GOVERNING BODY MEETING 30 July 2014 Agenda Item 2.2

Report Title Personal Health Budgets

Purpose of report

This report provides an overview of the use of Personal Health Budgets (PHBs) within NHS Eastern Cheshire Clinical Commissioning Group (CCG) This includes the background, approach to implementation, issues, risks and recommended actions to develop the implementation

Key points

The Governing Body is requested to:

acknowledge progress made and support the additional work required to implement arrangements further

note that the CCG has identified a number of areas of improvement following risks identified through the paper in relation to clinical quality, legal compliance and finance. Operational plans have been developed to mitigate these risks

note the expansion of Personal Health Budgets to a wider population including to children through the introduction of Education, Health and Social Care Personal Budgets

note that the CCG is one of the five CCGs within Cheshire and Wirral who have served notice on our contract with Cheshire and Merseyside Commissioning Support Unit (C&M CSU) for the clinical and operational management of the wider Continuing Health Care, Funded Nursing Care and Complex Care service

note the CCG is working with the other Cheshire and Wirral CCGs to develop a new model for the areas above and this includes joint working to review existing Personal Health Budget policies and processes which will inform the further roll out. This includes joint development of a “Choice and Equity” policy

The Governing Body is asked to: Approve Decide

Ratify Note for information

Endorse

Benefits / value to our population / communities

Personal Health Budgets are a nationally determined priority for commissioners. The CCG is aiming to maximise the benefits to our population by mitigating weaknesses in existing operational policies and developing robust approaches to ensure choice and equity to our population.

Report Author

Julia Curtis Service Delivery Manager

Contributors

Neil Evans Commissioning Director Mary Barlow Clinical Quality, Safeguarding& Performance Lead (C&M CSU)

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Agenda Item 2.2

Personal Health Budgets

1. Executive Summary 1.1 The national roll out of personal health budgets (PHB) was announced on 30th

November 2012 following a three year pilot programme. From 1st April 2014 those patients assessed as eligible for NHS Continuing Healthcare (CHC) have had a right to ask for a personal health budget which is then strengthened to becoming a “right to have” a PHB from October 2014. From April 2015 there are plans to allow “blended” personal budgets across health and social care.

1.2 NHS Eastern Cheshire Clinical Commissioning Group (CCG) has 19 Personal Health

Budgets, at an average cost of £50k each. Many of these predate April 2014 as Cheshire was one of the pilot sites. At the point the CCG became a statutory NHS body (1st April 2013) we inherited 12 PHB that were in place for Eastern Cheshire residents.

1.3 The paper highlights a number of areas of improvement following risks identified in

relation to clinical quality, legal compliance and finance. Operational plans have been, or are being, developed to mitigate these risks.

1.4 The CCG has commissioned Cheshire and Merseyside Commissioning Support Unit

(CMCSU) to provide the clinical and operational management of PHB since our inception. The CCG, along with our peer CCGs from five Cheshire and Wirral, has served notice on this arrangement, which was part of the wider Continuing Health Care, Funded Nursing Care and Complex Care service. This decision followed concerns relating to the quality of service being delivered and it is the intention of the five CCGs to develop a new model with greater strategic and operational leadership from the CCGs. The CCGs have committed resource to this project including the appointment of an interim Senior Nursing post who will lead on this work for the CCG.

1.5 A programme of work has been developed to implement this new model and this

includes a range of actions in relation to PHB where gaps in the existing strategic implementation and operational management have been identified.

2. Recommendation(s) 2.1 The Governing Body is asked to note for information:

progress in implementing PHB and the acknowledgement that there is emerging guidance on expanding PHB to a wider population

the risks identified through the paper in terms of clinical quality, legal and financial areas of improvement and to note that actions are being taken to mitigate these risks operationally

that the CCG is working with peer Cheshire and Wirral CCGs to strategically review delivery of PHB as part of a wider programme of work covering Continuing Health Care, Funded Nursing Care and Complex Care.

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3. Reasons for recommendation(s) 3.1 Whilst PHB are being routinely offered to CHC applicants, and have for some years,

there is additional work required to develop a strategy for the wider rollout of PHB, in line with national guidance. The guidance is still emerging and as there is limited local evaluation of PHB it is sensible to assess the options with our peer CCGs.

3.2 The work across Cheshire and Wirral is a significant piece of work involving both

interrelated processes and members of staff so including relevant, strategic, aspects of the development of PHB avoids duplication and ensures consistency across the wider Pioneer footprint

4. Peer Group Area / Town Area Affected 4.1 All

5. Population affected 5.1 All of Eastern Cheshire although specific groups are more likely to be affected

including those with complex care needs, including both mental and physical disability.

6. Context 6.1 A PHB is an amount of money to support a person’s identified health and wellbeing

needs, planned and agreed between the person and their local NHS team. The Government’s vision for PHBs is to enable people with long-term conditions and disabilities to have greater choice, flexibility and control over the health care and support they receive.

6.2 PHBs are based on a needs led process. At the centre of a personal health budget is

an individual care plan, the aim of which is to utilise the expertise of both clinicians and the individual and their family. The intention is to give each perspective its due prominence and to ‘co-produce’ the end plan of care.

6.3 The national roll out of personal health budgets was announced on 30th November 2012 following a three year pilot programme and the publication of an independent evaluation report, led by the University of Kent.1 From 1st April 2014 those patients assessed as eligible for NHS Continuing Healthcare (CHC) have a right to ask for, and should be offered, a PHB; which is then strengthened to becoming a “right to have” a PHB from October 2014. Furthermore, we must also consider the use of PHBs in the wide range of services we commission.

6.4 Nationally PHBs were piloted from 2009. Evaluation showed that personal health budgets had a significant positive impact on the quality of life and psychological wellbeing of budget holders but did not have a significant impact on clinical outcomes. Personal health budgets were also shown nationally to be cost-effective relative to conventional service delivery. The pilot suggested it was unlikely that a significant

1 https://www.phbe.org.uk/

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number of our population will come forward to request a PHB, although this may be more likely in our relatively well educated and informed population. The policy sets out a stepped approach, due to the particular challenges or risks of providing a PHB, the lower priorities for 2014-15 will be:

End of Life Care or following “fast track”

CHC assessment, where there is likely to be a delay to discharge

Hospital discharges, where there is likely to be a delay to discharge

Packages which require a disproportionate amount of CHC resource or excess cost

Children, due to the need to strategically and operationally align with the introduction of Education, Health and Care Personal Budgets, which will be available to eligible families from September 2014.

6.5 In July 2014 Simon Stephens, Chief Executive Officer of NHS England announced

plans to develop an “Integrated Personal Commissioning (IPC)” programme2 which would seek to offer people the opportunity to have health and social care personal budgets from April 2015 in the following areas:

people with long term conditions, including frail elderly people at risk of care home admission

children with complex needs

people with learning disabilities, and

people with severe and enduring mental health problem

6.6 Whilst there is no guidance available around this specific development there is a range of guidance available to commissioners, and the public, about the existing personal health budget programme.3

7. Finance 7.1 NHS Central and Eastern Primary Care Trust (as was) was part of the original pilot for

PHBs and had a number of cases where patients had opted for a PHB. These were transferred to the CCG on handover of responsibilities to CCGs meaning that NHS Eastern Cheshire CCG had an earlier start than most in preparing for the requirements and to develop a system to adequately administer PHBs. The CCG inherited 12 cases on 1st April 2013 when the pilot scheme ended. We now have 19 approved cases at a total cost in 2013-14 of £941k with an average annual budget of circa £50k each.

7.2 Currently the CCG has the following clients funded:

PHB funded clients in Eastern Cheshire Numbers of Patients

Fully Funded PHB: 15

Joint Funded PHB: 4

Total Active PHBs: 19

2 http://www.england.nhs.uk/2014/07/09/ipc-prog/

3 http://www.personalhealthbudgets.england.nhs.uk

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7.3 The CCG has identified issues with reuse of equipment purchased as part of a package. When the package ends there has been no structured way of reutilising the equipment. A managed service solution is being explored to achieve greater value for money.

8. Quality and Patient Experience 8.1 Whilst individual packages are monitored to assess the ongoing needs of the patient

the CCG does not have an effective consistent way about learning about the effectiveness of PHB in comparison to more traditional packages.

8.2 The use of PHBs can vary. Across the Cheshire pilot sites an assistive dog, a football season ticket, a caravan, a summer house, social events and other such items to support a patient’s wellbeing have been funded though PHB. Evaluation of these less traditional uses has not been undertaken and it would be helpful to undertake this work going forward and using previous evaluation from elsewhere.

8.3 Since the CCG became accountable these less traditional areas have not been put in

place within packages however the CCG has committed to the development of a consistent approach to CHC and PHBs through the shared development of a choice and equity policy. This policy will need to identify the personal outcomes that expenditure will achieve and then measure the impact.

9. Consultation and Engagement (Public/Patient/Carer/Clinical/Staff) 9.1 As the review of CHC takes place across Cheshire and Wirral wider engagement will

occur in relation to:

staff are being consulted formally as part of a TUPE (Transfer of Undertakings Protection of Employment) to transfer their employment from CMCSU as well as informally to help design revisions to the model

as new policies are being developed wider public consultation will take place. This will be from Autumn 2014.

10. Equality 10.1 Whilst Impact Analysis has been undertaken previously as part of the national

implementation, a local piece of work will be required as new policies are developed through 2014-15.

11. Legal 11.1 The CCG has encountered a number of issues following implementation of PHB and

required legal advice as to how to respond to these issues. As new issues are identified mitigating actions are being developed and built into future processes, examples include:

where staff are employed directly through a PHB (whether through direct payment or a broker) associated employment costs e.g. redundancy had not been built into the package

where a package was not fully committed the provision to “pull back” any overspend had not been adequately covered in the agreement

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11.2 Where a patient requires access to additional services there are not clear processes established to avoid dual running costs , e.g. if someone in receipt of a PHB is admitted to hospital, then there is difficulty in avoiding the PHB cost due to the employment implications on those people delivering the package.

12. Communication 12.1 Whilst the CCG does have information about CHC available both on the CCG Website

and in various public locations across Eastern Cheshire an immediate gap which has been identified is that within the CCG website only limited information is available on PHBs. This section is now being reviewed and updated.

12.2 Where an application for CHC is made, the applicant, or their representative, is made aware of PHB. The awareness of PHB will be reviewed in the context of the wider rollout of PHB.

12.3 As part of the rollout of PHB to Children with Special Educational Needs the CCG is

developing a statement to be used to highlight what is available to them. This statement can then evolve as further national guidance is received to influence our local policy.

13. Background and Options 13.1 NHS Eastern Cheshire CCG makes the decision on which type of PHB to offer to an

individual. This decision will currently be consistent with the CCG (Cheshire and Merseyside CSU) CHC Policy on the Commissioning of Care. Where a PHB is provided to arrange a package of continuing healthcare, it will only be used to meet an individual’s reasonable requirements. An individual’s reasonable requirements are determined by the CCG’s assessment.

13.2 The CCG is currently working collaboratively with the other CCGs within Cheshire and

Wirral to develop a new joint Choice and Equality policy for CHC. This policy will look at the approach to making decisions on Continuing Health Care as well as the wider agenda for the expansion of PHB: be robust, fair, consistent and transparent

be based on the objective assessment of the person’s clinical need, safety and best interests

have regard for the safety and appropriateness of care to the individual and staff involved in the delivery

involve the person and their family/representative wherever possible

take into account the need for the CCG’s to allocate its financial resources in the most cost effective way

support choice to the greatest extent possible in view of the above factors.

13.3 There are three types of PHB:

Notional Budget: No money changes hands. The service user finds out how much money is available and talks to their health professional or care manager about the

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different ways to spend the money on meeting their needs. The patient is informed of the amount that the CCG would spend on a traditional model of care, to meet their needs. They discuss with the Nurse Assessor alternative ways to meet their needs based on the same budget. The alternative is proposed to the CCG. If approved, the Nurse Assessor arranges the care and support for the patient. No money changes hands.

Managed Account OR Real budget held by a third party (Brokerage): A different organisation or trust holds the money for the service user, helps them decide what they need, and then together, they buy the services they have chosen. The patient is informed of the amount the CCG would spend on a traditional model of care, to meet their needs. They discuss this with the Nurse Assessor alternative ways to meet their needs based on the same budget. A different organisation or trust holds the money.

