Is having a personal health budget making a
difference to your life?
Help us to find out
QUESTIONNAIRE
What is this questionnaire about?
This questionnaire is being used by [NAME OF ORGANISATION] to evaluate the impact
of personal health budgets on the lives of people who have them.
A personal health budget can be held in different places but you (or your nominated
representative) should:
• know how much money is in your personal budget
• know the outcomes that have been agreed – what must the money be used to
achieve
• have full control over how the money is spent.
This questionnaire asks whether having a personal health budget has made a difference
to your life.
You can:
 read the questionnaire and answer the questions yourself
 ask someone to read the questions to you for you to answer
 or answer the questions with help from someone you know and trust.
If you agree, there are two ways that the answers you give to this questionnaire can be
used by [NAME OF ORGANISATION]. Whatever you agree to, your personal details will
not be shared with anyone outside [NAMEOF ORGANISATION] and no-one outside
[NAME OF ORGANISATION] will be able to identify you from your answers.
The first way we can use the information is to evaluate how well personal health budgets
are working locally. Please look at the box below and say whether you agree to your
answers being used in this way.
Agreement 1
I agree that [NAME OF ORGANISATION] can use the information I give in
this questionnaire to evaluate how well personal health budgets are working
locally.
I understand that my personal details will not be shared by anyone outside
[NAME OF ORGANISATION].
Yes, I agree
No, I do not agree
The second way we can use the information is to put your answers (but not your personal
details) together with answers from people in other areas, with help from Lancaster
University. Lancaster University is helping us to put our information together with
information from other areas to understand how well personal health budgets are working
nationally, and to improve the questionnaire. This will involve writing reports that will be
available to the public, but these reports will only be about large groups of people and you
will not be able to be identified in any reports that are written.
Agreement 2
I agree that
[NAME OF ORGANISATION] can pass the answers I give in
this questionnaire (but not my personal details) to Lancaster University, for
them to help us get a national picture of how well self-directed support is
working.
Yes, I agree
No, I do not agree
If you have agreed, we will send a copy of every completed questionnaire to Lancaster
University at the address below:
Professor Chris Hatton, Division of Health Research, Lancaster University,
Lancaster, LA1 4YT
[NAME OF ORGANISATION] should fill in the user ID and the date completed, and
keep the questionnaire on file.
Personal Health Budget
Questionnaire
1. Personal Details
Name:
Date Of Birth:
Gender:
Male
[NAME OF ORGANISATION]
2. What is your ethnic group? (please choose ONE)
WHITE
British
Irish
Any other White background
BLACK or BLACK BRITISH
Caribbean
African
Any other Black background
ASIAN or ASIAN BRITISH
Indian
Pakistani
Any other Asian background
Bangladeshi
MIXED
White & Black Caribbean
White & Asian
White & Black African
Any other mixed
CHINESE or OTHER ETHNIC GROUP
Chinese
Other
Female
3. How do you hold your personal budget?
I hold the money myself
Another person such as a friend, relative, holds my money for me
My money is held by an organisation providing me with support
My money is held by [NAME OF ORGANISATION]
My personal budget has not been set up yet
My budget is in the form of vouchers
4. What is the main condition (illness) that your personal budget is helping with?
Please write ‘1’ in the box next to your most important need.
If you have another need you want to mention, please write ‘2’ in the box next to
this second need.
Physical impairment
Sensory impairment
Learning disabilities
Mental health difficulties (other
than dementia)
Condition of older age (other
than dementia)
Please
specify............................
Other Illness Condition
(please write in e.g.
dementia, heart disease,
diabetes, substance misuse
problem etc)
5. How long have you had this condition(s).
Less than 1 month
1 year – 3 years
1 month - 6 months
More than 3 years
6 months - 1 year
All my life
6. How long have you been using your personal budget? (please tick one answer)
Less than 1 month
1 year – 3 years
1 month - 6 months
More than 3 years
6 months - 1 year
My personal budget has not been set up yet
Very
satisfied
Somewhat
satisfied
Neither
satisfied nor
dissatisfied
Somewhat
dissatisfied
Very
dissatisfied
7.1
Experience of health care
In the following areas how satisfied are you with the health care you have received over the last
year?
Control over the design of your care plan
The level of choice in how your needs were met
Control over the management and delivery of your health care
The quality of relationship you have with health care
professionals
The degree to which you are treated with dignity and respect
by those providing your health care
The Information available to you to make informed decisions
Access to help at a times that are right for you
Access to and ownership of your care plan and records
7.2
Impact of personal health budget
Control over the design of your health care plan
The level of choice in how your needs were met
Control over the management and delivery of your health care
The quality of relationship you have with health care
professionals
The degree to which you are treated with dignity and respect
by those providing your health care
The Information available to you to make informed decisions
Access to help at a times that are right for you
Access to and ownership of your care plan and records
Made things a
lot better
Made things
better
No Effect
Made things
worse
Made things a
lot worse
Using the following scale how would you say personal budget has affected each area?
Experience of everyday life
8.1
Very good
good
satisfactory
poor
Very poor
Thinking about your life in general. Over the last year how would you rate the following?
The symptoms of your condition
The management of your condition
Your general physical health and well being
Your general emotional health and well being
Capacity to make the changes you wanted in your life
Opportunity to Live with the people you want to
Your ability to work
Opportunities for personal or spiritual expression
General quality of life
Opportunities to take part in social activities
Important family roles (parent, partner etc)
8.2
Impact of personal health budget
The symptoms of your condition
The management of your condition
Your general physical health and well being
Your general emotional health and well being
Capacity to make the changes you wanted in your life
Opportunity to Live with the people you want to
Your ability to work
[Leave blank if Retired]
Opportunities for personal or spiritual expression
General quality of life
Opportunities to take part in social activities
Important family roles (parent, partner etc)
Made things a
lot better
Made things
better
No Effect
Made things
worse
Made things a
lot worse
Using the following scale how would you say having a personal budget has affected each area?
9. How did you answer the questions?
I answered the questions myself
I answered the questions with help from someone else
Someone else mainly answered the questions
Is there anything else you want to tell us about your self-directed support or the
questionnaire?
Thank you
Section for use by [NAME OF ORGANISATION]
User ID
Date completed
-----------------------------------------------------------------------Personal Health Budget Evaluation April 2009