2016

Personal Health Budgets POLICY GUIDELINES AND FRAMEWORK HOUNSLOW CCG

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1. Introduction .................................................................................................................................... 3

1.1 Background ................................................................................................................................... 3

1.2 Strategic Context ........................................................................................................................... 4

1.3 Legal and Policy Frameworks ........................................................................................................ 5

2 Personal Health Budgets ................................................................................................................. 5

2.1 What are Personal Health Budgets? ............................................................................................. 5

2.2 Eligibility for health funded support ............................................................................................. 6

2.3 Who may not be eligible to receive Personal Health Budgets? .................................................... 7

3 Personal Health Budget Process ..................................................................................................... 7

3.1 The End-to-End Process for Personal Health Budgets .................................................................. 7

3.2 Process for Implementation.......................................................................................................... 8

3.3 Further Detail .............................................................................................................................. 10

3.4 Methods and Frequency of Payments ........................................................................................ 11

4. Receiving Personal Health Budgets .............................................................................................. 11

4.1 Who is a suitable person to receive a Personal Health Budget? ................................................ 11

4.2 Ability to manage Personal Health Budgets ............................................................................... 12

4.3 Third Party ................................................................................................................................... 12

4.4 Pre-paid Card .............................................................................................................................. 12

4.5 Managed Payroll ......................................................................................................................... 12

4.6 Bank Account .............................................................................................................................. 12

4.7 Enduring and Lasting Power of Attorney .................................................................................... 13

5. Terminating Direct Payments ....................................................................................................... 13

5.1 Excess Funds ............................................................................................................................... 13

5.2 End of a Direct Payment Service ................................................................................................. 13

5.3 Settling the final costs and returning remaining funds............................................................... 14

5.4 Repayment of direct payments and debt recovery .................................................................... 14

6. Financial Contribution ................................................................................................................... 14

6.1 Paying customer contributions towards the cost of care ........................................................... 14

7. Monitoring Direct Payments ......................................................................................................... 15

7.1 What direct payments can be used for ....................................................................................... 15

7.2 What direct payments cannot be used for ................................................................................. 16

7.3 Balancing patient choice and value for money ........................................................................... 16

7.4 Monitoring direct payments ....................................................................................................... 17

8. Employing a Personal Assistant or Support Worker ..................................................................... 18

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8.1 Employing a personal assistant ................................................................................................... 18

8.2 Relatives living in the same household ....................................................................................... 19

8.3 Relatives/carer’s receiving direct payments in their own right .................................................. 19

8.4 Contract of employment ............................................................................................................. 19

8.5 Hospitalisation ............................................................................................................................ 20

9. Direct payments for equipment and minor adaptations .............................................................. 20

9.1 Eligibility ...................................................................................................................................... 20

9.2 Training for PA(s)......................................................................................................................... 20

10. Review ....................................................................................................................................... 20

10.1 Increase in level of support ....................................................................................................... 20

10.2 Reduction in level of support .................................................................................................... 21

11. Safeguarding ............................................................................................................................. 21

11.1 Safeguarding adults from abuse - legal framework .................................................................. 21

11.2 Safeguarding and mental capacity ............................................................................................ 21

11.3 Assessing risk (taking risk) and preventing abuse ..................................................................... 22

11.4 Safeguards that are designed to reduce risk to direct payment recipients.............................. 22

11.5 Disclosure and Barring Service .................................................................................................. 23

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1. Introduction This Policy Framework agreement for Personal Health Budgets (PHB) supports the Implementation of PHBs across CWHHE. 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’.

In November 2012, following the evaluation of the Personal Health Budgets national pilot programme the Government announced that anyone (adults and children) eligible for NHS Continuing Healthcare (CHC) would have the ‘right to ask’ for a PHB by April 2014 and the ‘right to have’ one from October 2014. The NHS mandate in 2014 also re-confirmed this commitment and extended this to anyone with a long term condition, who can benefit from a personal health budget, with a ‘right to ask’ for one by April 2015.

PHBs are one of the tangible ways the NHS can become significantly better at involving people and empowering them to make decisions about their own care and treatment. A PHB is not about new money, but about using resource differently.

The policy framework outlines the ‘as is’ position and areas for expanded implementation.

1.1 Background The Department of Health undertook a pilot programme between 2009 and 2012 involving 64 Primary Care Trusts to ascertain whether PHB would benefit users of specific NHS services. This pilot involved the Hammersmith & Fulham PCT, Kensington & Chelsea PCT and Westminster PCT. The core targeted areas were NHS continuing healthcare, mental health, stroke, long-term neurological conditions, diabetes, and chronic obstructive pulmonary disease. An independent evaluation of the pilot by the Personal Social Services Research Unit was undertaken and the report was published in November 2012. The evaluation concluded that ‘the use of personal health budgets was associated with a significant improvement in care-related quality of life and psychological wellbeing of patients’.

