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PERSONAL HEALTH BUDGET POLICY FOR CHILDREN AND YOUNG PEOPLE (0-18 years)

POLICY AND PROCEDURE

Issued by:

The Chief Officer

Policy Classification:Corporate

Policy No.

Issue No:001

Date Issued: 02/07/2015

Page No:1 of 33

Review Date: 02/07/2016

NHS BROMLEY CLINICAL COMMISSIONING GROUPPERSONAL HEALTH BUDGET POLICY FOR CHILDREN AND YOUNG PEOPLE

DOCUMENT CONTROL

Document Name: Personal Health Budget Policy

Location: Q/CCG POLICIES AND TEMPLATES/POLICIES/Corporate

Consultation:

Ratified by: CCG Governing Body Date: 25/06/2015

Supersedes: N/A

Description:

Audience: Member Practices, Governing Body, All Staff, Individuals working for the CCG

Contact details: [email protected]

Change HistoryVersion Date Author Approver Reason1.0 28 May 2015 Catherine Kane JICE Mandatory policy

requirement

1.0 25 June 2015 As above CEG

1.0 16/07/15/2013 As above Governing Body Audit Committee changes incorporated

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Equality Analysis

This Policy is applicable to all staff employed by the CCG and those staff who work on behalf of the CCG. This document has been assessed for equality impact on the protected groups, as set out in the Equality Act 2010. This document demonstrates Bromley’s CCG’s commitment to create a positive culture of respect for all individuals, including staff, patients, their families and carers as well as community partners.

The intention is, as required by the Equality Act 2010, to identify, remove or minimise discriminatory practice in the nine named protected characteristics of age, disability, sex, gender reassignment, pregnancy and maternity, race, sexual orientation, religion or belief, and marriage and civil partnership. It is also intended to use the Human Rights Act 1998 and to promote positive practice and value the diversity of all individuals and communities.

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CONTENTS PAGE

AIM OF POLICY.........................................................................................................4DEFINITION OF A PERSONAL HEALTH BUDGET.................................................4LEGISLATION AND GUIDANCE...............................................................................5PURPOSE OF PERSONAL HEALTH BUDGET........................................................6PRINCIPLES FOR PERSONALISATION IN HEALHT..............................................6STANDARDS FOR SELF-DIRECTED HEALTH SUPPORT.....................................7SCOPE – WHO CAN HAVE A PERSONAL HEALTH BUDGET?............................8WHAT A PERSONAL BUDGET CAN AND CANNOT BE USED FOR.....................8REVIEWING PERSONAL HEALTH BUDGETS........................................................9STOPPING OR RECLAIMING PERSONAL HEALTH BUDGETS............................10SUPPORTING SERVICE USERS IN MANAGING THEIR PERSONAL HEALTH BUDGET...................................................................................................................11APPROVAL OF PERSONAL HEALTH BUDGETS.................................................12EQUIPMENT PURCHASED USING A PERSONAL HEALTH BUDGET................13ORGANISATIONAL RISK.......................................................................................13THE PROCESS AND RESPONSIBILITIES FOR DELIVERING PERSONAL HEALTH BUDGETS.................................................................................................14INTEGRATION WITH BROMLEY LOCAL AUTHORITY (LA)................................15EQUAL OPPORTUNITIES/EQUALITIES IMPACT ASSESSMENT........................15REVIEW DATE.........................................................................................................15

Appendix 1 Terms of Reference for Personal Health Budgets Panel................16Appendix 2 Personal Health Budget Direct Payment Contract..........................19Appendix 3 Equality Impact Assessment.............................................................22Appendix 4 Disputes and Appeals.........................................................................26Appendix 5 End to End Process............................................................................28Appendix 6 Glossary of Terms..............................................................................29Appendix 7 Useful Links........................................................................................32

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1 AIM OF POLICY

1.1. The introduction of personal health budgets is one of several national policies to support personalisation, choice and empowerment in the delivery of healthcare. The document sets out how personal health budgets will be implemented locally by Bromley Clinical Commissioning Group.

1.2. The right to hold a personal health budget applies to service users in receipt of Continuing Care funding up to 18 years of age who request a Personal Health Budget (PHB) and to children with Education, Health and Care (EHC) Plans as a result of having special educational needs and disabilities.

1.3. Better Health for London, the Five Year Forward View and the National Information Board Strategic Framework provide a strong mandate for greater empowerment of service users to be at the heart of their care with more control over the support they receive working alongside health and other professionals.

1.4. In terms of the Public Sector Equality Duty, this policy reiterates the commitment by Bromley CCG to create a positive culture of respect for all individuals, including staff, patients, their families and carers as well as community partners. The intention is, as required by the Equality Act 2010, to identify, remove or minimise discriminatory practice in the nine named protected characteristics of age, disability, sex, gender reassignment, pregnancy and maternity, race, sexual orientation, religion or belief, and marriage and civil partnership. It is also intended to use the Human Rights Act 1998 and to promote positive practice and value the diversity of all individuals and communities.

1 DEFINITION OF A PERSONAL HEALTH BUDGET

2.1 A personal health budget is an amount of money to support a person’s individual healthcare and wellbeing needs which is planned and agreed between the individual and their local NHS team.

2.2 Personal Health Budgets can be held in one of three ways;- Notional budget: no money changes hands. The Clinical Commissioning Group holds the budget and makes arrangements to support the service user in meeting his/her care needs. The care coordinator will then arrange the agreed care. - Real budget held by a third party (managed budget): a different organisation or trust independent of the service user and Clinical Commissioning Group holds the money for the service user and helps him/her to decide what they need and then buys the services they have chosen.- Direct payment: the service user receives the cash to buy the services and training that they and their care coordinator decide they need. The service user becomes the budget holder and has to demonstrate what they have spent the money on but they can buy and manage the services themselves. Details of what services are available through the brokerage service. The definition of representatives for service users without capacity is set out in Appendix 6, page 31.

2.3 There are five essential characteristics of a personal health budget. The service user or representative on behalf of the service user must:

- Be able to choose the health outcomes they want to achieve.

