Personal Health Budgets And Organisational Culture Change

From a philosophical perspective there are five ‘frames’ or perspectives that successful managers of any organisation maintain a balance between: Behavioural, Humanist, Theatrical, Political, and Symbolic.

For this article I am interested in the behavioural and humanist frames. The Behavioural frame focuses on organisational process and procedure, paperwork and finance. The Humanist frame focuses on the nurturing of human potential within an organisation.

Primarily the NHS is a behavioural organisation with a clinical focus on getting people well as soon as possible - focusing on clinical process, procedure and ultimately organisational efficiency. The waiting times debate is a classic example of behavioural focus. Improvement in medical procedures is another.

The humanist focus is not quite as simple. Most organisations focus on personnel (i.e. professional) development to satisfy the humanist element. However, in the NHS, patient contexts, including lifestyle, also form a part of the humanist perspective. Clinical Governance is the framework that puts patient wellbeing at the centre of all medical (i.e. behavioural) decision making. This includes cooperation between the various service delivery departments/organisations involved in the case of every individual patient. In other words the NHS focus is ultimately on people rather than patients backed up by process and procedure.

Over the last decade politicians, The Treasury and NHS managers have emphasised behavioural elements as they struggle to balance the nation’s healthcare budget. As a result, less and less attention has been paid to people/patient wellbeing. An example of this is the way in which patients who qualified for a Continuing Health Care Budget lost their budget if they were re-admitted to hospital and had to start again setting up a new budget when they got out of hospital. Apart from which patients had no say in who came into their home to provide care. Little attention was given to overall patient wellbeing when such decisions were made. The introduction of personal health budgets redresses this imbalance between behavioural and humanist perspectives because a genuine diligent planning process places the PHB recipient at the centre of the process. This means that carers are properly paid and thoroughly trained in any daily medical procedures that are required to be administered. This means that personnel from different agencies meet and are trained to appreciate any conflicts that might arise between agencies as they follow ‘procedure’, thus eliminating or minimising any possible stress for the person as patient and respective family members. Local authorities seem to simply ignore such issues as they commission services from profit driven care agencies for people living at home. When carers need more help than the people they are sent to look after, such circumstances do nothing but promote an absolute sense of depression, promoting psychological helplessness among patients the local authorities and care agencies are meant to be helping. Indeed, how demeaning must it be for a local authority social worker to commission a walk in bathroom for a client only to find the local authority building service personnel, sub contracted or otherwise, do not have the skills to do the installation. Three and one half years and seven installations later the builders finally get it right. Apart from the fact that nobody involved in the delivery of such a service has any idea of the stress caused and it’s knock on medical impact, management scratch their heads and publicly complain about funding shortfalls!

Hence a real conundrum is emerging as to the Humanist (i.e. social context) within which personal health budgets function. Local authorities and the agencies they commission are being told to take responsibility for the delivery of an ever increasing range of services while their budgets are significantly squeezed. As a result agencies focus evermore on the behavioural elements of their roles while the humanist perspective is being sidelined. In terms of organisational psychology this results in well documented behaviour: employees focus more and more on their specific administrative role as defined by their respective departments. This role is Behavioural in nature, focusing on ticking boxes that denote the adherence to agency/departmental processes, procedures and responsibilities. Furthermore, employees rely on the tick box process to protect themselves when things go wrong. This means we hear the use of stock phrases such as, “That’s not our responsibility” or “…but I did my job”.

As a practical example consider the sheltered accommodation schemes run by local authorities across the country. These developments are communal and extremely confined by design - a means of creating social interaction between residents. Quality social interaction is accepted as a default requirement for the promotion of wellbeing and social capital within any given community. Such quality interaction was ensured by the presence of a resident supervising warden: someone who knew all residents, held working social relations with residents and was vested with power from the local authority to resolve any conflicts that might arise between residents. In the name of ‘Austerity’ these resident wardens were withdrawn with instructions to distance themselves from residents when they do make a visit. In further homage to austerity, ‘communal/sheltered’ accommodation has been administratively redefined as ‘independent living’. Apart from data protection breaches, the outcome is an institutional free-for-all; defined by hatred, bullying and intimidation, threats of violence, booby traps, obstruction of access for wheelchair users, obstructing access to disabled parking bays and social isolation. Whole families join the fray as well. Local authority Housing, Antisocial Behaviour and Social Service departments deny any responsibility for dealing with these problems and pass them on to the local police. When the police do act it is with great reluctance. Overwhelmingly, all frontline personnel are crystal clear, “…we have better things to deal with”. Very little sense of nurture here then. Instead, such environments crush any sense of wellbeing, instigating depression and lack of motivation through the creeping imposition of institutionally enforced helplessness. At the same time government departments, local authorities and prime providers include “No Disrepute” clauses in their funding contracts, gagging any form of official comment. This type of organisational culture is the complete antithesis of the self management philosophy that critically underpins every personal health budget and raises an interesting question. Given that PHBs increase the level of independence and wellbeing for recipients, do we want a two tier system of PHBs to emerge? A system whereby those who live in self-contained accommodation achieve the maximum out of their PHB and those who live in ‘sheltered/communal housing’ are lucky to get any benefit from their PHB at all? Furthermore, is it reasonable, even in these early development stages, that if a PHB recipient moves house they run the risk of losing said PHB? Such outcomes have the most severe impact within communities that often hold the least ‘psycho-social capital’, sustaining and/or promoting a variety of mental health issues concomitant to anti social issues.

The most incomprehensible and indeed frustrating element about such service outcomes is the seemingly total lack of awareness about the seed of the Equalities Act, namely the Social Model of Disability. The Social Model of Disability is predicated upon context; the context within which acts of discrimination occur. Context by definition is historical in nature. Isolating each and every incident of discriminatory anti social behaviour in the name of organisational expediency and fiscal efficiency dismisses out of hand the notion of context, leaving individuals who experience discrimination with no voice at all. Difficult to see how government policies and these outcomes essentially remain unchallenged. Not surprising given the Legal Aid system has been all but totally demolished. Ultimately driven by government policies these systemic longterm patterns of service delivery and outcomes are a classic root cause of radicalisation among those who feel muted and see no way out of their predicament. Raise this with statutory local service delivery organisations and one will be greeted with dismissal and roaring laughter. Ironically one cannot help but wonder whose ears are being deafened by such laughter.

Social care is healthcare, especially when people are sent home to recuperate under medical supervision. When will government and local authority management in general wake up to this? Is it too much to ask that all social care workers and housing authority officials be trained up in the skills that will allow them to rise to this necessary level of humanist awareness. Maintenance crews, builders, managers and constabularies that interact with the social housing sector are just as much involved in the delivery of healthcare as the nursing staff, maintenance personnel and management in any hospital.

Hopefully the free download of Manage-Able’s Self-Determination programme might be a small contribution to improving circumstances. Ultimately, I’m reminded of Einstein. “Not everything that counts can be counted, and not everything that can be counted counts”.