is a recent example of the pervasive drive towards personalisation in welfare sector organisation and delivery. As a heavily centralised and highly bureaucratic institution, the National Health Service (NHS) is an obvious target for personalisation. On the other hand, as a symbol of solidarity and nationhood it retains a powerful place within the collective psyche, such that radical reform might expect to encounter resistance. This paper analyses the assumptions that are inherent in personalisation and raises concerns over its ability to transform health-care services. At the heart of these concerns is the tension between appeals to tailored service provision and empowerment on the one hand, and promotion of a strong social contract, public trust in institutions, and collective identity on the other. Lessons are drawn for personalisation in other sectors and settings.

The Vexed Question of Market Stewardship in the Public Sector: Examining Equity and the Social Contract through the Australian National Disability Insurance Scheme

“…Driven in part by the philosophical influence of New Public Management, we have seen the creation of various forms of public sector markets (or quasi‐markets) (Hood ; Klijn and Koppenjan ). Here, governments create ‘markets’ through contracting and tendering processes and/or by individualized care budgets (LeGrand ; Needham and Glasby ; Williams and Dickinson ). In both approaches, governments aim to generate efficiencies through increased competition between providers.…”

“…; Gash et al . ; Needham and Glasby ; Williams and Dickinson ). While couched in terms of citizen choice and empowerment, the move towards public sector markets has also been driven by the spread of neo‐classical economic ideas about the free market.…”

“…52, NO. 1, JANUARY 2018 and/or by individualized care budgets (LeGrand 2007;Needham and Glasby 2015;Williams and Dickinson 2015). In both approaches, governments aim to generate efficiencies through increased competition between providers.…”

“…Across the political spectrum 'choice and control' of public sector services are seen as a way to gain economic efficiency, while enabling citizens to have a more empowered relationship with the state (Boettke et al 2011;Cutler and Waine 1997). Indeed, personalization through markets has been called the cornerstone of modernization of public services and is at the heart of reforms of major health and welfare structures in industrialized countries, including unemployment assistance in Germany, Denmark and the Netherlands (Knuth 2014;Van Berkel 2010), and the National Health Service in the UK (Williams and Dickinson 2015;Gadsby 2013). Most recently, this approach has become central to the biggest Australian policy reform in a generationthe National Disability Insurance Scheme (NDIS).…”

Skill mix: The potential for personal assistants to undertake health‐related tasks for people with personal health budgets

“…Despite this, PHBs have been subject to criticism that includes contestation about the robustness of the evidence (Davidson, Baxter, Glendinning, & Irvine, 2013;Limb, 2016) claims that clinician time will be spent on complex, expensive bureaucratic processes (Slasberg, Watson, Beresford, & Schofield, 2014); possible inefficiency arising from poor patient choices and fraud (Iacobucci, 2015); 'wasted' money on non-evidence-based therapies (Sheppard, 2015) being ideologically motivated and breaking with the NHS 'free at the point of delivery' ethos (Beresford & Slasberg, 2018;Hewitt-Taylor, 2008); and paving the way to a private insurance-based system (Scott-Samuel, 2015). Finally, the extension of PHBs is being undertaken at a time of reduced local authority resources, NHS restructuring and budgetary constraints-which has implications for their delivery (Williams & Dickinson, 2016).…”