- Know how much money they have for their health care and support.

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- Be enabled to create their own care plan, with support if they want it.

- Be able to choose how their budget is held and managed.

- Be able to spend the money in ways and at times that make sense to them, as

agreed in their plan.

2 LEGISLATION AND GUIDANCE2.1 The initiative for personal health budgets originated from social care and

organisations of disabled people pressing for the right for autonomy in their lives and for control over the assistance they needed in order to live independently. Relevant guidance includes the following:

NHS Next Stage Review: High quality care for all (Department of Health 2008) outlined plans for personal health budgets.Health Act (2009) Allowed selected Primary Care Trust sites to pilot direct paymentsHigh quality care for all: The operating framework for the NHS in England 2009/10 outlined NHS priorities such as better access, reduced inequalities, partnership working in delivering personalised care, and supporting service user contributions to improvement and shaping high quality provision.Guidance on Direct Payments for Healthcare: Understanding the Regulations (2014)Guidance on the ‘right to have’ a Personal Health Budget in Adult NHSContinuing Healthcare and Children and Young People’s Continuing Care (2014)National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules), Amendment No.3 Regulations 2014NHS England website has a section on personal health budgets: http://www.england.nhs.uk/healthbudgets/The Peer Network, a user-led organization for personal health budgets, has its own website: http://www.peoplehub.org.uk/?page_id=28

2.2 On 1 August 2013, the Direct Payment in Healthcare regulations came into force across England, meaning that the NHS can lawfully offer direct payments for healthcare.

3.3 Other relevant legislation includes:

Human Rights Act [1998] including Article 8 Right to respect for private and family life, and Article 14 Prohibition of discrimination

The Data Protection Act (2003)

The Carers (Equal Opportunities) Act (2005) which ensures that carers are able to take up opportunities that people without caring responsibilities often take for granted.

The Mental Capacity Act (2005). The need to apply the Mental Capacity Act features strongly in self-directed support where there may be concerns about a

http://www.peoplehub.org.uk/?page_id=28

http://www.england.nhs.uk/healthbudgets/

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service user who appears to lack the mental capacity to manage their own money and/or the ability to make decisions about their care.

The Equality Act 2010 replaced previous anti-discrimination laws with a single Act.

The Children and Families Act 2014 introduced integrated Education, Health and Care Plans for children and young people with special educational needs and disabilities along with the right to hold a personal budget from October 2014.

3 Purpose of personal health budget

3.1 The purpose of having a personal health budget is to enable service users to identify their health and wellbeing goals and together with their care coordinator set out how the budget will be spent to enable them to reach their goals and keep healthy and safe.

3.2 The CCG is committed to promoting service user choice – where available, while supporting them to manage risk positively, proportionately and realistically. Good practice must support choice. The attitude of the health care professional is to support and encourage service user’s choice as much as possible, to keep the service user informed in a positive way of issues associated with those choices and how to take reasonable steps to manage them.

3.3 Recognising the benefits to the lives of service users and carers, it is not only possible for each service user to have a support plan which enables them to manage identified risks, but also to achieve their potential and to live their lives in ways which best suit them.

4 Principles for personalisation in health

4.1 There are six key principles for personal health budgets and personalisation in health.

• Upholding NHS principles and values. The personalised approach must support the principles and values of the NHS as a comprehensive service free at the point of use, as set out in the NHS Constitution, and should remain consistent with existing NHS policy.

• Fully involve service users and their carers in discussions and decisions about their care using easily accessible, reliable and relevant information in a format that can be clearly understood

• There should be clear accountability for the choices made.• No one will ever be denied essential treatment as a result of having a

personal health budget.• Having a personal health budget does not entitle someone to additional or

more expensive services or to preferential access to NHS services.• There should be good and appropriate use of current NHS resources.

4.2 Quality, safety, effectiveness and experience should be central. The wellbeing of the individual is paramount. Access to a personal health budget will be dependent on professionals and service user and/or representative agreeing a care plan that is safe and will meet agreed health and wellbeing outcomes. There should be transparent arrangements for continued clinical oversight, proportionate to the needs of the service user and the risks associated with the care package. There may be risks arising from the proposed support plan; some of which may be appropriate for the personal budget holder to accept/carry, assuming s/he has the mental capacity to

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understand those risks. Risk may include the following: clinical risks arising from the procurement of a particular type of service risks arising from the employment relationship where direct payments

are used to secure services from an employee risks arising from a service provider procured by means of direct

payments who is operating under an inadequate or lack of procedure for the investigation of complaints arising from the provision of services

risks arising from a service provider secured by means of direct payments operating under inadequate or no insurance or indemnity cover for the service to be provided

risk that monies paid by way of direct payment may go missing, be misused or be subject to fraud

risks associated with a third party holding the personal health budget money for the service user.

Risks such as those highlighted above must be raised with the personal budget holder and ways of reducing the risk (where feasible) must be discussed. Each of these risks must be written into the support plan, and the service user or representative must sign to indicate full understanding of the nature of the risks, agree to act to reduce the risks where feasible and accept any risk remaining.

4.3 Tackling inequalities and protecting equality. Personal health budgets and the overall movement to personalise services could be a powerful tool to address inequalities in the health service. A personal health budget must not exacerbate inequalities or endanger equality. Lack of mental capacity1

should not be a factor. The decision to set up a Personal Health Budget for an individual must be based on their needs, irrespective of race, age, gender, disability, sexual orientation, marital or civil partnership status, transgender, religion or beliefs.

4.4 Personal health budgets are purely voluntary. No one will ever be forced to take more control than they want.

4.5 Making decisions as close to the service user as possible. Appropriate support should be available to help all those who might benefit from a more personalised approach, particularly those who may feel least well served by existing services or access, and who might benefit from managing their budget.

4.6 Partnership. Personalisation of healthcare embodies co-production. This means individuals working in partnership with their family, carers and professionals to plan, develop and procure the services and support that are appropriate for them. It also means the Clinical Commissioning Group, the Local Authority and healthcare providers working together utilise personal health budgets so that health and social care work together as effectively as possible.