Direct Payment for Healthcare: The service user receives the funds into a dedicated bank account or via a payment card to buy services they and their health professional or care manager decide what they need. The patient is informed of the amount the CCG would spend on a traditional model of care, to meet their needs. They discuss with the Nurse Assessor possible alternative ways to meet their needs based on the same budget. The patient (or their representative)

then receives the funds to buy the care and support whilst the local NHS team decide what they need. To show what they have spent it on, but they or their representative, buy and manage services themselves. The use of Direct Payments for Healthcare is prescribed in the National Health Service (Direct Payments) regulations 2013.

13.4 When an individual is eligible for CHC, the NHS is responsible for meeting all of the

assessed health and associated social care needs. Therefore when a PHB is used it cannot be ‘topped-up’ with additional funds from the individual or their representative. An individual can enter into a separate contract with providers for services beyond those which the NHS must arrange. Where an individual or their representative chooses to do so, they must ensure that the services funded by the PHB would be sustainable, should the additional services cease. The CCG is only required provide goods and services to meet its duties under the NHS Act 2006.

13.5 There are five essential features of a personal health budget. The budget holder/

representative should:

be able to choose the health and wellbeing outcomes they want to achieve, in agreement with a health care professional

know how much money they have for their health care and support

be enabled to create their own care plan, with support if they want to do so

be able to choose how their budget is held and managed, including the right to ask for a direct payment

be able to spend the money in ways and at times that make sense to them, as agreed in their care plan.

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13.6 PHBs are not intended to meet an individual’s entire health needs; rather, it is for specific aspects of on-going care. People can choose to have their care as a mixture of PHB and commissioned services. Certain aspects of NHS healthcare are not covered by a personal health budget, such as GP services, medication, dentistry and emergency services.

13.7 Clinical sign-off of the personal health budget ensures that clinicians are comfortable that all aspects of the care plan are safe and likely to help the individual to meet their chosen health and wellbeing goals. Empowering individuals and their families in this manner is considered valuable in itself. The final decision about whether a patient should receive a PHB and what type of PHB will rest with the CCG, supported by a panel of representatives from partner agencies including relevant the voluntary sector and patient led groups.

13.8 The Process currently used to implement a Personal Health Budget is shown in

Appendix One.

13.9 The Cheshire Centre for Independent Living (CCIL) is currently commissioned by the CCGs of Cheshire to provide support, advice and brokerage services to PHB applicants. They are a not-for-profit charitable user-led organisation. In cases where CCIL are involved they can provide the following support:

advice and support on all aspects of directing care

information about employing care staff or arranging support through a care agency.

supporting the patient to complete the necessary paperwork to manage their Personal Health Budget

carrying out police checks on personal assistants

creating specific job descriptions that are individual to their care needs

supporting the patient to recruit personal assistants by writing a job advert and advertising for staff, where necessary

creating specific job descriptions that are individual to their care needs

advising the patient how to manage any employment law issues, including drawing up contracts for employees

provide support to clients through the CCIL’s Payroll Service. The patient pays for this service on a monthly basis from their personal health budget. This service includes setting up new employees, creating P45’s, producing and sending monthly pay slips for my staff, making tax and National Insurance deductions and paying contributions to HMRC, completing employers’ end of year annual return and creating P60’s for employees. The patient will send timesheets in for each employee monthly or as required for bank staff

help identify and choose suitable Employers and public Liability insurance

set up a Managed Bank Account. The patient will receive their personal health budget through a Managed Bank Account with CCIL

provide the patient with timesheets and their Support Workers will record the hours they work. The patient will post timesheets to CCIL. CCIL will send a cheque to them to enable them to pay care staff. The patient pays for this service on a

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monthly basis

a CCIL Training Coordinator is available to discuss training needs.

13.10 It is recognised that there are a number of challenges to the implementation in Eastern Cheshire, particularly in terms of rolling out the expansion of PHBs to our population.

13.11 CHC is currently managed on behalf of the CCG by Cheshire and Merseyside Commissioning Support Unit (CM CSU). Whilst PHB are being made available to anyone eligible for CHC this “arms length” relationship means the CCG has lacked some control over the effectiveness of the wider service. Concerns over the effectiveness of the wider CHC service has led the CCG, working with the four other Cheshire and Wirral CCGs, to serve notice on our contract with the CM CSU and we are now working to develop a new model of delivery and CCG hosting approach.

13.12 A number of gaps have been identified specifically in relation to PHB, these include a recent audit by Merseyside Internal Audit (MIAA) on our behalf. This report is due to go to the CCG Governance and Audit Committee. The key areas of risk were summarised in their draft report as:

the current processes used by our CSU for accurate assessment and compilation of care plans including regular review are not sufficiently robust for the CCG to demonstrate accountability

the assessment process for the individual care plans and personal budgets does not factor in or assess costs of provision against any alternative models of care

the formal agreements between the CCG and the personal budget holder are not always signed by all parties and may not be legally water tight in the event of issues arising and resolution being sought

there is no evidence either holistically or on an individual PHB case basis to demonstrate that expected savings are being achieved or that this is a realistic aim

the expectation of the scheme in the medium/long term is to see de-commissioning of some areas off-setting the costs of PHB spend. There was no evidence during the review to show this and there is not a process in place as yet to effectively inform and manage this at the CCG

there is not a process in place to measure the success of individual care plan outcomes and that there has been an improvement either clinically or in a personal budget holders wellbeing. Lessons may not be detected and/or learned for the future. It may be difficult to demonstrate the positive outcomes and patient success stories.

13.13 The CCG has developed a set of actions to specifically respond to these concerns;

these will be presented to the next Governance and Audit Committee. In addition the CCG has identified a further range of areas which it wishes to improve. This work will be completed in association with our peer CCGs in Cheshire and Wirral as part of our redesign of CHC. The main actions being taken are:

develop clear policies covering the eligibility, assessment and monitoring processes for PHB. This includes developing a strategy to effectively roll out PHB beyond CHC, and in line with national requirements

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improvements in the quality of information regarding PHB in order to assess expenditure and value for money. This will include a greater ability to forecast future expenditure

ensure that the contractual agreements used for PHB are redesigned to overcome some of the identified legal/financial issues and the process for agreeing/varying agreements are robust

complete development and implementation of the new Cheshire and Wirral CCG staffing and delivery model for all aspects of CHC, Funded Nursing, Complex Care, and Care Home Quality. To support this work as well as deliver a greater focus on this area the CCG has already diverted resources, including the interim appointment to a Senior Nurse post.

14. Access to further information 14.1 For further information relating to this report contact

Name Julia Curtis

Designation Service Delivery Manager

Date 22 July 2014

Telephone 07958794686

Email julia.curtis2@nhs.net

15. Glossary of Terms CCG – Clinical Commissioning Group CCIL – Cheshire Centre for Independent Living CHC – Continuing Health Care CMCSU – Cheshire and Merseyside Commissioning Support Unit PHB – Personal Health Budget ICN- Individual Commissioning Nurse/ Care practitioner DST- Decision Support Tool OL- Operational Lead LL- Locality Lead PHBSS- Personal Health Budget Support Service CCN – Complex Care nurse

16. Appendices Appendices Table

Appendix One Personal Health Budget Flow Chart – CHC

Appendix Two Current PHB policy statement contained within CCG CHC documentation

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Appendix One Personal Health Budget Flow Chart

Personal Health Budget Flow Chart

By Emma Woolfall

Cheshire Centre for Independent Living- PHB Support Service

Patient is living at home. DST shows eligibility for NHS fully funded continuing care or a joint funded care package.

Patient is offered a Personal Health Budget and given a leaflet provided by the PHBSS. This offer is

recorded on the DST.

Patient does not want a PHB. Traditional care services should be

commissioned. No further PHB action.

Patient decides they would like a PHB or would like more

information about PHB’s.

Referral should be made to Emma Woolfall at the PHBSS using the referral form provided no more than 5 working days after DST

ICN to discuss assessed hours or budget required in order to complete patient care with OL.

Fully Funded Patients Joint Funded Patients

Discussion between ICN and OL regarding CCN involvement if relevant.

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Patient would like advice and support from PHB support service to complete support

plan and obtain funding Patient would like to complete support plan

and PHB process independently.

PHBSS to contact patient to arrange initial visit no more than 5 working days after referral date, offer further information and options around the PHB process.

Patient is provided with support service

contact details and signposted as to where

they can process their PHB plan.

NFA from PHBSS at this stage however file

kept and patient will be called in 6 months

to ensure that no further help is needed.

PHBSS will inform ICN of the above and ICN

will contact patient to ensure they are happy

to proceed independently.

