Personal Health Budgets
for Continuing Healthcare
Policy & Practice Guidance
First Edition - Version 0.8
October 2014
1
Contents
1.
2
Purpose & Introduction .................................................................................................................. 4
1.1
Consultation ............................................................................................................................ 4
1.2
Ratification .............................................................................................................................. 4
1.3
Scope ....................................................................................................................................... 4
1.4
Links to other policies ............................................................................................................. 4
Background ..................................................................................................................................... 5
2.1
What is a personal health budget ........................................................................................... 5
2.2
Underpinning legislation ......................................................................................................... 6
3
Value for money.............................................................................................................................. 7
4
Policy principles .............................................................................................................................. 7
4.1
Who can have a personal health budget? .............................................................................. 7
4.2
Who can receive a direct payment? ....................................................................................... 8
4.3
Exclusions for personal heath budgets ................................................................................... 9
4.4
Direct health payments and personal health budgets............................................................ 9
4.5
Who cannot receive a direct payment? .................................................................................. 9
5.0 Capacity and Consent ................................................................................................................ 11
5.1
Nominees .............................................................................................................................. 11
5.2 Personal Health Budgets and direct health payments for patients that lack capacity ............. 12
5.3
Direct health payments for people who lack capacity and appointing a representative ..... 12
5.5 Imposing conditions on a patients personal health budget / direct health payment .............. 14
5.6 Assistance to manage a direct payment – Supported Managed Accounts .............................. 14
6.0 How do Personal Health Budgets Work? .................................................................................... 15
6.1
Approvals .............................................................................................................................. 15
6.2 Appeals ....................................................................................................................................... 15
6.3
Reviewing personal health budgets, review of individual’s health needs. .......................... 16
6.4
Financial monitoring, financial review of how the direct health payment is being used ..... 16
7.0
How can Personal Health Budgets be used? ........................................................................ 17
7.1
What can and can’t be bought with personal health budgets ............................................. 17
8.0 Employing a family member or person living in in the same household ........................................ 18
9.0 Stopping or reclaiming personal health budgets and direct health payments .............................. 19
10.0 Using a direct health payment to employ staff or buy services ................................................... 19
2
10.1
Safeguarding and employment ............................................................................................. 19
10.2
Indemnity .............................................................................................................................. 20
10.3
Registration and regulated activities .................................................................................... 22
Appendix A ............................................................................................................................................ 24
Related concepts............................................................................................................................... 24
Coproduction .................................................................................................................................... 26
National policy and pilot programme ............................................................................................... 26
Appendix B ............................................................................................................................................ 27
Supporting people to make their own decisions .............................................................................. 27
The best interests principle............................................................................................................... 28
How to determine what is in a person’s ‘best interest’? .................................................................. 28
Making decisions about the treatment and care of patients who lack ............................................ 29
capacity ............................................................................................................................................. 29
Fluctuating Capacity.......................................................................................................................... 30
Appendix C ............................................................................................................................................ 31
How do personal health budgets work? ........................................................................................... 31
The end to end process for personal health budgets ....................................................................... 31
a.
Assessment / Review ................................................................................................................ 31
b.
Right to have a personal health budget and direct health payment ........................................ 32
c.
Budget Setting........................................................................................................................... 32
d)Personal health budget care / support planning ........................................................................... 33
Appendix D – Adults PHB Pathway ....................................................................................................... 34
Appendix E - Personal Health Budget Pathway (Children) ................................................................... 38
Appendix F - Referral and risk identification and mitigation form ....................................................... 39
Appendix G – PHB Agreement and Consent Form............................................................................ 48
PERSONAL HEALTH BUDGET AGREEMENT .................................................................... 48
3
1. Purpose & Introduction
This document sets out the policy and practice guidance developed to deliver
Personal Health Budgets and direct health payments for Continuing Healthcare for
adults and children. As personal health budgets are new and the national policy is
still developing, East and North Hertfordshire CCG will review this Policy when new
guidance, regulations or national policy are published.
1.1
Consultation
This Policy was developed in consultation with:
 East and North Hertfordshire CCG
 Personal health budgets peer development group
 Personal health budgets steering group
1.2
Ratification
This policy has been ratified by XXXXXX of East and North Hertfordshire CCG.
1.3
Scope
This policy applies to all employees of East and North Hertfordshire CCG and all
personal health budgets administered by East and North Hertfordshire CCG
1.4
Links to other policies
Personal health budgets are about using NHS money differently, personal health
budgets and personalisation fit with a number of existing policy agendas, including
choice, shared decision-making and self-care.
At a local level, personal health budgets fit with a number of existing policies in East
and North Hertfordshire CCG. This policy needs to be read in conjunction with the
documents listed below:





Policy for the provision of continuing healthcare to adults. Version 1.
Published August 2011.
Bedfordshire and Hertfordshire priorities forum final and interim guidance –
via http://www.enhertsccg.nhs.uk/final-and-interim-guidance
Individual funding requests policy for East and North Hertfordshire Clinical
Commissioning Group
East and North Hertfordshire CCG Decision Making Framework for Personal
Health Budgets
National Framework for NHS Continuing Health Care
4
2 Background
Following the evaluation of the national pilot programme for personal health budgets,
in November 2012, the Government announced that anyone eligible for NHS
continuing healthcare (CHC) will have the ‘right to ask’ for personal health budgets,
including direct health payments from 1st April 2014.
From 1st October 2014, this became a ‘right to have’ a personal health budget.
The Government also re-confirmed a commitment in the NHS mandate that anyone
with a long term condition, who can benefit from one, should have the right to ask for
a personal health budget by April 2015.
2.1
What is a personal health budget
According to NHS England, a personal health budget is an amount of money to
support a person’s individual health care and wellbeing needs, planned and agreed
between the individual and their local NHS team.
There are five essential characteristics of a personal health budget.
The person with the personal health budget (or their representative) must:
1. be able to choose the health outcomes they want to achieve
2. know how much money they have for their health care and support
3. be enabled to create their own care plan, with support if they want it
4. be able to choose how their budget is held and managed
5. be able to spend the money in ways and at times that make sense to them, as
agreed in their plan.
Personal health budgets work in the following ways, or a combination of them:

Notional budget – where an individual understands the amount of funding
available to them and decides how the budget is used. The CCG still
commissions services and manages contracts . Notional budgets could be an
option for individuals who want more choice and control over their healthcare but
who do not feel able or willing to manage a budget.

Real budget managed by a third party organisation – where the individual
knows how much funding is available to them but a third party organisation holds
the funding. The third party organisation helps the individual decide what they
need and then buys the services the individual has chosen.
5

Direct healthcare payments for people with capacity – where the individual
receives the funding that is available to them as a direct health payment for them
to manage (with or without assistance). The individual can elect to receive and
manage the payment, buying and managing the service themselves or decide for
it to be received and managed by a person of their choosing (a nominee). If the
individual chooses a nominee that nominee becomes responsible for managing
the payment, buying and managing the service and is responsible for the money
and all aspects of the direct payment and has to show what the money has been
spent on.