6 Standards for self-directed health support

6.1 The following standards for self-directed support are followed nationally and articulated as seven outcomes, which will be delivered through the implementation of this policy. These seven outcomes are:

Outcome 1 Improved health and emotional well-being: To stay healthy and

1 Mental Capacity Act 2005

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recover quickly from illness. Outcome 2 Improved quality of life: To have the best possible quality of life,

including life with other family members supported in a caring role. Outcome 3 making a positive contribution: To participate as an active

citizen, increasing independence where possible. Outcome 4 Choice and control: To have maximum choice and control. Outcome 5 Freedom from discrimination, harassment and victimisation: to

live free from discrimination, harassment and victimisation. Outcome 6 Economic well-being: To achieve economic well-being and have

access to work and / or benefits as appropriate. Outcome 7 Personal dignity: To keep your personal dignity and be

respected by others.

7 SCOPE – WHO CAN HAVE A PERSONAL HEALTH BUDGET?

7.1 This policy applies to Continuing Care service users from birth -18 years for whom Bromley CCG is the Responsible Commissioner2 including administration of this function.

7.2 Anyone eligible for Continuing Care can have a personal health budget. Please refer to Appendix 6 for section on use of a representative where the service user may lack capacity to hold a personal health budget.

7.4 Personal Health Budgets can only be used for care of service users in their own home.

7.5 While we recognise the ‘right to have’, there are circumstances where Bromley CCG may refuse a request. These are as follows:

there is evidence of financial abuse where the cost of the service to be purchased from a personal health budget

exceeds the cost which would have been paid for the equivalent service via usual commissioning arrangements. This is necessary to ensure the NHS Constitution principle ‘the NHS is committed to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources’ is upheld

where the service user, representative or third party are not deemed appropriate or able to manage their finances.

8 What a Personal Health Budget can and cannot be used for

8.1 The Continuing Care coordinator should advise the individual and their family or support planner about existing NHS services and other services.

8.2 Apart from those specified below, there are no hard and fast rules for what a Personal Health Budget (PHB) can be used for; the main determinant being whether a particular expenditure will meet the desired outcomes set out in the care plan.

8.3 Personal Health Budgets cannot be used to buy:

Alcohol, tobacco, fund gambling or debt repayment, or anything that is illegal emergency or urgent care

Primary medical services such as GP care, dental treatment

2 http://www.england.nhs.uk/wp-content/uploads/2014/05/who-pays.pdf

http://www.england.nhs.uk/wp-content/uploads/2014/05/who-pays.pdf

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Medication Inpatient care Long-term residential or nursing care

It should be noted that this list is not exhaustive and, if unsure, the service user should seek advice before the expense is incurred.

8.4 The Clinical Commissioning Group provides personal health budgets so that service users may use them to meet their health and well-being needs. The funding must not be used to purchase services that Bromley CCG or other bodies (e.g. Bromley Local Authority Social Services, Housing Authorities) has commissioned. If an individual wants to purchase these services using their personal health budget, they will need to discuss this with their care coordinator.

8.5 People who access their personal health budgets through Direct Payments or Direct Payments via Third Party are required to maintain sufficient records to be able to demonstrate, if required, that any money provided to them as personal budget has been used in accordance with achieving the outcomes agreed in their individual support plan.

9 REVIEWING PERSONAL HEALTH BUDGETS

9.1 There are two sets of reviews for service users who have personal budgets:

1) A review of an individual’s health needs. This review should be carried out in line with the National Framework for Children and Young People with the recommended minimum of three months after they become eligible for Continuing Care and annually thereafter depending on needs.

A review of needs may also be carried out if the Continuing Care team becomes aware of any change in the support needs of the service user.

2) Review of service users with direct payments. This review looks at how the personal health budget is being spent. This may vary from person to person but at a minimum, the review will be in line with the NHS direct payments regulations, i.e. within three months of the first direct payment being made and every three months thereafter.

NOTE: At the time of print, further work will be undertaken to align the systems for monitoring of direct payments in cases where a service user has an Education, Health and Care Plan in which s/he receives a direct payment from Education and/or Social Care as well as from Health.

In the meantime, where a service user receives a direct payment from both Bromley Clinical Commissioning Group and London Borough of Bromley, steps will be taken by both organisations to reduce the administrative burden on the service user on a case by case basis.

9.2 Bromley CCG has engaged with a Third Party organisation to provided brokerage, monitor and review the support plans.

9.3 Monitoring and reviewing of support plans should be proportionate to needs and risk in the context of our duty of care and statutory responsibilities.

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9.4 A face-to-face review must be held at least once a year. Frequent reviews will be a condition of higher risk Personal Health Budget requests receiving approval.

9.5 The personal health support plan will be reviewed against the following criteria: whether it meets personal health and well-being outcomes needs and risks associated with the plan cost neutrality or improved value for money the quality of support and service any changes in needs and circumstances

9.6 Intensity and frequency of review should be based on the risk assessment conducted for each service user.

10 STOPPING OR RECLAIMING PERSONAL HEALTH BUDGETS

10.1 Where direct payments/personal health budgets are stopped, Bromley CCG will give notice to the Continuing Care service user or his/her representative in writing. There is no fixed notice period for stopping direct payments/personal health budgets. The time taken before stopping personal health budgets will depend on any contractual obligations the personal health budget may have entered into.

10.2 Bromley CCG will ensure that alternative support to meet Continuing Care service user needs will be put in place.

10.3 Direct payments are not a welfare benefit and do not represent an entitlement to a fixed amount of money. Personal health budgets and direct payments in particular are paid to meet assessed health and care needs. Where individual’s needs change, a review of the personal health budget will take place; the result of which will be reflected in the value of the personal health budget/direct payment.

10.4 The use of Personal Health Budget (PHB)/Direct Payment does not absolve the CCG from its commitment and policy relating to Anti-Fraud measures. These will apply in all cases of PHB, irrespective of funding base. Risk of fraud will be a risk maintained on the PHB risk register and advice or proactive reviews will be provided by the Local Counter Fraud Service.

