Personal healthcare budgets: What can England learn from the Netherlands?

The English Department of Health wants to give patients more control over the care they receive. One way they propose to do this is through personal healthcare budgets for people eligible for NHS continuing care. The health secretary, Andrew Lansley, says the “budgets will give them more control over how their needs are met, allowing them to choose support and services that suit them and their families.”1 It builds on the English experience with personal budgets for social care, which has suggested potential benefits, especially in empowering budget holders.2 English experience with health budgets has so far been limited.1 Pilot projects are being undertaken in 64 primary care trusts, of which 20 are included in a Department of Health funded evaluation. A preliminary report from this evaluation, which concedes that the experiences reviewed may be atypical and which was undertaken before most of those interviewed had begun to receive services, identified the things that patients with long term conditions might wish to spend their budgets on, if they had the freedom to do so.3 They included not only conventional treatments but also alternative ones, some of which, such as reiki, reflexology, and aromatherapy, are not supported by scientific evidence. They also included services that might increase a sense of wellbeing, such as massage and manicures, and technology, such as laptops and mobile phones. Although some commentators, including the head of the NHS Confederation, have welcomed personal health budgets,4 many questions remain. How will the budgets be set, given that the best risk adjustment models can explain only about 12% of the individual variation in healthcare costs, so that many people are likely to receive budgets that are either substantially more or less than they need?5 What will happen when the budgets are spent? Will the NHS or the patient pick up the bill? Is there a risk that vulnerable individuals might be exploited by unscrupulous providers or brokering agencies, such as those that take extortionate sums to place foreign workers in employment? Will personal budgets accentuate inequalities, especially if they are taken up preferentially by those who are, or have carers who are, most articulate? Is it justifiable at a time of austerity to spend scarce resources on treatments known to be ineffective? None of these, except perhaps the last, can be answered definitively until the budgets are implemented. A recent research scan by the Health Foundation found that the evidence on the impact of health budgets is extremely weak, with no conclusive proof that they improve health outcomes or save money.6 There is, however, some limited evidence that they foster a greater sense of empowerment. The report included 60 studies, most of which were from the United States, the Netherlands, and Germany but only included literature in English, even though the most relevant publications are in Dutch. In this article we examine recent literature and information from the Netherlands, where personal budgets were introduced in 1997, for further insights on how they work