Hilary Blackwell asks whether putting people in charge of their own healthcare budgets could really work

Since April 2003, local authorities have been obliged to offer direct payments to people with social care needs instead of arranging services for them.

Anecdotal evidence suggests people are much happier with packages of care arranged in this way. The Department of Health concordat Putting People First promotes the direct payment system through grants to local authorities.

Could it work for healthcare?

Similarly, giving people the opportunity to choose who commissions their healthcare services could help reduce the inequalities and inefficiencies of the present system, particularly where patients are suffering from chronic disease.

However, until now the official position has been against permitting individual budgets in healthcare. This is because of a number of perceived risks, such as:

  • People might go abroad for healthcare and pay for their treatment with NHS money, thereby destabilisingUKacute trusts. Where patients have done this without authorisation, the NHS has refused to pay for treatment.

  • It is unclear who would decide which patients could choose their commissioner of services or indeed commission their own services.

  • Well-meaning relatives might try to help but lack the professional knowledge of what is required, or fail to check that appropriate professional qualifications are held by those offering services.

  • Patients or their relatives could misspend the money and it would be unclear whether the NHS would still have to treat them.

Despite these worries, there are indications that personal healthcare budgets could work:

  • There are some protections built into the current system requiring registration and regulation of, for example, domiciliary care services. The Health and Social Care Bill's proposed merger of the Mental Health Act Commission with the Healthcare Commission and the Commission for Social Care Inspection should help to avoid services falling into the gap between the different regulators.

  • A number of successful independent user trusts have been set up under the direct payments arrangements in local authority circles, in theory securing the accountability for correct spending of allocated money. However, there remains a risk that the money will be misapplied or wasted, regardless of trust arrangements.

  • One exciting possibility arises from the government's encouragement of the third sector. Primary care trusts are reviewing the possibilities for separating their commissioning and provider functions. The creation of Central Surrey Health last year, a nurse-led social enterprise in theEast Elmbridgeand Mid Surrey area, has established a useful precedent and it is likely that a number of other services may follow suit. These organisations would be ideally placed to arrange and deliver appropriate packages of care, and could even take on operational-level commissioning arrangements from practice-based commissioners.

As NHS chief executive David Nicholson said: "I think we will see a move to more and more individual budgets involving allocation of resources - either yearly resources or episodic resources - to people, and what we will see coming with that is the need for a kind of brokerage, bringing people together and then buying on their behalf or commissioning on their behalf."

This is an exciting development, which if properly implemented should give real benefit to people suffering from long-term conditions.