Document Version / FINAL V1
Issue Date / 4 May 2017
Prepared by / Tina Brown
Review date / June 2018

JOINT DERBYSHIRE CCG’s PERSONAL HEALTH BUDGET POLICY

This document is available to professionals and the general public. It gives a detailed background of how Personal Health Budgets play a part of the Person Centred Care approach we are developing.

  1. BACKGROUND AND CONTEXT

Personal health budgets play a part of the wider personalisation agenda, where there is a social move towards personalisation, meaning people taking greater choice and control over their own health needs. Personal health budgets are seen as a tool to drive this culture change forward.

The Government has publicly committed to supporting PHBs, and NHS England’s forward view holds the expectation that patients will hold more control over the care they receive. CCGs have a responsibility to deliver PHBs as part of their health and wellbeing strategy, and to ensure the information regarding their local offer is made available in a clear format to those involved with caring for patients who will meet the criteria for a PHB.

Personalisation is central to successfully supporting people with long term health conditions to live healthy and fulfilling lives in their community, reducing their demand on acute and other health and social care services. A personal care support plan, and understanding what is important to an individual to support them to improve their quality of life and wellbeing, is a key element of the integrated approach of case management and multi-disciplinary teams.

A personal health budget allows someone to take complete control and to buy services outside of the traditional services that the NHS provides to enable them to achieve thegoals from their plan. Traditional service delivery does not always fit with the way a person lives their life, this flexibility can support the person to start making their own decisions, live independently, move away from institutional care, in some cases return to work and significantly improve their and their carer, friends and family’s quality of life and wellbeing.

  1. NHS KEY PRINCIPLES

The Department of Health has advised of six key principles to be applied to personal health budgets in order to give people control, keep them safe and protect NHS resources.

  • Upholding NHS values. The personalised approach must support the principles of the NHS as a comprehensive service, free at the point of use, as set out in the NHS Constitution. No one will ever be denied essential treatment as a result of having a personal health budget. Having a personal health budget does not entitle someone to more or more expensive – services or to preferential access to NHS services. There should be good and appropriate use of NHS resources.
  • Quality – safety, effectiveness and experience should be central. The wellbeing of the individual is paramount. Ensuring an agreed support plan that is safe and that will meet agreed health and wellbeing outcomes, outlines risk and mitigation plans and includes arrangements for clinical oversight.
  • Tackling inequalities and protecting equality. Local organisations need to take care that their implementation does not exacerbate inequalities or endanger equality. The decision to set up a budget for an individual must be based on their needs, irrespective of race, age, gender, disability, sexual orientation or beliefs.
  • Personal health budgets are purely voluntary. No one will ever be forced to take more control than they want.
  • Making decisions as close to the individual as possible. Appropriate support should be available to help all those who might benefit from a more personal approach, particularly those least well served by existing services or access and who might benefit from managing a budget.
  • Partnership. Working in partnership withindividuals, family, carers and professionals to plan, develop and procure the services and support that are appropriate for them. It also means CCGs, local authorities and healthcare providers working together to use personal budgets so that health and social care work together as effectively as possible

NHS England has identified 5 essential characteristics of a PHB

The person or representative must:

  • Be able to choose the health outcomes they want to achieve.
  • Know how much money they have for their healthcare and support.
  • Be enabled to create their own care plan, with support if they want it.
  • Be able to choose how their budget is held and managed.
  • Be able to spend the money in ways and at times that make sense to them, as agreed in their support plan.
  1. PURPOSE

The purpose of this policy is to:

  • Support health professionals in taking a consistent, safe and effective process to develop, implement and review PHBs across the CCGs,for those patients with a long term condition.
  • Provide a procedural guidance enveloping best practice from the evaluations of the pilot sites for PHBs.
  1. ELIGIBILITY

Principle: a personal health budget embodies a new approach to care which acknowledges the individual as the expert on how their condition affects them and enables them to have choice and control over their care package. A personal health budget should be available to anyone eligible who may benefit from this additional flexibility and control.

The eligibility for a personal health budget is that:

  • The individual is diagnosed with one or more long term health condition(s)or be at end of life
  • The individual is registered with a Derbyshire CCG GP
  • The individual is in receipt of traditional healthcare services in relation to their condition
  • The individual is able to evidence engagement with NHS healthcare
  • The individual has stated health outcomes that are considered achievable and will not cause any harm
  • The individual has a health care professional to endorse their application

Personal health budgets will be available to all age-groups, those at end of life and in line with the nine protected characteristics as defined in the Equality Act 2010.