Direct healthcare payments for people who lack capacity – where the
individual lacks capacity an ‘authorised representative’ (agreed by the CCG)
receives the funding that is available to the individual as a direct health payment.
The authorised representative is responsible for managing the payment, buying
and managing the service and is responsible for the money, and has to show
what the money has been spent on. The ‘authorised representative’ must involve
the individual and act in their best interests.
In the case of children, direct health payments can be received by their parents
or those with parental responsibility for that child
2.2
Underpinning legislation
Notional budgets and real budgets managed by a third party organisation could be
provided under existing NHS legislation, prior to the pilot programme. Direct health
payments required new legislation. The 2010 Health Act allowed primary care trusts
(as they were then) to legally make direct payments using NHS money. The Act
allows for the Secretary of State to extend direct health payments to other
commissioning organisations.
Since the end of the pilot, direct health payments powers have been extended to all
clinical commissioning groups in England. The National Health Service (Direct
Payments) Regulations 20131 set out how direct health payments should be
administered and what they can be spent on. The regulations are similar to the
regulations and guidance for social care direct payments. It’s important to remember
that underpinning NHS principles remain in place, i.e. personal health budgets must
meet all assessed care needs and be free at the point of use. Guidance on the new
direct payments for healthcare regulations was published in March 20142.
1
National Health Service (Direct Payments) Regulations 2013 and National Health Service (Direct
Payments) (Amendment) 2013
2
Guidance on Direct Payments for Healthcare: Understanding the Regulations, DH, March 2014
http://www.personalhealthbudgets.england.nhs.uk/_library/Resources/Personalhealthbudgets/2014/Guidanc
e_on_Direct_Payments_for_Healthcare_Understanding_the_Regulations_March_2014.pdf
6
3 Value for money
East and North Hertfordshire CCG will ensure that personal health budgets
represent value for money for patients and the CCG. This will be done though the
way in which personal health budgets are set up, through robust support planning
and through effective monitoring of direct health payments.
The national pilot programme for personal health budgets showed that, where
implemented well, giving personal health budgets (with a comprehensive support
plan, created with the patient) led to fewer hospital admissions and visits to the GP.
East and North Hertfordshire CCG will deliver personal health budgets in line with
good practice and underpinned by the principles in the East and North Hertfordshire
CCG Decision Making Framework for Personal Health Budgets
In East and North Hertfordshire CCG everyone who is given a personal heath budget
will go through a support planning process, which leads to a person-centred care /
support plan. The care / support plan will be created jointly with patients and families
and must be signed off by the care co-ordinators who manage continuing healthcare
patients, this process includes a peer review and additional sign off at a risk
enablement panel. As numbers increase for personal health budgets, it is likely that
the majority of cases will be signed off as a desk top sign off and that only high risk
or high cost cases will be presented to a risk enablement panel.
When taking up a personal health budget, the patient or their nominee must sign a
‘personal health budget agreement’, which explains the responsibilities of personal
health budget recipients or their representative and sets out that the personal health
budget will be spent as agreed in the support plan and if receiving the personal
health budget as a direct health payment, in accordance with the direct payments for
healthcare regulations.
As well as general information about personal health budgets, patients and families
will be provided with information specifically about direct health payments, including
their responsibilities around monitoring.
4 Policy principles
East and North Hertfordshire CCG is introducing personal health budgets in line with
national policy. Therefore policy principles follow national policy and regulations
where appropriate.
4.1
Who can have a personal health budget?
In November 2012, following the publication of the final evaluation report from the
national personal health budgets pilot programme, the Government announced that
anyone who is eligible for NHS continuing healthcare will have the ‘right to ask’ for a
personal health budget by April 2014. The NHS Mandate also says that by April
7
2015, anyone who has a long term condition and could benefit from a personal
health budget will have the option to have one.
From April 2014, individuals who have the right to request a personal health budget
and as of October 2014 individuals who have a right to have a personal health
budget include
o Existing CHC recipients at review;
o Fast track patients at point of eligibility being determined
o Individuals transferring from Adult Social Care to Continuing healthcare
funding.
4.2
Who can receive a direct payment?
A direct health payment can be made to, or in respect of, anyone who is eligible for
NHS Continuing healthcare [under the National Health Service Act 2006] and any
other enactment relevant to a CCG or the Board. This includes aftercare services
under section117 of the Mental Health Act 1983, where they are:

a person aged 16 or over, who has the capacity to consent to receiving a
direct health payment and consents to receive one;

a child under 16 where they have a representative who consents to the
making of a direct health payment;

a person aged 16 or over who does not have the capacity to consent but has
a representative who consents to the making of a direct health payment;
and where:

a direct health payment is appropriate for that individual with regard to any
particular condition they may have and the impact of that condition on their
life;

a direct health payment represents value for money and, where applicable,
any additional cost is outweighed by the benefits to the individual and is in line
with the CCG’s Personal Health Budget Decision Making Framework

the person is not subject to certain criminal justice orders for alcohol or drug
misuse (see Section 4.5) or has been convicted of financial related crimes.
People aged 16 or over who have capacity, representatives of people aged 16 or
over who lack capacity, and representatives of children can request that the direct
payment is received and managed by a ‘nominee’ (see section 5).
8
4.3
Exclusions for personal heath budgets
There are some people to whom the right to have a Personal Health Budget does
not apply from October 2014 in East and North Hertfordshire CCG.
This includes:
o those newly eligible for CHC and/or being discharged from hospital, the offer
of a Personal Health Budget will be made at review, unless they already have
a direct payment from social care or it is felt that a personal health budget
would be beneficial to the patient at an earlier opportunity.
4.4
Direct health payments and personal health budgets
Direct health payments for Continuing Healthcare are also part of the personal health
budget offer and a right for the patient. As such individuals have a right to request
that their Personal Health Budget is delivered as a direct health payment.
4.5
Who cannot receive a direct payment?
There are some people to whom the duty to make direct health payments does not
apply. This includes those:
a. subject to a drug rehabilitation requirement, as defined by section 209 of the
Criminal Justice Act 2003 (drug rehabilitation requirement), imposed by a
community order within the meaning of section 177 (community orders) of that
Act, or by a suspended sentence of imprisonment within the meaning of
section 189 of that Act (suspended sentences of imprisonment);
b. subject to an alcohol treatment requirement as defined by section 212 of the
Criminal Justice Act 2003 (alcohol treatment requirement), imposed by a
community order, within the meaning of section 177 of that Act, or by a
suspended sentence of imprisonment, within the meaning of section 189 of
that Act;
c. released on licence under Part 2 of the Criminal Justice Act 1991 (early
release of prisoners), Chapter 6 of Part 12 of the Criminal Justice Act 2003
(release on licence) or Chapter 2 of the Crime (Sentences) Act 1997 (life
sentences) subject to a non-standard licence condition requiring the offender
to undertake offending behaviour work to address drug or alcohol related
behaviour;
d. required to submit to treatment for their drug or alcohol dependency by virtue
of a community rehabilitation order within the meaning of section 41 of the
Powers of Criminal Courts (Sentencing) Act 2000 (community rehabilitation
orders) or a community punishment and rehabilitation order within the
meaning of section 51 of that Act (community punishment and rehabilitation
orders)
9
e. subject to a drug treatment and testing order imposed under section 52 of the
Powers of Criminal Courts (Sentencing) Act 2000 (drug treatment and testing
orders)
f. subject to a youth rehabilitation order imposed in accordance with paragraph
22 (drug treatment requirement) of Schedule 1 to the Criminal Justice and
Immigration Act 2008 (“the 2008 Act”) which requires the person to submit to
treatment pursuant to a drug treatment requirement;
g. subject to a youth rehabilitation order imposed in accordance with paragraph
23 of Schedule 1 to the 2008 Act (drug testing requirement) which includes a
drug testing requirement;
h. subject to a youth rehabilitation order imposed in accordance with paragraph
24 of Schedule 1 to the 2008 Act (intoxicating substance treatment
requirement) which requires the person to submit to treatment pursuant to an
intoxicating substance treatment requirement
i.
required to submit to treatment for their drug or alcohol dependency by virtue
of a requirement of a probation order within the meaning of sections 228 to
230 of the Criminal Procedure (Scotland) Act 1995 (probation orders) or
subject to a drug treatment and testing order within the meaning of section
234B of that Act (drug treatment and testing order)
released on licence under section 22 (release on licence of persons serving
determinate sentences) or section 26 of the Prisons (Scotland) Act 1989 release on
licence of persons sentenced to imprisonment for life, etc.)34 or under section 1
(release of short-term, long term and life prisoners) or section 1AA of the Prisoners
and Criminal Proceedings (Scotland) Act 1993 (release of certain sexual offenders)
and subject to a condition that they submit to In addition to this East and North
Hertfordshire CCGs will refuse to make a direct payment if:

There is significant doubt around an individual’s ability to manage a direct
payment

There is a high likelihood of direct payment being abused demonstrated for
instance through previous criminal convictions
Such a view to refusal, both for the individual or a representative of the individual,
may be formed from information gained from anyone known to be involved with the
individual, including health professionals, social care professionals, the individual’s
family and close friends, and carers for the individual.
In all cases of refusal the person and their representative will be informed in writing
of the refusal and the grounds by which the request is declined.
10
If a direct health payment is refused other options to improve the choice and control
of the Continuing healthcare package for the individual will be explored and
facilitated where possible.
Direct payments can only be made where appropriate consent has been given by:

a person aged 16 or over who has the capacity to consent to the making of
direct payments to them;

the representative (see section 5.1) of a person aged 16 or over who lacks the
relevant the capacity to consent3;
the representative of a child under 16.

5.0 Capacity and Consent
5.1
Nominees
If a person aged 16 or over who is receiving continuing healthcare has
capacity, but does not wish (for whatever reason) to receive direct health
payments themselves, they may nominate someone else to receive them on
their behalf. A nominee is responsible for managing the direct payment on behalf of
the person receiving care. The nominee is responsible for fulfilling all the
responsibilities of someone receiving direct health payments, as described below
They are responsible for fulfilling all the responsibilities of someone receiving direct
payments. These include:
a. acting as the principal person for all contracts and agreements with care
providers, employees, etc;
b. using the direct payment in line with the agreed care plan; and
c. complying with any other requirement that would normally be undertaken
by the person receiving care as set out in this guidance (e.g. review,
providing financial information).
3
In this document, when we refer to people who lack capacity we mean people who lack capacity to consent
to the making of a direct health payment to them.
11
A representative (for a person aged 16 or over who does not have capacity or
for a child) (see section 5.2 – 5.10) may also choose to nominate someone (a
nominee) to hold and manage the direct health payment on their behalf.
It is important to understand that the role of nominee for direct payments for
healthcare is different from the role of nominee for direct payments for social
care.
For social care direct payments, a nominee does not have to take on all the
responsibilities of someone receiving direct payments, but can simply carry
out certain functions such as receiving or managing direct payments on behalf
of the person receiving them. In direct health payments for healthcare,
however, the nominee is responsible for fulfilling all the responsibilities of
someone receiving direct health payments
5.2 Personal Health Budgets and direct health payments for patients
that lack capacity
Personal health budgets should be made available to all eligible patients regardless
of whether they are deemed to have capacity or not.
People who lack the capacity to consent to and manage personal health budgets can
still receive one including a direct health payment although a ‘representative’ will
need to be appointed by East and North Hertfordshire CCG (subject to the
regulations). The benefits and risks in relation to having a personal health budget
and a direct health payment (if applicable) will need to be explored. The benefits are
likely to be similar for people with and without capacity. The risks are likely to be
different and a risk assessment is required. See appendix B In line with East and
North Hertfordshire CCGs Mental Capacity Guidance, and at all stages of the
personal health budget processes, the ability for a person to consent is assumed
unless proven to be otherwise.
5.3 Direct health payments for people who lack capacity and
appointing a representative
If an eligible person lacks the mental capacity to consent to and manage a direct
health payment themselves, a representative may be appointed by the CCG. The
representative must consent to receive and manage the direct health payment on the
person’s behalf. Direct health payment regulations permit CCGs to appoint someone
to act as a ‘representative’ on the individual’s behalf. In some cases, it may be
appropriate to do so.
This should occur if the individual receiving care would benefit from a Personal
Health Budget / direct health payment, but does not have capacity to agree to and /
12
or manage one. An appointed ‘representative’ could be anyone deemed suitable by
the CCG, and who would accept the role. The representative can be:

a friend, carer or family member

a deputy appointed by the Court of Protection

an attorney with health and welfare or finance decision-making powers
created by a lasting power of attorney
The choice of the ‘representative’ must satisfy the best interests requirements of the
Mental Capacity Act. This includes seeking the views of the eligible person about
who they would want to manage their direct payment.
The decision making process around who the ‘representative’ is must be
documented and discussed as part of the care / support plan, when the plan is
agreed in principle and at the risk enablement panel.
5.4
Direct Health Payments and Nominees
A ‘representative’ or ‘individual with capacity’ can appoint a nominee, the nominee
role includes taking on all of the contractual relationships involved in receiving and
managing a direct health payment on behalf of the ‘individual with capacity’ or a
‘representative’.
The CCG will expect the nominee to be responsible for managing the payment,
buying and managing the service and the nominee is responsible for the money, and
has to show what the money has been spent on. The ‘nominee’ must consult with
the individual and the appointed representative (for individuals without capacity)
before making decisions on their behalf and involve the individual and act in their
best interests.
Where a ‘nominee’ is appointed and is therefore responsible for managing the
Personal Health Budget / and direct health payment on behalf of the individual or the
appointed representative (for individuals without capacity) they must:





act on behalf of the person, e.g. to help develop a Personal Health Budget
care / support plan(s) and to hold the direct payment;
act in the best interests of the individual when securing the provision of
services;
be the principal person for all contracts and agreements, e.g. as an employer;
use the Personal Health Budget and direct payment in line with the agreed
Personal Care / Support Plan
comply with any other requirement that would normally be undertaken by the
individual (e.g. review, providing information).
13
If the proposed nominee is not a close family member of the person (see Appendix
B), living in the same household as the person, or a friend involved in the person’s
care, then East and North Hertfordshire CCG require the nominee to apply for an
enhanced Disclosure and Barring Service (DBS) certificate (formerly a CRB check)
with a check of the adults’ barred list4 and consider the information before giving
their consent. If a proposed nominee in respect of a patient aged 18 or over is barred
the CCG will not give their consent. This is because the Safeguarding Vulnerable
Groups Act 2006 prohibits a barred person from engaging in the activities of
managing the person’s cash or paying the person’s bills5.
5.5 Imposing conditions on a patients personal health budget / direct
health payment
Conditions should only be imposed on a patient’s personal health budget / direct
health payment in exceptional circumstances. The reasons for the imposed
conditions should be documented clearly in the support plan.
5.6 Assistance to manage a direct payment – Supported Managed
Accounts
Where an individual chooses a direct health payment there are extra responsibilities
on the individual (or their appointed representative and/or nominee) necessary to
manage their care package legally and safely described within the Personal Health
Budget Agreement – see Appendix G
It is essential that either the individual or their representative has the ability to
consent to and manage their direct health payment and the dedicated bank account.
Where the individual or ‘representative’ feels assistance is required, where mental
capacity indicates, or where financial audit skills in managing finances are high risk
the individual or their representative can benefit from a Supported Managed
Account.
The CCG has a contract with a third party delivery partner to offer direct health
payment Managed Bank Accounts. who also supports individuals in activities such
as recruiting, employing staff, and payroll. This option for support is open to people
with Personal Health Budgets and direct health payments, along with a range of
other services.
Individuals, representatives and appointed nominees employing staff are strongly
recommended to utilise the information, advice, guidance and payroll and HR
facilities of the CCG’s delivery partner to ensure the legal responsibilities of being an
employer are satisfied. Should the individual, representative or nominee not wish to
accept this recommendation the request for a direct health payment may be refused
4
This is an enhanced DBS check including suitability information relating to vulnerable adults.
Such activities fall into “the provision of assistance in relation to general household matters to an adult who
is in need of it by reason of age, illness or disability”, which is a regulated activating relating to vulnerable
adults under Part 2 of Schedule 4 to the Safeguarding Vulnerable Groups Act 2006.
5
14
because requirements of employment law fall to the individual, their representative or
their nominee as the employer.
6.0 How do Personal Health Budgets Work?
6.1
Approvals
Personal health budget care / support plans are agreed in principle by the Care Coordinator. All personal health budget care / support plans are then reviewed by the
personal health budget risk enablement panel in accordance with the guidance, and
set out in a ‘terms of reference’ paper.
The panel will consist of the following members;
CHC Clinical Manager or CHC Commissioning Manager
CHC Clinical Verifier
Support planner from ecdp
Note taker
PHB Project Manager
Other professionals will be invited when appropriate for individual cases being
presented eg. Social worker, District Nurse
Patient or their representative will be invited to present their case
If the value of the plan is more than £1000 per week then this will also need financial
sign off from the Chief Finance Officer outside of panel.
6.2 Appeals
The patient shall be entitled to lodge an appeal against the decision of the Panel.
Any such appeal will be heard at the different steps as detailed below.
The first step in the appeals process: If a patient or their representative indicates
that he or she wishes to appeal, it is for them to set out the reasons for their appeal
in writing. The appeal will be reviewed by a director within East and North
Hertfordshire CCG. They will ensure that any decision taken by the panel was taken
in line with the decision making framework and will decide whether to uphold the
appeal or to dismiss it.
The second step within the appeals process is for the case to be reviewed by
another Clinical Commissioning Group Panel who are familiar with the East and
15
North Hertfordshire Decision Making Framework and the Personal Health Budget
processes. All members of the Panel should have had no prior involvement with the
case.
The External PHB Panel shall consider all the papers which were before the
originating Panel and any further material provided by the patient or those acting on
his or her behalf. It may request that the a member of the original panel attends and
make their case for refusing funding and the patient and/or their representatives shall
be entitled to put their case in writing for consideration by the External Panel.
In reaching its decision the External Panel should apply the same approach and
tests as set out in this policy.
The External Panel will be able to uphold the patient’s appeal and shall refer the
case for reconsideration by the originating Panel, in the event that the External Panel
considers that the originating Panel has:
 failed in a material way properly to consider the evidence presented to it (e.g.
by taking account of an immaterial fact or by failing to take account of a
material fact); and/or
 come to a decision that no reasonable Panel could have reached this decision
on the evidence before the Panel;
 Not followed due process or the approach outlined in this decision making
framework
The External Panel shall not have power to authorise the Personal Health Budget,
but shall have the right to make recommendations to the originating Panel and to
request the Chair to take urgent decisions.
All patients also have the option of putting in a formal complaint to ENHCCG
concerning the policy, the process or the decision.
The patient is also entitled to make a complaint to the Ombudsman and to request a
judicial review of their case.
6.3 Reviewing personal health budgets, review of individual’s
health needs.
For continuing healthcare patients, this review is carried out in line with the
continuing healthcare national service framework, i.e. three months after they
become eligible for continuing healthcare and annually thereafter.
6.4
Financial monitoring, financial review of how the direct health
payment is being used
This will vary from person to person but, at a minimum for those receiving a direct
health payment, this will be in line with the NHS direct payments regulations, i.e.
16
within three months of the first direct health payment being made and quarterly
thereafter. This ‘financial review’ is completed by the CCG’s delivery partner.
Where concerns are raised regarding how the personal health budget is being spent
The CCG’s delivery partner must inform East and North Hertfordshire CCG to alert
them to any concerns, as well as the Continuing healthcare lead
7.0
How can Personal Health Budgets be used?
In East and North Herts CCG, the regulations are applied to all forms of personal
health budgets as far as possible.
7.1
What can and can’t be bought with personal health budgets
The statutory instrument which provides the legal basis for the use of personal health
budgets covers direct health payments only. The NHS direct health payments
regulations set out what direct health payments (using NHS money) can be used for
and can’t be used for, and how they should be administered.
In East and North Hertfordshire CCG, the regulations are applied to all forms of
personal health budgets as far as possible. The NHS direct health payments
regulations came into force in August 2013 and the guidance on these regulations
were published in March 2014.
How a personal health budget will be used (however it is managed) must be set out
in a support plan. The support plan needs to show how an individual’s health needs
will be met and the personal health budget used to support their agreed health and
care outcomes.
There are some restrictions on how personal health budgets can be used. These are
not intended to reduce choice and control for individuals, but to ensure that personal
health budgets are used for maximum benefit and to ensure they are administered
consistently and fairly for everyone.
The NHS direct payments regulations state that direct payments cannot be used to
pay for the following6:
 alcohol
 tobacco
 gambling
 debt repayment (other than for a service specified in the support plan)
 core GP services
 planned surgical interventions
6
The National Health Service (Direct payments) Regulations, 2013, page 9
17




prescriptions
services provided through vaccination or immunisation programmes
any service provided under the NHS healthcheck or National Child
Measurement Programme
NHS dentist and opticians.
The regulations for direct payments will apply to all forms of personal health budgets.
In addition to the national regulations, East and North Hertfordshire CCGs personal
health budgets decision making framework may exclude the use of a personal health
budget to purchase any drug or non drug treatment;
 that would not routinely be provided through existing contracts for services
 that are considered low priority
 where there is no national guidance or where national guidance requires local
interpretation and implementation
 where an analysis of clinical efficacy or economic effectiveness of the
intervention thresholds is required
 where a decision is required as to whether it is a priority treatment in terms of
population health
This approach is in line with East and North Hertfordshire CCG’s approach taken for
any patient requesting a drug or non-drug treatment that fits within one of the defined
parameters described above7.
Where a patient requests any drug or non-drug treatment that’s falls within one of the
parameters above then the traditional IFR process will be followed. This process
can be found within the Individual Funding Requests Policy for East and North
Hertfordshire Clinical Commissioning Group.
Items that would be considered as normal living requirements eg fridge freezers etc
will also not be funded.
8.0 Employing a family member or person living in in the same
household
The NHS Direct Payments regulations state that direct health payments should not
be used to employ a close family member (see definition in Appendix B) or anyone
living in in the same household. This should only happen in exceptional
circumstances, i.e. when there is no other reasonable way of meeting someone’s
care needs or “to promote the welfare of a patient who is a child”. Any arrangement
of this nature must be formally agreed by the risk enablement panel and East and
North Hertfordshire CCG and recorded in writing and the suitability reviewed at least
every three months.
7
Bedfordshire and Hertfordshire Priorities Forum Updated Terms of Reference
18
9.0 Stopping or reclaiming personal health budgets and direct health
payments
In accordance with the NHS direct health payments regulations, the CCG will stop
making direct health payments where the patient no longer wants this. The CCG
may stop a personal health budget and direct health payments where the money is
being spent inappropriately (e.g.to buy something which is not specified in the
support plan), where there may have been theft or fraud or if the patient’s assessed
needs are not being met.
Where personal health budgets and direct health payments are stopped, East and
North Hertfordshire CCG will give notice to the patient or his / her appointed
representative in writing. There is no fixed notice period for stopping a personal
health budget / direct health payment. Although the time taken before stopping a
personal health budget / direct health payment will depend on any contractual
obligations the patient / representative and/or nominee may have entered into.
Personal health budgets and direct health payments are not a welfare benefit and do
not represent an entitlement to a fixed amount of money. Personal health budgets
and direct health payments are paid to meet assessed health and care needs.
Where individuals’ needs change, this needs to be reflected in the value of the
personal health budget / direct health payment.
East and North Hertfordshire CCG can claim back personal health budgets and
direct health payments where the patient’s health needs have changed and they no
longer need the money, there has been theft or fraud, the money has not been used
and has accumulated or where the money has been used not in accordance with the
support plan.
10.0 Using a direct health payment to employ staff or buy services
10.1 Safeguarding and employment
When deciding whether or not to employ someone, patients and their families should
follow best practice in relation to safeguarding, vetting and barring including
satisfying themselves of a person’s identity, their qualifications and professional
registration if appropriate and taking up references.
East and North Herts CCG has commissioned a third party delivery partner to
provide advice and accessible services in relation to the provision of DBS checks for
individual employers.
Individuals cannot request DBS checks on other individuals. However, an individual
or their nominee or representative may wish to ask the CCG or another umbrella
organisation if it is possible to arrange for the prospective employee or contractor to
apply for an enhanced DBS check with a check of the adult’s (or children’s if
19
appropriate) barred lists when employing or contracting with people who are not
close family members or people living in the individual’s household providing care to
the individual but who are:



regulated health care professionals – for example, nurses or physiotherapists;
people providing healthcare under the direction or supervision of a health care
professional;
people providing personal care8.
Alternatively, if the individual can satisfy the DBS that they have a legitimate interest
in knowing if that person is barred, the DBS may supply this information.
If the potential employee is barred they must not be used to supply services as they
pose an ongoing risk to adults or children.
If the individual is contracting with a close family member or a person who is living in
the individual’s household or a friend it is not possible to undertake any DBS checks.
The DBS has recently launched the Update Service. This is a service that allows
people to reuse their certificate for multiple roles. If a potential employee or
contractor has subscribed to the Update Service and has a check of the appropriate
level, the individual should ensure they see the person’s original certificate and use
the free online portal to check for up to date information on that certificate. If the
certificate is not up to date the individual should ask the potential employee or
contractor to apply for a new certificate.
10.2 Indemnity
Direct health payments can be used to pay for a personal assistant (PA) to carry out
certain personal care and health tasks that might otherwise be carried out by
qualified healthcare professionals such as nurses, physiotherapists or occupational
therapists. In such cases the healthcare professional will need to be satisfied that the
task is suitable for delegation, specify this in the care plan and ensure that the PA is
provided with the appropriate training and development, assessment of competence
and have sufficient indemnity and insurance cover. More information on this can be
found in the ‘Personal assistants: Delegation training and accountability’ document in
the toolkit9.
8
These are examples of regulated activity relating to vulnerable adults and children within the meaning of
Schedule 4 to the Safeguarding Vulnerable Groups Act 2006 (“regulated activity”). An enhanced Disclosure and
Barring Service check including a barred list check may be obtained to assess a person’s suitability to engage in
regulated activity. Refer to sections 113B, 113BA and 113BB of the Police Act 1997 (c.50) and S.I. 2002/233 and
2009/1882.
9
http://www.personalhealthbudgets.england.nhs.uk/_library/Resources/Personalhealthbudgets/Toolkit/
MakingPHBHappen/TrainingandDeveloping/PersonalAssistantsSummary.pdf
20
Indemnity is a complex area for individual employers, and one where sufficient
support will need to be in place from the start to enable people to understand and be
supported to meet any obligations they have.
Providers of some services may need to conform with prospective legislation which
will implement the Finlay Scott Recommendations (June 2010)10 on indemnity cover
and Article 4(2)(d) of Directive 2011/24/EC11. The Department of Health will provide
further guidance on what this covers in due course12.
PAs employed via a direct health payment do not need to comply with the legislation
that will require them to have indemnity cover if practising unless they are a member
of a regulated health profession (see Box 3), even if carrying out activities which
might otherwise be performed by health professionals. Care coordinators will need to
consider and discuss with the person, their nominee or representative, the potential
risks associated with the clinical tasks being carried by the PAs on a case by case
basis. This needs to form part of the risk assessment and care / support planning
process and outcome recorded in the care / support plan.
The person buying services needs to be aware of whether the provider needs to
comply with prospective legislation discussed above. If the provider does not need to
comply people may, if they wish, buy services from providers who have limited or no
indemnity or insurance cover. So long as the person buying the service is aware of
the potential risks and implications, limited or no indemnity should not automatically
be a bar to purchasing from a provider. This should be included in the discussion
around risks when developing the care / support plan.
In the first instance, it will be the responsibility of the person buying the service to
check the indemnity cover of the provider from which they are buying services. They
must make enquiries to ascertain whether the provider has indemnity or insurance,
and if so, whether it is proportionate to the risks involved, and otherwise appropriate.
If the person buying the service asks East and North Herts CCG to undertake these
checks on their behalf, the CCG must do so. Care coordinators and support planners
should also ensure that people are aware that this is an option, and may wish to offer
this as part of the risk assessment and care / support planning process.
Regardless of who carries out the initial check, the CCG will review this as part of the
first review, to ensure the checks have been made and are appropriate.
10
https://www.gov.uk/government/publications/independent-review-of-the-requirement-to-haveinsurance-or-indemnity-as-a-condition-of-registration-as-a-healthcare-professional
11 Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011 on the
application of patients’ rights in cross-border healthcare -OJ L 88, 4.4.2011
12 This will be available in the toolkit.
21
10.3 Registration and regulated activities
If someone wishes to buy a service which is a regulated activity 13 under the Health
and Social Care Act 2008, they will need to inquire as to whether their preferred
provider is registered with the Care Quality Commission (CQC). A direct health
payment cannot be used to purchase a regulated activity from a non-registered
service provider14.
If a person employs a care worker directly, without the involvement of an agency or
employer, the employee does not need to register with CQC. CQC guidance makes
it clear that where a person, or a related third party on their behalf, makes their own
arrangement for nursing care or personal care, and the nurse or carer works directly
for them and under their control without an agency or employer involved in managing
or directing the care provided, the nurse or carer does not need to register with the
CQC for that regulated activity. A related third party means:
a. An individual with parental responsibility for a child to whom personal care
services are to be provided.
b. An individual with power of attorney or other lawful authority to make
arrangements on behalf of the person to whom personal care services are to
be provided.
c. A group or individuals mentioned in a) and b) making arrangements on
behalf of one or more persons to whom personal care services are to be
provided.
d. A trust established for the purpose of providing services to meet the health
or social care needs of a named individual.
This means that individual user trusts, set up to make arrangements for nursing care
or personal care on behalf of someone are exempt from the requirement to register
with the CQC.
Also exempt are organisations that only help people find nurses or carers, such as
employment agencies (sometimes known as introductory agencies), but who do not
have any role in managing or directing the nursing or personal care that a nurse or
carer provides.
If someone wishes to use a direct health payment to purchase a service which is not
a regulated activity, they may do so.
13
14
The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, S.I 2010/781
http://www.cqc.org.uk/organisations-we-regulate/registering-first-time/regulated-activities
22
In some circumstances, the provider may also need to be a registered member of a
professional body affiliated with the Council for Healthcare Regulatory Excellence. If
the care / support plan specifies that a task or tasks require a registered professional
to undertake it, only a professional who is thus registered may be employed to
perform that task or tasks.
In the first instance it will be the responsibility of the person buying the service to
check whether the provider they are purchasing from is appropriately registered.
They can request that East and North Herts CCG investigate this, and if they ask the
CCG must do so. As with indemnity cover, the CCG must also review this as part of
their assessment as to whether the direct health payment is being effectively
managed.
While some service providers, for example aromatherapists, are not statutorily
required to be registered, there are professional associations with voluntary registers
that practitioners can choose to join. Typically, such practitioners can only join these
associations or registers if they meet the standards of education, training, conduct
and performance required by the professional body. However, there is no legal
requirement to join these registers, and practitioners can still offer unregulated
services without being a member of any organisation. However, if a provider is not
registered with an appropriate body this should not automatically be a bar to
purchasing from that provider but this should be included in the discussion around
risks when developing the care plan.
Which are the statutory regulatory bodies?