The key findings and recommendations from the evaluation were as follows:

• Personal Health Budgets did not appear to have a notable impact on health status but a marked decrease in the use of primary and acute care services was found among the NHS continuing healthcare and mental health cohorts;

• the wellbeing of people with personal health budgets, as measured by the ASCOT indicator, was significantly better than those who had conventional services;

• the underlying health conditions of people in the PHB group did not change; • the PHB group had fewer hospital admissions and visits to their GPs than the control group. • the potential cost efficiencies among these two groups were considered ‘significant’ for people

with high value packages of care and thus recommended that ‘personal health budgets should be initially targeted at people with greater need’;

• the pilot analysed different models of PHBs and showed that, how they are implemented, determines how effective the new approach is at achieving good outcomes;

• people who were offered personal health budgets and given an indicative budget at the start of care planning and had flexibility over how funding could be spent, showed a higher wellbeing than the control group; and

• when implementing personal health budgets, it needs to be undertaken in a way to ensure the realisation of the benefits through good care planning at the start of the process.

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The personal health budget epitomises the Government’s vision of a patient-centred NHS, summed up by the often quoted edict” no decision about me without me”1.

1.2 Strategic Context Personalisation and personal health budgets sit within Central London CCG, West London CCG and Hammersmith and Fulham CCG local commissioning intentions, the shared five-year vision, including the ‘Out of Hospital’ Strategies and Whole System Integrated Health and Social Care programme. The PHB programme for NHS continuing healthcare is currently implemented across all care groups in a consistent manner, with evaluation and quality assurance mechanisms developed and monitored. The development of an integrated approach to the provision of PHBs and personal budgets (social care), so that people who are eligible for both budgets can use them to commission integrated packages of services, needs to be expanded to include people ‘who could benefit’ from a personal health budget. PHBs fit with other Government policies and are part of the move towards ‘self-direction’ in health and social care. They are related to other concepts in public policy as follows:

• Personalisation: starting with the individual as a person with strengths and preferences, as opposed to the services that are available.

• Self-Directed Care: a way of accessing and delivering care services where the individual is central to determining how to manage their own care and has more choice and control.

• Personal budget: a transparent allocation of resources so that individuals know how much they have to spend on their support. Individuals have more control over how the money is spent and should go through a supported self-assessment process. In adult social care, the term ‘personal budget’ is used to mean a budget which includes only social care funding. Personal budgets are now provided in children’s services and may include funding from social care, education and health.

• Personal health budget: this is like a personal budget but only includes NHS money and must be administered in line with NHS legislation.

• Co-production: co-production means co-design and co-delivery of (health and social care) services. Central to this concept is the principle that people have or have access to the skills and resources needed to create and develop their own solutions.

1 Department of Health ‘Equity and excellence: liberating the NHS’ (White Paper, Cm 7881, 2010) 3

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Figure 1: Relationship between the key concepts

1.3 Legal and Policy Frameworks Hounslow CCG’s PHBs are in line with national policy, with policy principles following national policy and regulations as far as possible. PHBs within CWHHE CCGs are being developed in conjunction with CWHHE local authorities. Therefore, this policy will remain aligned to existing local authority personalisation policies wherever possible.

The National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules (Amendment) Regulations 2013, sets out the legal duties for CCGs for PHBs including a duty to:

• consider any request for a PHB; • inform people eligible of their right to ask for a PHB; and • provide information, advice and support in relation to PHBs.

The National Health Service (Direct Payments) regulations 2013 sets out how the direct payments should be administered and what they can be spent on. The regulations are similar to the regulations and guidance for social care direct payments. The NHS principles also remain in place, PHBs must meet all assessed care needs and be free at the point of use.

2 Personal Health Budgets 2.1 What are Personal Health Budgets? As defined by NHS England, ‘a personal health budget is an amount of money to support a person’s individual health care and wellbeing needs, planned and agreed between the individual and their local NHS team.’

There are five essential characteristics of a PHB. The person with the PHB (or their representative) must:

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• be able to choose the health outcomes they want to achieve; • 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 it; • be able to choose how their budget is held and managed; and • be able to spend the money in ways and at times that make sense to them, as agreed in their

plan.

A PHB can take three forms or a combination of the three forms:

• notional budget - no money changes hands. The person is notified of the cost of their personalised care package but the care and the costs continue to be managed by the local health service;

• real budget held by a third party - a different organisation or trust holds the money on the person’s behalf; and

• direct payments - the money is paid directly to the person or their nominated representative.

A PHB can be spent on any services or care which meets the individual's agreed health and wellbeing needs. The services and care will need to be set out and agreed in a care plan.

The only restrictions set by the Department of Health are that PHBs cannot be spent on things that are inappropriate for the state to fund, such as alcohol, tobacco, gambling or debt repayment, or anything that is illegal.

At this time, some aspects of a person's care will also be excluded from a PHB– namely primary medical services (i.e. GP services) and emergency services.

2.2 Eligibility for health funded support Since April 2014, people who are eligible for NHS Continuing Healthcare have the right to ask for a PHB, including a direct payment for healthcare. This became a ‘right to have’ a PHB in October 2014. