The idea of personalisation is about putting service users and carers in the “driving seat” of their care, and offering a service that can be tailored to their individual needs and preferences instead of a traditional “one size fits all” approach (NHS England, National Voices and Think Local Act Personal, 2014).
Personalisation is central to the Recovery movement. One aspect of personalisation is “Personal Budgets”.
So what is a personal budget?
The aim is to receive funds directly, to then use to support individual health needs, in order to give more choice and control. People either have the money paid directly to them, and then use this to pay for services (such as the services of a personal assistant to help them with independent living), or the budget can be allocated straight to a service that the person has identified as meeting a specific need.
Personal budgets were first developed in social care for people with physical disabilities, and have been widened to health budgets for other groups who have long term conditions, including people using mental health services. Interestingly, whilst the uptake of personal budgets has been high in people with physical disabilities and learning disabilities, it has been less popular with people who use mental health services.
Martin Webber and colleagues have been right to question what evidence exists for personal budgets for people who use mental health services. Like the concept of peer support, it feels like an intuitively good thing, but it’s also important to have a sense of what defines a personal budget; how it impacts on a person’s recovery outcomes, and also (important more than ever in these years of austerity) whether it is an efficient and cost-effective use of distributing health resources.
So, Webber et al undertook a systematic review to see if personal budgets improved the outcomes of people who use mental health services.
Stakeholders (including service users, carers, academics and clinicians) devised and agreed the search terms and inclusion criteria to be used.
The search was undertaken in 15 databases (although these are not listed). A random sample of 20 papers were screened by another researcher to check for inter-rater reliability. Disagreements were settled by group discussion. They also hand-searched journals based on references in papers found by their electronic search. Duplicates were removed before screening.
An initial total of 17,193 papers were identified (after duplicates removed). At stage 1, titles and abstracts were screened and the reviewers found that 16,950 papers were ineligible. At stage 2, a total of 15 studies were included for data extraction. Only 2 of these were randomised controlled trials, a further 2 were quasi-experimental, and the rest were qualitative studies.
The Cochrane Risk of Bias tool was applied to the RCTs and the quasi-experimental studies. CASP checklists were used to appraise the quality of the other studies. All of the included studies demonstrated some risk of bias.
From the search that was undertaken in 2013 (date not given) now around 2 years old, the state of evidence for personal budgets for people who use mental health services is in its infancy. The main observation is that there is a distinct lack of robust trials of personal budgets, with only 2 of the 15 included studies being RCTs.
Themes from synthesis
- Choice and control
- 4 studies demonstrated an increase in perceived control and choice by people using personal budgets
- 1 study found users felt less in control
- 2 studies found an increase in flexibility about how personal budgets could be used, but also a level of uncertainty in some service users, particularly when they found it hard to say what their needs were
- Impact on life
- Personal budgets improved quality of life, community participation and sense of hope and recovery
- 3 studies reported benefits to mental health
- 2 studies reported generally better relationships with people
- 1 study reported a positive impact on employment, another showed no impact on employment
- Use of services
- None of the studies reported increased use of inpatient services
- 5 studies reported a decrease in the use of community services
- Only 2 of the 15 studies looked at this
- 1 study showed personal budgets were cost-effective, and the other showed that personal budgets were cost-neutral.
The reviewers concluded that the included studies indicate some positive benefits of personal budgets, but the methodological shortcomings of the studies limit the conclusions that can be drawn.
They also point out the potential for selection bias, in that those service users who are “less complex” may have been recruited to studies. There is a need for high quality experimental studies to inform personal budgets policy and practice for people with mental health problems.
It would have been useful to have had some information in the paper about the reasons why studies were excluded from the review at stage 1, as such a large quantity of papers were discarded at this point. However, it’s important to appreciate that the broader the literature search, the less likely it is to miss potentially eligible papers.
There are many questions that need to be answered around personal budgets in mental health.
We need to understand why there has been such slow uptake of personal budgets in mental health, not just for service users but amongst service providers too, where there remains a need for a cultural shift from one of paternalism to truly person-centred care.
We also need evidence that personal budgets are an effective way of allocating resources and promoting choice and control.
One could argue that personal budgets are not an intervention in of themselves, but simply a method of allocating resources. The challenge in terms of evidence is that people use personal budgets in a variety of ways. One idea would be to group personal budgets into sub-groups (create a typology) and make some comparisons i.e. getting out and about (transport), sports and exercise, personal assistant, additional therapy or treatment (i.e. private counsellor), social activities, and hobbies. Even with this, there are obvious cross-overs (a sporting activity could also be construed as social).
One thing is clear: choice and control doesn’t have to mean holding the budget itself. The most important thing is that people decide what’s right for them and their recovery at the time. The system needs to be flexible and allow for adjustment as needs change, and people need adequate support should they choose a personal budget.