The General Chiropractic Council (GCC) regulates chiropractors.
The General Dental Council (GDC) regulates dentists, dental nurses, dental
technicians, dental hygienists, dental therapists, clinical dental technicians and
orthodontic therapists.
 The General Medical Council (GMC) regulates doctors.
 The General Optical Council (GOC) regulates optometrists, dispensing opticians,
and dispensing opticians, specialist practitioners and optical
11.0student
Moreopticians
information
businesses.
 NHS
The England
General Osteopathic
regulates
osteopaths.
The
website has Council
a section(GOsC)
dedicated
to personal
health budgets. This
has
information
about
national
policy,
the
implementation
toolkit,
and other
 The Health and Care Professions Council (HCPC) regulatesstories
the members
of 15
resources.
health professions: arts therapists, biomedical scientists, chiropodists/podiatrists,
www.personalhealthbudgets.england.nhs.uk
clinical scientists, dietitians, hearing aid dispensers, occupational therapists,
operating
department
practitioners,
orthoptists,
paramedics,
physiotherapists,
The Peer
Network,
a user-led
organisation
for personal
health budgets,
has its own
practitioner
psychologists, prosthetists/orthotists, radiographers, speech and
website:
www.peoplehub.org.uk
language therapists, and social workers in England.
 The Nursing and Midwifery Council (NMC) regulates nurses and midwives. 23
 The Royal Pharmaceutical Society of Great Britain (RPSGB) regulates
pharmacists, pharmacy technicians and pharmacy premises in Great Britain in
England, Wales and Scotland.
Appendix A
Related concepts
“It must not be forgotten that personalisation is something that disabled
people and their allies have been pioneering and campaigning to achieve for
the last 30 years. Indeed taking personal control over one's publicly funded
support began with a group of disabled people who lived in residential care in
the 1970s. The blueprint for what we talk about today, was devised by the first
ever recipients of an individualised budget in 1979.”15
Personal health budgets are a concept which form part of the Government’s wider
drive to give people more choice and control over how their NHS needs are met.
There are close links to other initiatives which support people to manage a long-term
health condition such as shared decision making, care planning and the recovery
approach in mental health. Personal Health Budgets build on already operational
programmes of personal budgets in social care and personalised care planning for
people with long term conditions.
Personal health budgets are related to other relatively new concepts in public policy,
which are explained below.
A definition of personalisation is “starting with the individual as a person with
strengths and preferences”, as opposed to a traditional approach to public services,
where the starting point is the services available. The diagram below shows how the
concepts of personalisation, self-directed support and personal budgets / personal
health budgets fit together:
15
Speech: Social care as an equality and human rights issue Speech by Baroness Jane Campbell,
Chair of the Disability Committee and EHRC Commissioner, at the IPPR 'Power to carers and users:
transforming care services' event, 19 February 2008.
24
There is a drive to move public services to become more personalised – i.e. towards
a ‘self-directed’ model. Local authorities in England are moving towards self-directed
support becoming the standard way to deliver social care services. The introduction
of personal health budgets and personalisation in health is based closely on selfdirected support in social care.

Self-directed care: a way of accessing and delivering care services where
the individual is central to determining how to manage his or her own care and
has more choice and control

Personal budget: “a transparent allocation of resources so that individuals
know how much they have to spend on their support”. Individuals have more
control over how the money is spent and should go through a supported selfassessment process. In adult social care, the term ‘personal budget’ is used
to mean a budget which includes only social care funding. Personal budgets
are now being introduced in children’s services, and here the term means a
budget which may include funding from social care, education and health.

Personal health budget: this is like a personal budget but only includes NHS
money, and must be administered in line with NHS legislation.
25
Coproduction
There is no single definition of co-production. The concept represents a set of values
and principles which have emerged over a period of time.
The Department of Health defines co-production as 'when you, as an individual,
influence the support and services you receive, or when groups of people get
together to influence the way that services are designed, commissioned and
delivered.'
The idea builds upon the belief that people have equal rights, choices and control
over the services they need and use. It means doing things together in a spirit of
openness and fairness, so that people using services are equally involved alongside
staff and providers in working out what needs to be done, and making sure it
happens.
Co-production is not the same as service user involvement. It is not the same as
service user participation, nor is it the same as service user
engagement/consultation.
Broadly speaking, co-production means co-design and co-delivery of (health and
social care) services. Whilst social care services are involving service users in
designing services, genuine co-production represents quite a radical change for
health and social care services.
The design, and delivery of Personal Health Budgets in East and North Hertfordshire
CCG has been coproduced with the personal health budget peer development
group.
National policy and pilot programme
Between 2009 and 2012 personal health budgets were piloted in over 60 sites
across England. As with personal budgets in social care, people with a personal
health budget could choose how their budget was spent to meet their individual
needs, in line with a care plan which they agreed with the NHS. After the success of
the pilot programme, personal health budgets will be introduced in the NHS across
England, starting first in NHS Continuing Healthcare.
The pilot was evaluated by an external team and their final report was published in
November 2012. The Department of Health has documented these findings and their
implications or how personal health budgets should be implemented16.
Based on the results of the pilot, the Government announced that everyone who is
eligible for NHS continuing healthcare will have the ‘right to ask’ for a personal health
budget by April 2014.
16
How to get good results: key findings from the evaluation, Department of Health, 2012
26
This became a ‘right to have’ by October 2014.
The pilot programme had a very broad remit and produced five evaluation reports in
total, including a final report17. A few of the key, statistically robust, findings are
outlined below:

the wellbeing of people with personal health budgets, as measured by the
ASCOT indicator, was significantly better than those who had conventional
Services;

the underling health conditions of people in the personal health budgets group did
not change;

the personal health budgets group had fewer hospital admissions and fewer visits
to their GPs than the control group;

the pilot analysed different models of personal health budgets and showed that
how personal heath budgets are implemented determines how effective the new
approach is at achieving good outcomes. Where people were offered personal
health budgets and told an indicative budget at the start of care planning, had
flexibility over how funding could be spent and were given a choice of deployment
options, their wellbeing was higher than the control group. Where they offered a
personal health budget and the opposite was true (people were not told an
indicative budget, had little flexibility over how their budgets could be spent and
were not given a choice of how the budget could be deployed) then their
wellbeing declined in comparison with the control group.
A key message from the pilot therefore seems to be that, if we are implementing
personal health budgets, we need to ensure we do this in a way to ensure we realise
the benefits. The evaluation also suggests that investing in good care planning at the
start of the personal health budgets process can help to realise potential savings in
the wider health system.
Appendix B
Supporting people to make their own decisions
There are a number of important decision-making points in setting up and managing
personal health budgets. Where a person lacks the capacity to make a particular
decision, their views must still be sought. Their ability to make decisions on other
matters should be assumed. For example, a person may be able to make a decision
about who they would like to support them, but not about how to manage a personal
health budget. Wherever possible a person should be supported to be as involved
17
Evaluation of the personal heath budgets pilot programme, Department of Health, November 2012
27
as possible in all aspects of their personal health budget including the support
planning process.
To enable a person to understand their options and to help them feel at ease, those
supporting them in their decision making need to think about:

Using the person’s preferred methods of communication;

A suitable location;

The persons’ privacy and dignity;

Letting the person make the decision at their own pace.
The best interests principle
The best interests principle as set out in Section 1 (5) of the Mental Capacity Act
should be used when setting up and managing a personal health budget for a patient
who is deemed to lack capacity.
This states that:
"An act done, or decision made, under this Act for or on behalf of a person who lacks
capacity must be done, or made, in his best interests"
The principle covers all aspects of financial, personal welfare and healthcare
decision-making and actions. It applies to anyone making decisions or acting under
the provisions of the Mental Capacity Act, including family carers, care workers,
healthcare and social care staff, attorneys appointed under a Lasting Power of
Attorney or Enduring Power of Attorney, and deputies appointed by the Court of
Protection.
How to determine what is in a person’s ‘best interest’?
Section 4 of the Mental Capacity Act sets out how to determine the best interests of
a person who lacks capacity to make a decision at the time it needs to be made.
It sets out a checklist of common factors that must always be considered by anyone
who needs to decide what is in the best interests of a person who lacks capacity in
any particular situation. The following is a summary of what the decision maker
should do to determine "best interests" under Section 4:
o encourage the person to participate or improve their ability to take part in
making the decision;
o identify all the relevant circumstances;
o find out the person’s views;
o avoid discrimination - not simply make assumptions about someone’s best
interests on the basis of their age, appearance, condition or behaviour;
o assess whether the person might regain capacity;
o if the decision concerns life-sustaining treatment the decision maker should
not be motivated in any way by a desire to bring about the person’s death;
28
o consult others for their views about the person’s best interests;
o avoid restricting the person’s rights by seeing if there are other options that
may be less restrictive of the person’s rights;
o weigh up all of the above factors in order to determine best interests.
The provisions of Section 4 do not set out an exhaustive list of factors which need to
be taken into account in determining "best interests" as the decision maker is under
a duty to take into account "all relevant circumstances" (Section 4 (2)), not just those
which they consider important. The decision-maker must not act or make a decision
based on what they would want to do if they were the person who lacked capacity. If
a person’s incapacity is likely to be temporary, it may be possible for the decision to
be postponed until capacity is regained.
Who is a close family member?
A person’s close family members are described in the regulations as:
a. the spouse or civil partner of the person receiving care;
b. someone who lives with the person as if their spouse or civil partner;
c. their parent or parent-in-law;
d. their son or daughter;
e. son- in- law or daughter- in- law;
f. stepson or stepdaughter;
g. brother or sister;
h. aunt or uncle;
i. grandparent; or
j. the spouse or civil partners of (c)- (i), or someone who lives with them as if their
spouse
civil partner.
Makingordecisions
about the treatment and care of patients who lack
capacity
Decisions about the treatment and care of a patient who lacks capacity should be
made jointly with the representative, the care co-ordinator and any other
professionals who work regularly with the patient. When decisions are made the
following needs to be taken into account;
o any evidence of the patient's previously expressed preferences, such as an
advance statement or decision
29
o the views of anyone the patient asks you to consult, or who has legal authority
to make a decision on their behalf or has been appointed to represent them
o the views of people close to the patient on the patient’s preferences, feelings,
beliefs and values, and whether they consider the proposed treatment to be in
the patient's best interests
o what you and the rest of the healthcare team know about the patient's wishes,
feelings, beliefs and values.
Fluctuating Capacity
Where a person who has agreed to a care plan and consented to the making of
direct health payments to them subsequently loses their capacity to consent, the
CCG may, where it is satisfied that the loss of capacity is temporary, allow a
representative to be appointed to receive direct health payments on their behalf, or
an existing nominee to continue to receive them, until they regain capacity. In these
circumstances, the role will be similar to that of a representative for someone who
has been assessed to lack capacity on an ongoing basis.
Where someone's capacity to consent fluctuates, for example where a person’s
mental illness is such that it impairs their capacity to make decisions at certain times
but not others, it is important that there should be continuity of care, and any
disruption should be as minimal as possible. It may be helpful to work with people
with fluctuating conditions to draw up advance decisions under the Mental Capacity
Act and contingency plans to ensure that their care in a crisis better meets their
wishes, including the identification of a nominee or representative who may take
control of the direct health payment at such times.
When a person with fluctuating capacity gains or regains their capacity to consent,
their consent is needed to continue the direct health payments. If they consent, the
representative or nominee must agree to continue their role in respect of the direct
health payment until a review is held. This is because it is the representative, not the
person who has gained or regained capacity who, consented to the arrangements.
This allows direct health payments to continue until the CCG can arrange a review,
which it must do as soon as is reasonably possible. At this review, the CCG and the
person receiving care will review and if necessary develop a new care plan.
However, if the person who has gained or regained capacity, does not consent to the
representative or their nominee continuing in that role until a review is held, or if the
representative or nominee does not wish to continue in that role, then direct
payments must stop. As in all circumstances when direct payments stop, alternative
provision should be made to ensure continuity of care until the required review takes
place and new arrangements, which may include direct health payments, are put in
place.
30
Appendix C
How do personal health budgets work?
East and North Hertfordshire CCG, has commissioned a delivery partner to provide
information, advice and guidance to prospective personal health budget recipients,
and their families.
This includes:
o How a personal health budget can be used;
o Producing a personalised care / support plan;
o Advice and support to manage a personal health budget, including a direct
health payment
o What records to keep;
For eligible Continuing health care patients East and North Hertfordshire CCG care
co-ordinators will inform patients of their right to have a personal health budget and
direct health payment at review.
Individuals who want to find out more about personal health budgets will be referred
to the CCG’s delivery partner to explore the option in more detail and the care coordinator will be supported by the newly appointed personal health budget nurse to
progress the request.
The basis of the amount of personal health budget is:
o The money that would otherwise have been spent on Continuing healthcare
provision for existing Continuing healthcare patients offered the right to
request a personal health budget at the 12 week or annual review;
However, the introduction of personal health budgets is about more than just freeing
up money. Personal health budgets represent a move towards ‘self-directed care’
that is becoming embedded in social care services and being introduced to the NHS.
The end to end process for personal health budgets
For East and North Herts CCG, personal health budgets are being introduced for all
patients who are in receipt of NHS Continuing healthcare at either the 12 week or
annual review. See exclusions in section 4.3
The revised personal health budgets pathways are shown in Appendix D (Adults)
and Appendix E (Children)
a. Assessment / Review
The introduction of personal health budgets does not require new or additional
assessments and or reviews for continuing healthcare patients. The continuing
healthcare review and assessment processes, risk assessments and safeguarding
policies remains as it is, with the same tools, i.e. the Decision Support Tool etc.
31
b. Right to have a personal health budget and direct health
payment
At review the care co-ordinator will need to inform eligible Continuing healthcare
recipients and their families of their right to have a personal health budget and a
direct health payment. Personal heath budgets are entirely voluntary and there is no
obligation for a patient to accept the offer. Patients and their families will need to be
provided with the East and North Hertfordshire CCG Personal Health Budget Leaflet.
Patients and families who wish to consider and explore personal health budgets
further will need to be referred to the CCG’s delivery partner by the care coordinator.
They will require the care coordinator to work alongside the patient and their family
to complete the consent, referral and risk identification and mitigations form.
c. Budget Setting
Under the traditional model of continuing healthcare, an assessment would be
followed by the care co-ordinator producing a care plan, i.e. a schedule prescribing
episodes of care and defining specific tasks for the care worker. Under the personal
health budgets approach, after a Continuing health care annual or 12 week review
an ‘indicative budget’ is set. The indicative budget gives a financial envelope within
which the personal health budget care / support plan is completed.
During the national personal health budgets pilot programme, a number of different
budget-setting approaches were used. Broadly speaking, these are either a form of
‘resource allocation system’ (RAS) or a ‘ready-reckoner’.
A ‘RAS’ sets an indicative budget based on an individual’s level of need – it puts a
monetary value on any particular level of need. In theory a RAS is not driven by
existing services and having a RAS-generated indicative budget should enable more
creative care planning.
A ‘ready reckoner’ approach is one where an existing Continuing healthcare care
plan / package of support is used to calculate an indicative budget. Whilst the ready
reckoner approach is based on existing services, it can be simpler to use, more
transparent and easier to understand.
East and North Hertfordshire CCG is using a ready reckoner approach to set the
level of the personal health budget. Once a person is reviewed and continues to be
assessed as eligible for NHS continuing healthcare, the care co-ordinator and
Finance Manager at the CCG will work together to calculate the indicative budget.
A banded Resource Allocation Tool has been developed and will be continue to be
tested to ensure it is fit for purpose.
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d)Personal health budget care / support planning
Care / Support planning is fundamentally different from traditional care planning
carried out for continuing healthcare patients. As mentioned above, a traditional care
plan is a timetable showing episodes of care and tasks. It should be produced in
consultation with the patient and their family.
Whereas a care plan starts with the existing services, a personal health budget
support plan has the indicative budget as the starting point.
A personal health budget support plan is developed by the individual / their family
and support planner, working closely with the care co-ordinator. The plan shows
how a personal health budget will be used to achieve the patients’ identified health
and care outcomes. This includes:

who will be providing each element of support,

who will be managing the budget,

how the plan will meet the agreed outcomes and clinical needs

how the individual has been involved in the production of the plan

how any training needs will be met,

identifying any risks, consequences and mitigating actions,

contingency planning.
Good support planning involves looking holistically at a person’s life to improve their
health, safety, independence and wellbeing. Support plans should be developed with
all individuals, regardless of the personal health budget management option they
choose, i.e. whether to take direct health payments, a notional budget or a real
budget managed by a third party organisation
33
Appendix D – Adults PHB Pathway
34
35
36
37
Appendix E - Personal Health Budget Pathway (Children)
38
Appendix F - Referral and risk identification and mitigation form
Personal Health Budget Referral Form
Referral Checklist (please make sure you have included all of the items below).
Please e-mail completed referrals to Elisabeth Byrd [email protected] 01245 392311
Clinical Practitioners
Have you included a copy of the signed information sharing consent form?
Have you fully completed Part A of the referral form?
Have you completed the patient details section at the top of Part B (nhs number, name and date of birth)?
Have you completed the Health needs section of Part B (you do not need to complete any further sections)?
Have you included the patients current care plan?
If you are including any additional documents please write details of these below.
39
Personal Health Budget Referral Form (PART A)
Name:
Date of birth:
Address:
Telephone number/s:
Does the patient require an advocate to
support them through the support planning
process?
Name and contact details of advocate/relative including relationship to
patient:
Yes
No
Name of CHC nurse
responsible for the patient:
Contact details for CHC nurse responsible
for patient (phone and e mail):
Any known issues for a lone worker? (eg. Pets, history of violence etc)
Current cost of care package
(per month)
Are there any wellbeing needs that you or anyone else has identified for the patient that they would like to be met through
the personal health budget?
40
Background information about the client (it is sufficient to attach the current care plan if this has enough detail in it)
Current situation and care package (if this is already detailed in the care plan, there is no need to repeat here)
Reason for referral
Form completed by:
Signature:
Date:
41
Personal Health Budgets Patient/ Client Support Plan Summary (PART B)
Patient/ Client name:
Date Support Plan Summary was completed:
(support planner to complete)
D.O.B:
Patient/ Client NHS number:
Health needs (CHC/DN to complete)
Activities/ provisions (support planner to
complete)
How do the activities/ provisions meet the health
and wellbeing needs? ( support planner to
complete)
42
43
Please sign this document to show you agree (on the date of signing) that the activities meet your Health and Wellbeing needs and that in your opinion you have been sufficiently
involved in the putting together of your support plan .
Patient / client Signature:
Date signed:
If patient/ client is unable to sign, an appropriate adult representative with decision making responsibility OR consent from the patient/client should complete the fields below.
Name:
Signature:
Support Planner’s Name:
Signature:
Relationship to patient:
Telephone:
Date signed:
Support planning organisation/agency:
Telephone:
Date signed:
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Personal Health Budget Support Plan Risk Identification and Mitigations
Individual’s name
Risk Identified
Example
Patient has no PA support overnight when there
is a risk of choking.
NHS Number
Impact on Health & Wellbeing
Consequence could be fatal
Proposed/ advised mitigating action Action taken/ agreed by patient Y/N( if
no or partial agreement provide
explanation)
Fund overnight PA support.
Patient has agreed to overnight support on
occasions when choking risk is increased. E.g.
when they have a respiratory infection. But do
not want constant 24 hour support from PAs
as they would like to maintain some hours of
privacy in their home.
Clinical
1
2
3
4
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Financial
1
2
3
4
Other
1
2
3
4
Providers to be used
1
Example: Personal Assistant with little
experience in wound management has
been nominated to manage wounds in the
contingency plan.
Patient’s wound may become
infected.
Additional training in wound
management from Nurse and
supervision for first 2 weeks from
Head PA with 5 years’ experience in
managing patient’s wound.
Proposed mitigation agreed by patient
and PA.
2
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3
4
I certify that the risks related to the decisions I have made regarding activities in this support plan have been fully
explained to me by (name of Nurse and or support planner) …………………………………………………………………………………………………………
and that I have made my decisions having fully understood the risks to my Health and Wellbeing.
(Individual)
Name …………………………………………………………………… Signature……………………………………………………………… Date……………..
(Individual’s representative or Power of Attorney (POA), if applicable)
Name …………………………………………………………………… Signature……………………………………………………………… Date……………..
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Appendix G – PHB Agreement and Consent Form
PERSONAL HEALTH BUDGET AGREEMENT
This document tells you about having a Personal Health Budget
This document may be revised in light of legal advice currently being sought.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Information about you
Basis of the Agreement
About your personal health budget
Review
Changing needs, contingency and emergency arrangements
Ending the agreement
Comments, complaints and compliments
Signatures
Other information you will need to know about a Personal Health Budget
a. Responsibilities of your nominated representative (if you have one)
b. General rules for how to use your money
c. Using a care agency
d. Employing your own staff
e. Record keeping and audit
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1. Information about You
This agreement is between: East and North Hertfordshire Clinical Commissioning Group.
(Referred to in this agreement as ‘we’ or ‘us’)
And
Name and address of person receiving the Personal Health Budget.
(Referred to in this agreement as ‘you’)
And if applicable
Name and address of your Nominated Representative or chosen decision maker
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2. Basis of the Agreement
This agreement is made with you because:  You are eligible to receive health care funding.
 Your support plan has identified the care or support that you have chosen to meet your assessed
healthcare needs and wellbeing goals. .
 You are willing and able to purchase the care or support that you need yourself or with support from a
Nominated Representative, or have chosen that your budget will be spent on your behalf either by an
agreed third party (A managed account) or by the local NHS team (a virtual account). ().

We agree to make your Personal Health Budget available to you for you or your Nominated
Representative, the agree third party or your NHS team to purchase the care and support that you
need, as outlined in your support plan.
 You agree to regular checking of your financial statements by us, or by someone on our behalf, so that
we can monitor how you spend the Personal Health Budget payments.
 You agree to use the Personal Health Budget we have made available to you to meet the healthcare
and wellbeing goals outlined in your Personal Health Budget support plan.
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3. About your Personal Health Budget
The amount of money you will receive
Total sum paid per year:
.
The frequency of your payments will be discussed with you. However, payments are usually made in advance
on a monthly basis and will be reviewed annually unless your assessed health care needs change.
When you will receive your money
Once we have received a signed copy of this document from you we will initiate the transfer of funds, as soon as
we know the date your Personal Health Budget can be transferred we will write to you to let you know.
We will then agree the official start date of your personal health budget, ensuring all the necessary procedures
and support structures are in place.
How you will receive your money
You can choose to receive your personal health budget in one of, or a combination of the 3 options below.
1.
A direct payment
2.
A Managed Account
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3.
A ‘Virtual’ budget
You should have had all the options explained to you before you decided which option is best for you. Please
mark in the box how you have chosen to receive your Personal Health Budget.
Direct Payment
 You will need a separate, designated bank account where your direct payment can be paid into.
 If you have received a direct payment from Social Care in the past then it will be possible to use the same
bank account for your Personal Health Budget.
 Your Personal Health Budget will be paid into a Bank Account, which will be in your name / or your
Nominated Representative's name and managed by you or your Nominated Representative.
 You will need to sign this agreement and BACS payment form with us. We will advise you about this.
 You will be required to provide evidence of how you have spent the payments so that we can check how
the payments are spent. You will need to keep a record of your income and expenditure including receipts,
invoices, timesheets, payslips and bank statements. You must agree to make these documents available
to us for inspection upon request.
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 You and/or your Nominated Representative will be responsible for arranging your own care and support.
We will have no responsibility for these arrangements.
Managed Bank Account
 Your managed account will be held and managed by ecdp on your behalf.
 You will not have to open your own bank account
 ecdp will buy the care and support you have chosen.
 You will need to sign a Managed Bank Account agreement with ecdp, who will advise you about this.
 You can request to see the balance of your bank account during working hours, Monday-Friday.
 you and ecdp will be responsible for managing the account and any contracts or obligations.
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Virtual budget
 You can be involved in planning your own care but we will pay for any assessed care and support.
 You cannot employ your own Personal Assistant with a virtual budget. We will arrange care through a
registered care provider.
4. Review
The care and support arrangements agreed within your support plan will be reviewed at least annually. The
review will determine if your needs and your personal goals have been met or have changed, and to establish
what has worked well or not worked well for you. The review will be coordinated by your Care Manager who is
named in your support plan.
If your assessed needs have changed during the year you may request an earlier review of your care needs by
contacting your named health professional.
5.
Changed Needs, Contingency and Emergency Arrangements
You are required to make arrangements within your support plan for changes in need or support arrangements,
which may include having a contingency or emergency fund. In crisis situations we may, in the absence of
alternative support, step in and help you on an interim basis.
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Access to your GP and hospital and emergency services such as Accident and Emergency will always be
available to you regardless of having a Personal Health Budget. These services are not included in your budget.
If your needs change or something is not working, you or your Nominated Representative, must contact your
named health professional.
6.
Ending the Agreement
Either you or we may end this agreement by giving 4 weeks' notice in writing to the other party. We may end this
agreement with immediate effect if, after investigation, there are concerns that:
 You are using the payments for an illegal or unauthorised purpose
 You are not using the payments effectively to support your assessed care needs
 Your Nominated Representative is not acting in a way that is not in your best interests.
Wherever possible, we will work with you and your Nominated Representative to resolve any concerns before
ending the agreement.
At the end of the agreement, any money which is in your account or Managed Bank Account which covers a
period after the termination date must be paid to us in full.
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7.
Comments, Complaints and Compliments
You have a right to comment, complain or compliment through the Clinical Commissioning Group’s complaints
procedure about any action, decision or apparent failing of the Clinical Commissioning Group. A copy of this
procedure can be accessed via www.enhertsccg.nhs.uk
8.
Signatures
We agree to the arrangements set out in this Agreement
1st Party:
East and North Hertfordshire Clinical Commissioning Group
Signature on behalf of the Clinical Commissioning Group:
Date:
By signing this Agreement you acknowledge that you have received advice and support and Personal Health
Budgets and the choices that are available to you:
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2nd Party:
The person receiving the Personal Health Budget
Signature:
Date:
3rd Party: (If applicable)
Nominated Representative – the person receiving and managing the Personal Health Budget on your behalf
Signature:
Date:
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9.
Other information you will need to need to know for a personal health budget
a. Responsibilities of Your Nominated Representative (If you have one)
By agreeing to someone purchasing care and support for you, your Nominated Representative, must be
willing to accept the following responsibilities:




To involve you in decisions about your support
To act in your best interests
To consent to receiving and managing the payments for you, and
To agree to all of the responsibilities of someone receiving direct payments
If you choose a Nominated Representative to manage the payments for you still have the right to be involved
in any decisions about support or how the payments are used whenever possible. There is a duty placed on
your Nominated Representative to involve you in all decisions where possible.
If your Nominated Representative does not accept their responsibilities or, in our reasonable opinion, does
not act in your best interests then we can review the arrangement.
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b.
General Rules about How to Use the Money
Your Personal Health Budget allows you to buy the care, support or service that is agreed in your care / support
plan to achieve your healthcare and wellbeing goals.
The money is to be ONLY used to buy care and support or services or goods which support that care and
promote wellbeing. It cannot be spent on illegal services or activities, or spent on alcohol, tobacco, and gambling
or debt repayment.
c. Using a Care Agency
If you wish to use a care agency to support your care needs then you must purchase care and support from a
provider who is registered with the Care Quality Commission who regulate the standards of care agencies
nationally. There is a list of registered providers available, please see www.cqc.org.uk for more information.
ecdp or your named health professional can also advise you about choosing a care agency.
If you choose to purchase a service through a care agency then any agreement and agreed price is a private
contractual arrangement between you and the care agency. We will not be responsible for any arrangements.
Should the care agency increase its prices in the future above our payment rate, or require you to give a period
of notice to end the service we may not be responsible for meeting any additional costs you incur and any
additional payments would be at our discretion.
59
d. Employing your own staff
You may use your Personal Health Budget to purchase a service from any trained person or provider. This may
include employing a Personal Assistant. We will not be responsible for any arrangement or contract of
employment you enter into. You will be responsible as the employer. If a Personal Assistant requires training to
carry out their duties then you are responsible for training, training must be undertaken to ensure that you
receive a high quality service. ecdp can support you to access training as an employer and for your Personal
Assistant(s).
We strongly recommend that a DBS check (Disclosure and Barring Service) is completed as part of the
employment process.
If you choose to employ your own staff you will have legal responsibilities as an employer. These include but are
not limited to providing:
 It is a legal requirement to have a written contract of employment between you and your member of staff.
This will include highlighting the location of the work, remuneration, period of notice etc.
 meeting all Tax and National Insurance requirements as an employer.
 Adhering to Statutory Sick Pay and Maternity Entitlements and Responsibilities, Paternity leave and pay,
Adoption, Redundancy, Equal Opportunities, Unions and Health and Safety policies.
 You are legally required to take out Employers and Public Liability Insurance which will be funded as part
of your initial payment.
You will be responsible for all the employer responsibilities. Guidance can be obtained online at:
www.direct.gov.uk: ‘Employing a professional carer or personal assistant’ or www.hmrc.gov.uk
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You cannot employ family members living in the same household unless you have prior written approval from us
which will be allowed only under exceptional circumstances.
e.
Record Keeping and Audit
You are required to keep records of the payments you receive from us and how the payments are used by you
so that we can review your expenditure.
If you receive a direct payment you must agree to us reviewing your accounts
If you use a Managed Bank Account, your bank account will be audited through ecdp. ecdp are only able to
make payments that are agreed in your support plan. The records will be subject to audit arrangements and
ecdp will be audited annually (as a minimum).
The balance of the managed bank account will be reviewed regularly by us and any money that has not been
used for care or support will be returned to us (unless a prior agreement has been made with your named health
professional).
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Personal Health Budget
Personal Information Sharing Consent Form
How do I get a Personal Health Budget?
Before you are able to receive a Personal Health Budget you will need to find out more about what it involves. You will then need to write your
support plan. Your support plan will include your healthcare and wellbeing goals and the care and support you need to meet these goals.
Once your support plan is written it will go to an approval panel. They will either approve it or make some changes.
Although a Personal Health Budget means you have more control over the care and support you receive the NHS still has a responsibility to
make sure you are safe and receiving the best care possible. The NHS also need to make sure you understand all the responsibilities,
expectations and legal obligations you will need to follow if you receive a Personal Health Budget.
Before we approve any Personal Health Budgets we need to be completely satisfied that you have understood all the requirements and what
it will mean for you. Therefore we have made it a requirement that you seek professional advice from an independent organisation. We have
appointed ecdp to provide information, advice and guidance for anyone who would like to have a Personal Health Budget. We have also
appointed ecdp to support people to develop their support plans. They will help you think about what to put in your support plan and the
different options you might have for care and support that is available.
Why do you need to share my information?
We will need to give ecdp some personal details about you so that they can give you the best advice and support. For example they will need
to know who you are and how to contact you. But they will also want to see what is in your care plan so that they can help make sure you
choose the right kind of care and support for you healthcare needs.
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Before we can give them this information, we need your permission.
What personal information will you be sharing?
The information we will need to share will include

Your contact details –your name, address, telephone numbers and email address.

The contact details of anyone who might have legal responsibility for you or who you have already given us permission to contact about
your healthcare or wellbeing needs.

Details about you – age, ethnicity, religion etc

Medical or Health information: Existing care plans (which will include an assessment of your medical needs), medical assessments from
other Health Professionals etc. The contact details of other professionals or services involved in your health or social care support.
Is there anyone else who might need to see this information?
In order to help you develop a really detailed and effective plan they may also need to contact other professionals or services on your behalf to
find out more about you or more details about care and support you need.
They will only contact other people when it is appropriate and necessary. They will tell you when they are doing this.
By giving your consent to this now it will mean you will only have to give your information once.
63
What if there are some people or organisations I don’t want to share my personal information with?
If there are some people or organisations you don’t want ecdp to contact then please let us know and we will make sure that this does not
happen.
Please list these organisations below;
If I give you my consent how are my rights protected?
We will also ensure your details are processed and shared in a manner that protects your rights under the Data Protection Act.
(http://www.legislation.gov.uk/ukpga/1998/29/contents).
You have the right to withdraw your consent at any stage.
By signing below you confirm that you understand:




Why your information is being shared.
Who it is being shared with.
That other people who are involved with your health care and support may be contacted
That you may withdraw your consent at any time.
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Patient’s name: (please print)
Patient’s address:
Name of representing adult*(if required, please print):
Representing adult’s relation to service user/ patient (please print):
Patients’ / representing adults’ signature:
Date:
* The “representing “ adult should be a person over the age of 18 who has either legal permission or verbal consent from the patient to make
decisions and/ or sign documents on behalf of the patient.
OR
The parent/ guardian of the patient (if the patient is under the age of 18 or 25 if they have a learning difficulty or disability).
NB. This form needs to be retained in the Patient’s record and a copy for Patient. The Referring Team also need to send a copy of this form
with the referral form to ecdp at [email protected] 01245 392311
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Appendix H – Glossary of Abbreviations
CCG
CHC
CQC
CRB
DBS
DN
ecdp
GCC
GDC
GMC
GOC
GOsC
GP
HCPC
IAG
IFR
NHS
PA
PHB
RAS
Clinical Commissioning Group
Continuing HealthCare
Care Quality Commission
Criminal Records Bureau
Disclosure & Barring Service
District Nurse
Essex Coalition of Disabled People
General Chiropractic Council
General Dental Council
General Medical Council
General Optical Council
General Osteopathic Council
General Practitioner
Health & Care Professionals Council
Information Advice and Guidance
Individual Funding Request
National Health Service
Personal Assistant
Personal Health Budget
Resource Allocation System
66