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Personal budgets will challenge plans for accountable care organisations

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Have you heard of Madame Auguste Deter? She was admitted to hospital in 1901 with a “helpless expression” and difficulty remembering her husband’s name.

An autopsy when she died five years later started a chain that lead to two proteins being identified as causing symptoms of poor mental health.  We have forgotten Madame Deter but remembered her doctor, Aloysius Alzheimer.

It’s just as easy to forget the individual patient when we are thinking grand thoughts about integrating health and social care.  If I were awarding research grants, I would like some clever econometrician to explore the correlation between how well scarce resources are allocated and the frequency of someone of importance meeting patients affected by their decisions.

This is why cases studies of an individual patient’s experiences will be remembered long after the conceptual diagrams in the powerpoint presentation have been forgotten.  This is why the democratic process is enriched by an elected member’s mission to change a policy because of a single experience that a resident had.

For many integrationistas, the mission of bringing providers of health and social care together is the same as putting the patient at the heart of the system.  This can be true, but it can also be the system speaking to itself.  The inexorable movement to provide more personal budgets for health and social care is where integration will take place most fully.

This is a sour cherry in the trifle of capitated budgets and accountable care organisations.  The actuary’s final honed predictions of population demand will not translate as well into a single programme budget, if patients and carers hold a personal budget for both their health and social care.  Patient choice becomes not just a right in the NHS constitution but an informed economic decision in a market place.

This will challenge the integrated organisation to be a broker as well as a provider.  To protect equality of access, the integrated provision will have to develop markets and nurture skilled entrepreneurs, social and private, to allow these choices to be real ones.  Perhaps the real integration is between the skills for economic growth and health in devolved settings.

Rich Hornby, chief financial officer, Coastal West Sussex CCG

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