10.5 Except in exceptional circumstances, it is the responsibility of the PHB holder to ensure that the CCG is informed if they are admitted to hospital.

10.6 In the event of a surplus on the PHB, the CCG reserves the right to reclaim any funds required to meet the needs identified in the support plan.

10.7 The CCG reserves the right to recharge the PHB holder for any expenditure not used in accordance with the support plan.

10.8 The bank account set up by the PHB holder must not have an overdraft facility.

11 SUPPORTING SERVICE USERS IN MANAGING THEIR PERSONAL HEALTH BUDGET

11.1 Where the CCG manages a service user’s personal budget on their behalf in a Notional Budget, there is no requirement for the service user to maintain financial records.

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11.2 In the case of both ‘managed budgets’ on behalf of the service user and ‘direct payments’ to the service user, the CCG will assess the suitability of both individuals and companies to hold and manage these budgets and ensure that it is satisfied that any representative is compliant with the National Health Service (Direct Payments) Regulations 2013.

11.3 How a personal health budget is used or managed must be set out in a support plan.

11.4 A support plan is developed by the individual/their family and the Continuing Care coordinator. The plan shows how a personal health budget will be used to achieve the identified health care outcomes. The plan should include details of who will be providing each element of support, who will manage the budget and include any contingency planning. Good support planning involves looking holistically at a person’s life to improve their health, safety, independence and wellbeing.

11.5 Personal health budgets are based on individual’s health needs and desired outcomes.

11.6 Bromley CCG uses the Bromley Resource Allocation Tool to help decide the level of funding in each person’s personal health budget. The Resource Allocation Tool allocates resources fairly and in a transparent manner so that each service user knows how much money is available, before beginning to plan their support. The cost of different types of support available will be made explicit, so people can make informed choices as to the best possible use of their personal health budgets and achieve value for money.

11.7 Service users will be able to choose to take their budgets in one of three ways; as a notional budget managed by the CCG; appoint a ‘third party’ to manage it for them or take a ‘direct payment’ and manage it themselves.

11.8 Existing Continuing Care service users will be given the opportunity to discuss personal health budgets at their next Continuing Care review.

11.9 There is support available to personal budget holders who opt for direct payment. This support is known as brokerage. Independent advisors or brokers work closely with the budget holders, representatives and service users to choose services to meet their health outcomes and develop a plan to describe these as identified within the support plan.

11.10 The following costs will normally be paid as part of the Personal Health Budget (PHB):

The direct cost of providing the service, including support service costs Start-up costs such as initial staff trainingDisclosure and Barring Service ChecksRefresher trainingEquipment costs (where equipment specifically forms part of the PHB and is not provided via the CCG’s community equipment contract)

Funding to cover the contingency plan (such as using an agency if a Personal Assistant is off sick)

Equipment contingency (e.g. hire fee to cover breakdown not covered by insurance or by the CCG’s community equipment contract)Risk assessments (e.g. moving and handling)

11.11 Additional elements may be required to be funded within the PHB for the following contingencies:

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Redundancy costs when a service provided by PA’s ceases, if the PA is entitled Maternity pay, if the PA is entitledLong term sicknessTraining to support newly employed staff

12 Approval of Personal Health Budgets

12.1 Personal health budget support plans will be taken to the Personal Health Budget Panel and reviewed against the following criteria:

That the Personal Health Budget criteria have been fulfilled.

The support plan reflects the views of the Continuing Care service user.

That both Continuing Care service user and/or their representative and Continuing Care co-coordinators have signed the support plan.

That the service user and/or their representative have signed to indicate full understanding of the nature of the risks, agree to act to reduce the risks and accept any residual risk.

Bromley CCG recognises that certain risks (assessed on a case by case basis) may be viewed as clinically and/or organisationally acceptable. In such instances, the service user will be fully informed in writing by the panel.

That the value of the indicative budget is checked for accuracy and the final budget is within 10 per cent (10%) of the indicative budget.

Determine whether the support plan will deliver the agreed outcomes including plans for review.

Be assured that safeguarding provisions are in place.

Be assured that contingency plans are in place.

Ensure that the plans for the direct payments are in line with NHS Direct Payments regulations

Where a direct payment has been authorised, the panel will need to have sign of the compliance statement(s) with the Direct Payment Regulations (2013).

Membership of the Personal Health Budget Panel is comprised of the following members:

Vibrance representativeLocal Authority representativeFinance Representative – CCGCCG Lead ManagerCCG Senior Manager (Chair)CCG Risk/Quality Team

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13 Equipment purchased using a personal health budget

13.1 Bromley CCG would expect any specialist equipment purchased with a personal health budget to be returned to the CCG, when no longer required. Any other equipment purchased will be assessed on a case by case basis, once it is no longer required.

13.2 Bromley CCG currently provides the equipment service via its provider contract with Medequip. This includes repatriation, re-cycling and/or write-off of equipment purchased via a personal health budget which is no longer required.

13.3 All equipment where possible should be purchased and maintained. However, we do recognise that certain items may provide a more personalized and/or better value option when procured direct through the personal health budget. This is an option which Bromley CCG will consider, but any such items must be subject to quality assurance and sign off by the relevant CCG CHC case manager.

14 Organisational risk

14.1 Responsibility for authorising PHBs is the responsibility of the CCG which has an obligation to ensure the following are met:

o health and well-being needs are being meto safeguarding duties are fully meto it is fulfilling its duty of care and broad statutory obligationso it is fulfilling its responsibility to ensure that public funds are used to

enable customers to live independent and full lives – ensuring value for money

o PHB expenditure is managed within the overall CCG budgetary allocation for CHC ensuring the CCG meets its statutory duty to breakeven on its resource limit,

o that public funds are used appropriately

14.2 The CCG is committed to shifting the balance of risk towards a positive approach of supported decision-making for service users, the organisation, and its partners.

14.3 The CCG will work with partner organisations to promote a wider understanding of this approach to risk. It will also seek to secure from partners, a complementary approach to risk which is as light touch as is reasonable.

14.4 The CCG will work with the Local Authority as lead agency should any safeguarding concerns arise in relation to physical, sexual or financial abuse of an individual receiving a PHB. These will be investigated accordingly.

14.5 To sign off a PHB request, the Personal Health Budgets Panel will approve:

the proposed budgetthe outcomes plan including a plan for contingencies the supporting risk assessmentEffective reporting mechanisms to demonstrate improved outcomes, benefit and value for money

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14.6 The CCG will have an appeal process (see Appendix 4) to consider appeals in the following situations:

A request for a PHB was not approvedThe type of PHB requested was not approved, and the type of PHB offered is not acceptable to the service userthe final funding allocation is challenged by the service user, or the decision making process is challenged by the service user.

15 THE PROCESS AND RESPONSIBILITIES FOR DELIVERING PERSONAL HEALTH BUDGETS

The service user:1. Makes a request for a personal health budget to the CCG.

The CHC Provider:2. establishes a clear understanding of an individual’s needs,3. identifies the cash value of the PHB to which that person is entitled. This is the

indicative PHB.

The service user:4. decides what kind of PHB they want (this may come later when they have

decided how they want to use their PHB to meet their needs)5. is supported to develop a care plan, which identifies the goals (outcomes) a

person has for their health and wellbeing

The CCG6. approves the care plan on the basis of being financially affordable and clinically

appropriate (approval is dependent on achievement of agreed goals).7. Approves the type of PHB requested (i.e. direct payment, brokered/3rd party, or

notional budget8. agrees the final budget

The Service user/3rd Party Organisation/Broker (holding the budget in collaboration with the service user):9. implements, the services and supports in the plan can be10. provide the care manager and CCG with evidence of expenditure and other

monitoring information as required

The Care Manager/Provider:11. reviews the support plan every three months and its effectiveness is

measures against achievement of goals (outcomes) identified in the care plan.

12. If a person’s needs change significantly, a new assessment will be required which may necessitate the need for a new PHB.

13. The personal budget is reviewed every three months in terms of spend against planned needs and outcomes.

The CCG (or via its agents such as the Commissioning Support Unit, Internal Audit service or Local Counter Fraud Service):14. ensures financial flows/information and reports are timely15. undertakes financial monitoring16. refers matters of fraudulent expenditure for further investigation

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Table 1 in Appendix 5 sets out the process in greater detail.

16 INTEGRATION WITH LONDON BOROUGH OF BROMLEY

16.1 The LA is an integral partner in the effective delivery of PHB and member of the Personal Health Budget Panel.

16.2 The CCG will work with the LA to:

ensure that the processes for managing PHB where there is an interface with the LA, is aligned to minimise the impact on the service user, for example those in receipt of Social Care Direct Payment (DP) or Education Direct Payment.

ceasing eligibility for Continuing Care and returning to Local Authority Direct Payment

explore approaches to providing direct payments develop a shared understanding of risk develop other shared approaches, as appropriate work with service users, user groups and voluntary sector groups, to

minimize duplication and maximise opportunities for involvement.

17 EQUAL OPPORTUNITIES/EQUALITIES IMPACT ASSESSMENT

17.1 An Equality Impact Assessment has been completed for this policy and procedure and it does not marginalise or discriminate against protected population groups (see Appendix 3)

18 REVIEW DATE

18.1 This policy and procedure is for one year only and will be reviewed and updated in June 2016, or earlier at the request of either staff or management side, or in light of any changes to legislation or National Guidance.

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APPENDIX 1 Terms of Reference for Personal Health Budgets Panel

1 Aims:

To approve Personal Health Budget (PHB) requests To provide assurance to the CCG on all aspects of PHBs To oversee and refine the ongoing implementation of PHB To review the policy for 2015 onwards for approval by the CCG Ensure PHB implementation is affordable within the CCG’s overall budgetary

provision for CHC and represents an improvement in value for money

2 Objectives:

The PHB Panel will:

Approve PHB requests from providers on behalf of the CCG by approving PHBs, Outcomes plans and the associated risk assessments and risk management plans

Receive complex reviews Consider high cost requests Provide a forum to consider complex or potentially higher risk PHB requests/cases

ahead of the request for CCG approval Ensure all paperwork is correctly completed including signed agreements with service

users (or their nominated representatives) Undertake financial monitoring of PHBs and make changes as required where

forecasts indicate budgetary pressures Provide an opportunity for ongoing PHB learning and support within all partners,

including service users and the voluntary sector Disseminate learning from implementation Devise a work plan to include at least an annual review of PHB policy Develop service user involvement focus, including monitoring and evaluation Receive

Personal Health Budget activity reports Receive provider reports, to include quality report on incidents, complaints,

safeguarding Receive PHB Appeals Panel reports Maintain the Risk Register for Personal Health Budget

Approve reports for CCG governance processes Approve reports for CCG external reporting and performance management Make recommendations relating to roll out to Long Term Conditions based on

continuing care personal budget implementation learning in 2015

3 Members:

Vibrance representativeLocal Authority representativeFinance Representative – CCGCCG Lead ManagerCCG Senior Manager (Chair)CCG Risk/Quality Team

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Members should ensure that a delegate is sent, or at minimum, a written report provided if they are unable to attend.

4 Frequency:

The meetings will take place on a monthly basis or as and when required.

5 Reports to: Quality & Governance Committee for matters of policy and quality and to the Finance Committee for financial matters

6 QuorumThe panel is quorate when the following members are present: Provider Finance CCG Risk/Quality Team CCG Lead ManagerPlus case coordinator if presenting a PHB for approval

7 Proposed monitoring schedule

1. Finance: routine and trend reports on each Personal Health Budget spend including recommended changes to budget values, e.g. where a large surplus is accruing

breakdown of the overall cost of Personal Health Budgets to the CCG, including direct and indirect costs

detailed report on any additional costs incurred which was not part of the agreed PHB

Any other as identified

A detailed procedure note has been produced for PHB direct payments andfinancial review for use by CCG and CSU finance staff.