Plan meets needs

ICN to advise PHBSS within 3 working

days if plan meets identified needs and

return to PHBSS signed.

Plan does not meet

needs

PHBSS will complete support planning visit

with patient no more than 5 working days

after initial visit, this will be sent to ICN for

review to ensure that health needs have been

met.

Plan to be revised with patient, PHBSS and

ICN to ensure that health needs are met at

an agreed cost.

Support Plan will be sent to OL for approval. If high cost, ICN to complete high cost form and submit to LL for submission

to CCG. If joint funded, support plan will also be taken to joint funded panel for approval.

**Unless sent to CCG plan will be signed and returned to PHBSS within 3 working days

Fully Funded Patients Joint Funded Patients

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NB

It should be noted that by using these time scales PHB approval should take no longer than 23 working days

from DST to approval. Although this may not always be possible in exceptional circumstances, it should speed

up the overall process meaning that patients are not waiting as long for care. Eventually it is hoped that these

timescales can be reduced to mean that PHB’s can be approved within a 2 week period.

PHBSS will send the support plan

and PHB contract to patient for

signature.

Once contract returned, this will

be sent to OL for sign off (to be

signed and returned within 2

working days). Admin teams to

load figures onto Broadcare.

Support plan agreed, signed and

returned to OL (with high cost

form if needed).

Support plan not agreed by OL,

LL or CCG (as applicable).

PHBSS will contact social care worker to advise that health direct payment will be starting and how to claw back any money owing.

Support with implementing support plan, recruiting, organising agencies, collating quotes for equipment etc to be coordinated by PHBSS.

Regular reviews to ensure that PHB is successful will be conducted by PHBSS. Ongoing support, advice and information provided by PHBSS.

Annual NHS reviews to be completed by ICN to ensure that health needs are still being met. If joint funded package, social care will also complete annual review to ensure social needs are being met.

Signed contract, BACS form and

front sheet to be sent to finance

dept. by PHBSS.

Direct payment to be made to nominated account

as detailed on forms. A schedule of payments will

be sent to patient.

If patient is joint funded, social care direct

payments should be made into nominated account

and separate schedule to be sent.

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Appendix Two - Current PHB policy statement contained within existing CCG CHC documentation

1. Personal Health Budgets 1.1. By April 2014 everyone in receipt of NHS Continuing Healthcare will have a right to ask

for a personal health budget, including a direct payment. This will form part of a broader rollout of personal health budgets to people with long term health conditions.

1.2. A personal health budget is an amount of money that is allocated to an individual to

allow them to meet their health and well-being needs in a way that best suits them. At the heart of a personal health budget is a care/support plan which sets out the individual’s health (and social care) needs and includes the desired outcomes, the amount of money in the budget and how this will be spent. The care/support plan has to be agreed between the individual and the health care professional, before being checked and signed off by the NHS.

1.3. Personal health budgets potentially offer greater integration of health and social care

for both individuals who need care and their carers, and better partnership working between the NHS and local authorities.

1.4. Personal health budgets do not alter the legal obligations to assess for NHS Continuing

Healthcare, nor do they alter the eligibility criteria or the assessment of the level of need. Personal heath budgets should be considered as a way of planning and delivering NHS Continuing Healthcare once the level of care has been agreed, and clearly fit into the pathway

1.5. A factsheet is available in an easy read leaflet for people being offered a personal

health budget is available.

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Governance

Prior Committee Approval / Link to other Committees

N/A

CCG Health Needs Priorities addressed by this report – please indicate To protect our citizens from harm To make care more integrated &

co-ordinated

To prevent alcohol related harm To ensure high quality and effective mental health services are available to all

To prevent people dying prematurely

To address inequalities across our towns and villages

CCG 2013/14 Annual Plan programme of work this report is linked to – please indicate Caring Together

Quality Improvement

Mental Health & Alcohol Other

Key Implications of this report – please indicate Strategic

Consultation & Engagement

Finance Equality

Quality & Patient Experience Legal

Staff / Workforce

CCG Values supported by this report – please indicate Valuing People Innovation

Working Together Quality

Investing Responsibly

NHS Constitution Values supported by this report – please indicate Working together for patients Compassion

Respect and dignity Improving lives

Commitment to quality of care Everyone counts