  1. CAPACITY

Principle: in line with the Mental Capacity Act, personal health budget individuals will be empowered to make decisions for themselves wherever possible and where they lack capacity over certain decisions, this will be managed by a flexible approach that places the individual at the heart of the decision making process.

Guidance:

a)Where the individual does not have capacity to make a decision as identified by a Mental Capacity Assessment, professionals can work with a 'suitable person' or ‘representative’. For the sake of this document they shall be referred to as the suitable person.

b)A suitable person receives a direct payment on behalf of a service user who lacks capacity. The suitable person takes on the full legal responsibilities of having the direct payment and of being an employer. They can identify someone else to manage the direct payment money e.g.: a family member, friend or direct payment support service. However, the full legal responsibilities of the direct payment including being an employer remain with the ‘suitable person’. The suitable person will be required to sign the direct payment agreement.

c)The suitable person must be:

  1. a family member or friend involved in the person’s unpaid care and support.
  2. someone who has been given lasting power of attorney by the person needing services at some point before they lost mental capacity
  3. someone who has been appointed a deputy for the person needing services by the Court of Protection under section 16 of the Mental Capacity Act 2005.

d)It is possible for the assessment workers and suitable person (as listed above) to agree for someone else to act as the suitable person if it is in the best interest of the individual.

e)If the suitable person is not a close family member, someone living in the same household or a friend involved in their care then the Clinical Commissioning Group will advise them to apply for a DBS check. Where there is a child under 18 years living in the household then a DBS check is mandatory.

f)A suitable person should not be agreed if:

  1. There are protection of vulnerable adults and safeguarding issues that compromise this role.
  2. There is a conflict of interest, where a situation has the potential to undermine the impartiality of a person because of the possibility of a clash between the person’s self-interest, professional interest or public interest. For example where a person is providing support to the service user for which they will be paid but also acts or plans to act as a suitable person for the direct payment. In this situation, the advice would be that the person could not do both, to act in both capacities would effectively be acting as employer (suitable person) and employee.
  1. The Clinical Commissioning Group has any other significant concerns.

If the suitable person does not meet the essential criteria then the Clinical Commissioning Group has a right to refuse a direct payment but an alternative personal health budget management option can be offered. The final decision must be made by the Personal Health Budgets Approval Panel.

g)Either the individual or their suitable person can request for the personal health budget to be paid to a nominee or a third party organisation.

  1. SUPPORT PLANNING

Principle: a good support plan is at the heart of a personal health budget; it involves active listening, focusing on the outcomes the individual wants to achieve, having a ‘good conversation’ and having hope that things can be better.

To ensure the individual’s needs are fully met, a personalised support plan will be completed. This forms part of the application pack (see Appendix 1). A support plan is a record of the discussions and agreements between the individual and their NHS healthcare team, (and where appropriate social care team) outlining the commissioned care package required.

The support plan should include:

  • Their health (and where appropriate social care) needs
  • The health and wellbeing outcomes that they want to achieve
  • How they intend to use their budget to do this with detailed costs
  • How any risks will be managed
  • The name of the healthcare professional responsible for managing the support plan

The support plan is an evolving document with changing needs reflected when appropriate. The support plan can take any format that the person finds easier to use.

The support plan must contain details of any proportionate means of mitigating risks, and this should be informed by a discussion of the significant potential risks and their consequences. The CCG must agree with the individual the procedure for managing risk and must include this in the support plan

Individuals must be asked to sign a consent form to share information between relevant organisations during the personal health budgets process.

  1. MANAGING RISK

Principle: Throughpersonal health budgetswe should support individuals to make fully informed choices about the risks they may be taking, modelling a risk enabling rather than risk adverse approach.

Guidance:

a)In personal health budgets there is potential risk to:

  1. the individual's health and wellbeing: clinical risk
  2. the individual's safety (or those around them): safeguarding risk
  3. those that are caring for the individual: employment risk
  4. the individual's budget: financial risk
  5. the individual’s personal information: information governance risk
  6. the Clinical Commissioning Group: corporate risk

b)Where risk incidents occur, (e.g: safeguarding, financial abuse etc) normal procedure should be followed for personal health budget holders.