2. Uptake of Personal Health Budgets

The following information by protected characteristics:

a. number of service users eligible for Personal Health Budgetsb. number of service users exploring Personal Health Budgetsc. number of service users taking up Personal Health Budgets (breakdown of

uses of Personal Health Budget)d. number of service users giving up Personal Health Budget whilst

entitled to hold a PHBe. any externally required reporting not covered above

3. Service user experience of Personal Health Budget’s 4. Any other agreed user focused monitoring5. Address any requirements from the Quality and Governance

Committee

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6. Provider report from Vibrance:

8 Review date

1 year

Accepted by Quality and Governance Committee Date

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APPENDIX 2 Personal Health Budget Direct Payment Contract

Bromley CCG Personal Health Budget Direct Payment Contract

Person agreement

I agree to only use my personal health budget/direct payment to buy the services as detailed in my support plan, and any related expenses that have been agreed with______________________. I will not misuse the money in any way. The product or service as agreed is for ___________________________________________and the money to be paid is ______________________________ which is a one-off payment and/or ongoing payment of ___________ [delete as appropriate].

I understand that my support plan and direct payment will be reviewed every 3 months, and if I am assessed for different services I may be re-assessed for direct payments.

In accordance with _____________ financial monitoring policy, I agree to open a dedicated, separate bank account for the payments and send copies of bank statements to ________________ every 3 months. For a one-off purchase I will send the receipt or invoice to the same office.

Or *

I will use a bank account already set up to receive direct payments from _____________ Council and send copies of bank statements to the _________________ every 3 months. For a one-off purchase I will send the receipt or invoice to the same office.

Or *

I will ask a third party ____________________________________ to act as my agent by holding the money on my behalf.

(*Please delete as applicable)

I agree that I (or my agent) will send ____________________ , details of how the money has been spent at intervals of ___________ or otherwise as requested.This refers to ongoing payments and not one-off payments.

I agree that I will meet all legal requirements and obligations relating to the services I pay for using my direct payments.

I agree to take out employers and public liability insurance if I am employing my own staff. The direct payment will cover this cost.

I agree that I will not use my direct payment to employ my partner (married or not) or any of my close relatives who live with me. This means a parent, parent-in-law, aunt, uncle, grandparent, son, daughter, son-in-law, daughter-in-law, step son or daughter, brother, sister, or the spouse or partner of any of these. (In exceptional circumstances, relatives may be employed, but only by prior agreement with __________________ )

I understand that _______________ strongly recommend that I should ask for appropriate checks to be made through the Criminal Records Bureau on all my prospective employees.

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*I intend to seek Disclosure and Barring Service (DBS) Checks for my employees

OR

*I do not intend to seek DBS Checks for my employees

(*Please delete as applicable)

I understand that _______________ has the right to stop my direct payment if they decide that my employee or care provider is unsuitable.

I understand that I can stop my direct payment by giving four weeks’ notice and agree to repay any unspent money.

I will be given at least 4 weeks’ notice by _______________ of any suspension or stoppage of my direct payments and advice about what I can do to prevent this happening.

In the case of equipment or products, I agree to maintain and safely look after the item and insure as necessary to prevent from theft or damage.

I understand that if I do not keep to the above terms and conditions _______________ may stop the payments and I may be required to return all or part of the money I have received.

Signed: ______________________________________________________

Print name: ___________________________________________________

Dated: _______________________________________________________

Bank account detailsPersons approved for a personal healthcare budget direct payment must complete the following bank account details form to ensure prompt payment can be made. Please note: this information will be stored in the strictest confidence and in accordance with the Data Protection Act, 1998.

Person’s Name

Person’s Address

Account Number

Sort Code

Bank account name / address

Is this account separate to your personal bank account?

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Is this account set up to receive social care direct payments from your council?

Do you consent to the CCG making payment?

For CCG Completion Only

Frequency of payment agreed

Date of first payment

Type of payment

Purchase agreed

Confirmed account is separate toperson’s personal bank account

Budget holder authorisation –name and signature is required

Date

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APPENDIX 3 Equality Impact Assessment

Equality Impact Assessment

A full EIA will be needed if the initial assessment has identified the potential for negative impact, on the basis of race, sex disability, age, sexual orientation or religion.

Policy/Strategy/Project - Aims and objectives

1. What is the name of the policy/strategy/project?

Personal Health Budgets Policy(NHS Continuing Care service users)

2. Briefly describe the aim the purpose of the policy/strategy/project? How does it differ from any existing policies/strategies or projects and who is it intended to benefit?

Personal health budgets should help children and young people (0-18 years) get a more personalised service from the NHS.

A personal health budget 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. Our vision for personal health budgets 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.

People who are eligible for NHS Continuing Care have had a right to have a personal health budget since October 2014. Since April 2015, children and long term conditions have the right to request a personal budget.

Clinical commissioning groups (CCGs) can also offer personal health budgets to others that they feel may benefit from the additional flexibility and control.

3. Who are the main stakeholders of the policy/strategy/project or proposed process?

Children and young people 0-18 years and their families/representatives

Bromley CCG

Bromley Local Authority

4. Have you consulted externally as part of your assessment? Who have you consulted? What methods did you use? And what have you done with the results i.e. how do you intend

http://www.nhs.uk/chq/pages/2392.aspx

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to use the information gathered as part of the consultation.

All views were given full consideration. Consultation would have been undertaken as part of Health and Social Care Act.

5. Is there any evidence to suggest that this could have an adverse impact on some groups? If so, please specify the nature and reasons for this adverse impact?

This policy is expected to have a positive impact for children and young people and their families

6. Is there any evidence or reason to believe that some groups could be differently affected by this policy/strategy or project (e.g. lower rate of participation, directly excluded or discouraged)?

Those children and young people with complex and enduring disabilities or have long term conditions are the target group for personal health budgets. The policy allows for those service users lacking capacity and those with fluctuating capacity to be supported to hold a personal health budget or have one held on their behalf. This policy is expected therefore to have a positive impact.