Webber M, Treacy S, Carr S, Clark M, Parker G. (2014) The effectiveness of personal budgets for people with mental health problems: A systematic review. Journal of Mental Health 23: 146–155
Personal budgets in mental health: power to the people? https://t.co/fL8C9hbD6a via @sharethis
New @NatElfService @Mental_Elf blog on @mgoat73 review of personal budgets in mental health http://t.co/JWSQXk3zz3
Thanks, Liz. This is a really insightful critique of the review. We were very constrained by the JMH word length and had to cut out lots of the detail, but hopefully that doesn’t detract from the overall message about the paucity of literature in this field. It is also difficult to review this literature systematically when personal budgets are not conceived and used differently internationally. As ever, more research is needed!
I can see how the literature search and selection process for this review would have been a real challenge.
Were additional details of this aspect of your work published in an appendix or supplement somewhere online? I expect that other researchers working in this field would be interested in seeing how you went about it.
Also, do you have any plans to update this review? What is your sense of the amount of new evidence that has been published in the field since you completed your search two years ago?
There were no additional details published. The JMH word limits were very constraining and there were no options for appendices – which don’t really help transparency and completeness. We have the full protocol somewhere which we can send to anyone interested in further detail.
We’ve done a quick and dirty search of the literature recently. Not much more has been published since 2013. It will be good to do a proper update of the review though.
All the best,
RT @Mental_Elf: The effectiveness of personal budgets for people with mental health problems, by @mgoat73 @SchrebersSister @Intipton http:/…
@Mental_Elf says some positive benefits in #personalisedbudgets http://t.co/PZJn4Uws2k
Today @LizHughesDD considers the lack of evidence for personal budgets in mental health http://t.co/ERkXfuEeob
@hhsdeanhud @UoHHealthSocSci @allofusinmind my latest blog for @Mental_Elf http://t.co/JWSQXk3zz3
RT @mgoat73: Personal budgets in mental health: power to the people? https://t.co/UzFOkGhaJW via @Mental_Elf and @LizHughesDD
.@mgoat73 Tx for yr comment on @LizHughesDD’s blog http://t.co/ZtatYf6ERO I’ve posted a reply with some Qs @SchrebersSister @Intipton
.@Mental_Elf piece on personal budgets: review finds little ev, reflects practice info: uptake/ outcomes lower for MH http://t.co/DoufJuOrQk
We need to understand why there has been such slow uptake of personal budgets in mental health http://t.co/ERkXfuEeob
@aeon456 Thanks for your comments Vanessa. Do post a longer comment on the blog itself if you have time http://t.co/ERkXfuEeob
Most councils will not provide a personal budget for mental health needs alone in my opinion. Funds are usual only provided for anyone for critical and substantial and levels of need and for that level in mental health you’d be in a mental hospital anyway hence they wouldn’t see it as a social care need.
Plus, the average person isn’t even aware that personal budgets are available full stop as councils certainly don’t advertise the fact, with their budgets being generally too low to provide for them.
Interesting but inconclusive SR highlights lack of research about personal budgets for mental health service users http://t.co/ERkXfuEeob
A study on personalized #mentalhealth budgets; better or worse results than the old system? @Mental_Elf @MindCharity http://t.co/rHc8deSHQ3
We need evidence that personal budgets are an effective way of allocating resources and promoting choice & control http://t.co/ERkXfuEeob
Personal budgets in #mentalhealth: power to the people? http://t.co/nNZ61fDicP @Mental_Elf looks at a #systematicreview on #personalbudgets
Don’t miss: The effectiveness of personal budgets for people with mental health problems http://t.co/ERkXfuEeob #EBP
@Mental_Elf has anyone done an RCT of paternalistic care vs person-centred care? http://t.co/VDGevOKt7N
Mental Elf: Personal budgets in mental health: power to the people? http://t.co/1j787hwKhz
Personal budgets in #mentalhealth: power to the people? via @Mental_Elf http://t.co/EoQRNl1usC
Personal budgets in #mentalhealth: Power to the people? via @Mental_Elf http://t.co/mTfsc4V2TO #bizitalk
Personal budgets in mental health: power to the people? http://t.co/EJ8sXM7VHO
Power to the patiënt: personalisation of care http://t.co/CAbID0l5vP via @Mad_In_America
Liz Hughes asks are do personal budgets in mental health really offer power to the people?
RT @anniecoops: Personal budgets in mental health: power to the people? https://t.co/naCXYNPD9E via @Mental_Elf
@anniecoops: Personal budgets in mental health: power to the people? https://t.co/7oK24Htzr9 @Mental_Elf @IASW_IRL @SWSP_TCD @UCDSocWorkPol
The effectiveness of personal health budgets for people living with mental health conditions http://t.co/ypXCbCysax by @Mental_Elf
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