(Details of Safeguarding for Adults and Children polices can be found on the Clinical Commissioning Group’s website ; )

c)The support plan must acknowledge any potential risks and explain the decisions made to mitigate these risks.

d)Risk will be mitigated by the appropriate Derbyshire Clinical Commissioning Group through ensuring the local NHS team, alongside Local Authority colleagues, carry out regular case management and reviews of personal health budget individuals.

  1. EMPLOYING PERSONAL ASSISTANTS

Principle: A personal health budget can be used to employ personal assistants (PAs); this often allows for the greatest flexibility, choice and control over a care packageand also comes with greater responsibilities.

A direct payment cannot usually be used to employ someone that lives in the same household as the direct payment recipient. This is to safeguard the individual from risks around abuse. However, it will be at the sole discretion of the responsible CCG. See appendix 2 for exceptional circumstance referral form.

Guidance:

a)Where a PA is employed through a personal health budget, the individual (or third party organisation) becomes the employer and must comply with all the legal obligations of an employer.

b)Individuals are strongly advised to:

  1. carry out a DBS check on their employees
  2. receive confirmation of professional registration, where appropriate
  3. request two references for any potential employee

c)It should be noted that employers cannot force adults to work more than 48 hours a week on average (normally averaged over 17 weeks) according to the EU Working Time Directive. There are some exceptions to this which can be found at

d)The support plan should cover all costs around PAs including National Insurance, training, insurance, emergency cover, payroll, redundancy costs, pension, statutory sick pay etc. Not all of these costs are compulsory but it is recommended that they are clarified and written into a contract with the PAs.

e)Individuals must have sufficient Employer’s Liability Insurance.

f)Individuals cannot employ someone who lives in the same house as them other than where it is necessary in order to satisfactorily meet their needs.

g)The tasks PAs are permitted to carry out must be carefully considered and risk assessed within the support planning process; there must be appropriate training and assessment of competence. How this will be done should also be detailed in the support plan.
The employer is responsible for ensuring PAs are trained appropriately to carry out the tasks required and the Clinical Commissioning Group will ensure this training is suitable and available.

h)When a registered practitioner (e.g.: district nurse, physiotherapist etc.) trains a PA in a clinical task, the practitioner remains accountable for the decision to delegate this task to the PA but not for the standard of work that the PA carries out after training. The PA is accountable for both taking on this task and the standard to which it is carried out.

i)It is important that the PAs are supported in their role and are provided with line management, continuing professional development opportunities etc. Unison provides a Personal Assistants Support Network which could also be utilised.

j)PAs do not have to have indemnity cover.

To ensure the CCGs have a clear audit-able trail of delegated health care tasks there is a form at appendix 3 to support clinicians in the correct decision and input that will be required to monitor the task safely.

  1. CHOOSING SERVICE PROVIDERS

Principle: the flexibility of a personal health budget means the individual can purchase services from any provider. It is the responsibility of the Derbyshire Clinical Commissioning Group to ensure that theindividual is provided with good sources of information during support planning and understands the risks involved with different choices.

Guidance:

a)Providers of services must:

  1. be appropriately trained in any healthcare tasks they are employed to undertake
  2. have appropriate indemnity cover which is proportionate to the risks involved in providing the service.
  3. comply with any obligation that they have to be registered as a member of a profession regulated by a body mentioned in section 25(3) of the 2002 Act (the Professional Standards Authority for Health and Social Care). An individual can override this as long as it is clearly discussed within the risk assessment of the support plan and agreed with the Clinical Commissioning Group.

b)It should be clear that the person receiving the direct payment is contracting directly with the provider or individual employee and therefore NHS procurement rules do not apply.

c)To ensure continuity of service provision, it is recommended other service providers should be considered, and contacted if chosen provider is not available.

  1. MANAGING THE MONEY

Principle: Individuals should always have the choice to receive their personal health budget as a direct payment and be offered the support necessary to manage this. Direct Payments offer more choice and control as well as increased responsibility. There are some situations where a direct payment would be inappropriate.

The NHS has identified four different ways of managing a PHB.

ANotional budget

This budget is where the funding is held by the CCG and used to commission services. This type of budget could be an option for people who want more choice and control over their healthcare, but who do not feel able or willing to manage a budget. This may also be more appropriate when the individual’s needs are expected to change over a relatively short period of time. The CCG will commission the service and manage the funding, however the individual understands the amount of funding available to them and is able to contribute to decisions about how the budget is used as described in their support plan.