7. Is there a public concern (in the media etc.) that this function or policy is being operated in a discriminatory manner?

None

8. Is the policy/strategy/project directly or indirectly discriminatory?

No

9. If in your judgement, the proposed policy/strategy/project does have an adverse impact, could that impact be justified? You need to think whether the proposed change will have a positive or negative effect on the promotion of equality of opportunity, if it will help eliminate discrimination in any way, or encourage or hinder community relations.

The Continuing Care team will work alongside the service user at all stages of the personal budget process from initial contact through to the development of the care plan and the

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desired outcomes and needs to be met by the personal budget.

10. What amendments could be made to the policy/strategy/project to eliminate discrimination, if any has been identified?

The personal budget policy will be amended to describe the process for children and young people with long term conditions who may request a personal budget. This is under review at time of writing.

11. If you have identified an adverse effect which cannot be justified or illegal discrimination what action will be taken to rectify the situation?

The Personal Health Budgets Panel comprised of multi-agency representation will review and identify the most appropriate course of action

12. What arrangements have been/will be made for publishing the results of this EIA?

Information will be provided on request.

13. Can you please outline what arrangements you have made to monitor the impact of this policy/strategy/project in the future?

Signed by the Manager undertaking the assessment :

Full name (in capitals please):

Dated:

Job Title:

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Monitoring and Review

Date for review

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Appendix 4 Disputes and Appeals

Disputes and Appeals

1 Introduction

1.1 From October 2014 everyone who receives NHS continuing care funding will have a right to ask for a personal health budget rather than receiving services commissioned by others. The Clinical Commissioning Group (CCG) has the right to refuse this request, but must provide a transparent process and rationale for decision.

1.2 The care manager or support service provider should work with the service user to address the reasons why the PHB has been refused, and to revise the PHB to increase the likelihood of it accepted by the CCG.

1.3 The CCG will have an Appeals Panel to consider appeals in the following situations:

- A request for PHB was not approved- The type of PHB requested was not approved, and the type of PHB offered is

not acceptable to the service user- The final funding allocation is challenged by the service user, or the decision

making process is challenged by the service user.

1.4 All disputes will be managed through Bromley CCG complaints process.

1.5 The appeal process should only be started when this process cannot deliver a suitable PHB proposal, or when the service user refuses to engage in any revisions.

2 Purpose of the Appeal Process

2.1 To provide recipients of Personal Health Budgets (PHB) with a mechanism for appeal against personal health budget decisions. Appeal to the CCG may be against:

a PHB not being giventhe type of PHB granted the assessment of need the funding allocationthe decision making process, orany element of the PHB decision

2.2 Appeals cannot be made in relation to any aspect of NHS Continuing Healthcare, as this is a separate process.

2.3 Any service user dissatisfied with the response of the panel has recourse to the CCG’s complaints procedure and the Patient Advice Liaison Service (PALS). Any complaints about PHB received by the Complaints/PALS service which have not been through the appeal process will be passed to the panel for consideration

3 Principles

o All decisions relating to the granting of Personal Health Budgets are made in

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accordance with the principles set out within the Personal Health Budget Policy

o The local PHB appeal process should be applied before any case can be considered within the CCG’s Complaints Procedure

o Any appeal made will not delay or compromise the provision of a care package to an individual or their timely discharge from hospital.

o Appeals raised should be supported by evidence available within PHB records. Bromley CCG will make no changes until the appeal Panel’s decision has been made i.e. the status quo is maintained.

o If the appeal is upheld, the CCG’s PHB Manager will agree the timescale for action with the appellant.


Appendix 5 End to End Process

Table 1 The end to end process for personal health budgets for service users with Continuing Care (CC)

1. Assessment and Continuing Care approval

Eligibility for NHS Continuing Care is established If approved Continuing Care team send eligibility letter, CC leaflet

and PHB leaflet to CC service user/ their representative

2. Indicative budget setting and support plan development

CCG finance & CC coordinator input assessment information into Resource Allocation Tool to calculate indicative budget

CC coordinator inform CC service user of indicative budget and explains PHB process including options of using brokerage services

CC Nurse – produces draft support plan with CC service user/representative

Draft support plan approved or adjusted by CC Clinical Manager. Final support plan submitted for approval by PHB panel. Final budget confirmed as ‘Notional budget’ CC service user informed of final agreement and asked to sign PHB

agreement. Brokerage service referral instigated if required If Direct payments requested, referral to third party advisor, to begin

setting up DP arrangements

3.Service delivery- home care package; direct payments: PA employment

Brokerage – set-up home care package and or provide support for Direct payments

Brokerage – regular updates & liaison with CC service user and CC coordinator.

Financial audit– check payments are being spent appropriately.

4. Review CC review – at three months after eligibility established and annually

thereafter. CC review health and ensure that support plan is meeting needs.

Inform commissioning/brokerage if services not working Financial audit– check payments are being spent appropriately at

three month intervals

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APPENDIX 6 Glossary of Terms

GLOSSARY OF TERMS

Service user This refers to children and young people from birth to 18 years of age

AdvocacyActions to help people say what they want, secure their rights, represent their interests, and obtain services.

BrokerageBrokerage is the help and support that people may need to work out how best they can achieve their health outcomes as set out in their care plan, and gives them the support they need to plan spending their budget. This is wider than the traditional service provided by traditional care and nursing agencies. Brokerage functions may include: exploring what's available and possible, providing information and technical advice, developing informal support, co-ordinate resource, obtaining clinical support where necessary

Care ManagerThe Care Manager is responsible for oversight of a person’s care. In PHB, this means assessing need, ensuring that the service user can access support to plan their care, and ensuring that the care plan is signed off, monitored and reviewed at agreed intervals.

Children’s Continuing CareAn equitable, transparent and timely process for assessing, deciding and agreeing bespoke continuing care packages for children and young people whose needs in this area cannot be met by existing universal and specialist services. Assessment of these needs and the delivery of bespoke packages of care to meet them will take place alongside services to meet other needs, including education and social care. (Department of Health 2010)

Continuing HealthcareThis applies to adults. It is a complete package of ongoing care arranged and funded solely by the NHS, where it has been assessed that the individual’s primary need is a health need. It can be provided in any setting including in a person’s own home. It means that the NHS funds all the care that is required to meet their assessed health needs. In care homes, it means that the NHS also makes a contract with the care home and pays the full fees including for the person’s accommodation and all their care. (Department of Health 2009)

Co –productionCo-Production is about Equal and Respectful, Trusting and Purposeful relationships between policy-makers and those affected by policies, and budget decision-makers and those affected by budget decisions. Co-Production goes further than consultation or participation –in the broadest sense it is to encourage service to use their human skills and experience to share in public sector policy and processes.

Direct PaymentsPayments made by a local authority to a person who is eligible for social care support and who agrees to receive the money to enable them to make their own arrangements to meet their needs, instead of using services arranged and provided by the local authority.

Direct Payments to a “Suitable Person”Payments made to an appointed ‘Suitable Person’ (third party) to act on behalf of someone who is eligible for health care support, but who is unable to consent to receiving Direct Payments because they have been assessed as lacking the mental capacity to do so. The

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role is specified in the Mental Capacity Act 2005.

Education, Health and Care PlansThe Children and Families Bill 2013-14 requires that Statements of SEN will be replaced by a new birth- to-25 integrated education, health and care plan, to deliver better support for children and young people with special needs.

Final budgetThe final budget is an amount of money that is agreed once a support plan has been written. This is usually calculated by estimating the costs of the care and support arrangements included in the plan. This is likely to be a more accurate guide to the actual costs of support. The final budget – rather than the indicative budget (below) – is the point at which an approval process is needed.

Indicative budgetAn indicative budget is an amount of money identified at an early stage in the process to inform care and support planning. It is a prediction of how much money it is likely to cost to arrange the care and support that would be sufficient to meet the assessed health needs and achieve the outcomes in the care plan. The indicative budget is a guide – it should not be used as a limit, a fixed allocation or an entitlement. The indicative budget does not need to be exact, and in practice it is difficult to design a tool that will predict the costs of support accurately. Most approaches to setting budgets are accurate in no more than about 80 percent of cases.

NICE guidanceThe National Institute for Health and Care Excellence (NICE) provides national guidance and advice to improve health and social care. Guidance is available on a range of clinical topics, and the expectation is that services are commissioned in line with NICE guidance. NICE are accountable to the Department of Health.

Nominated RepresentativeThis may be the same as the Suitable Person (see below), or the organisation chosen to provide the service.

Outcome for an individualWhat the person achieves based on their support plan.

PersonalisationThe process by which state provided services can be adapted to suit you. In social care this means everyone having choice and control over the shape of their support along with a greater emphasis on prevention and early intervention.

Personal Health BudgetA personal health budget helps people to get the services they need to achieve their health outcomes, by letting them take as much control over how money is spent on their care as is appropriate for them.

SELF-DIRECTED SUPPORT (SDS)The system that gives people increased choice and control over the support they use to meet their social care needs including using personal budgets.

Support PlanA plan which describes how a person will use their personal health budget to meet their outcomes. It is likely to have a wider scope than a traditional health “care plan”.

Support Service providers

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Organisations that can provide a range of services to support the employment of PA’s, including payroll and ensuring that the requirements of employment legislation are met.

Definition of “representative” as used in this policy:

(a) any deputy appointed by the Court of Protection under section 16(2) (b) of the 2005

Mental Capacity Act.

(b) any done of a lasting power of attorney within the meaning of section 9 of the 2005

Mental Capacity Act.

(c) any person who has created an enduring power of attorney within the meaning of

Schedule 4 to the 2005 Mental Capacity Act (provisions applying to existing enduring

powers of attorney), which is registered in accordance with paragraphs 4 and 13 of that

Schedule .

(d) any person with parental responsibility for the child;

(e) in the case of a person aged 16 or over but lacks capacity and in respect of whom there

is a person with parental responsibility.

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Appendix 7 Useful Links

Useful Links:

Getting the sums right: How to sustainably finance personal health budgets

Joining up health and social care personal budgets: Key points on implementation

A wealth of information: Your questions on personal health budgets answered

Facing up to the challenge of personal health budgets: the view of frontline professionals

Personal health budgets: countdown to roll-out

Personal health budgets: the views of service users and carers

http://www.nhs.uk/choiceintheNHS/Yourchoices/personal-health-budgets/Pages/ getting-started.aspx

http://www.legislation.gov.uk/uksi/2013/1617/pdfs/uksi_20131617_en.pdf


http://www.personalhealthbudgets.england.nhs.uk/_library/Resources/ Personalhealthbudgets/2014/Guidance_on_Direct_Payments_for_Healthcare_Understanding_the_Regulations_March_2014.pdf

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http://www.personalhealthbudgets.england.nhs.uk/_library/Resources/Personalhealthbudgets/2014/Guidance_on_Direct_Payments_for_Healthcare_Understanding_the_Regulations_March_2014.pdf





http://www.nhs.uk/choiceintheNHS/Yourchoices/personal-health-budgets/Pages/getting-started.aspx

http://www.nhs.uk/choiceintheNHS/Yourchoices/personal-health-budgets/Pages/getting-started.aspx

http://www.nhsconfed.org/Publications/reports/Pages/Personal-health-budgets.aspx

http://www.nhsconfed.org/Publications/briefings/Pages/Personal-health-budgets.aspx

http://www.nhsconfed.org/Publications/reports/Pages/Facing-up-to-the-challenge-of-personal-health-budgets.aspx

http://www.nhsconfed.org/Publications/reports/Pages/Facing-up-to-the-challenge-of-personal-health-budgets.aspx

http://www.nhsconfed.org/resources/2014/09/a-wealth-of-information-your-questions-on-personal-health-budgets-answered

http://www.nhsconfed.org/resources/2015/01/joining-up-health-and-social-care-personal-budgets

http://www.nhsconfed.org/resources/2015/03/getting-the-sums-right-how-to-sustainably-finance-personal-health-budgets

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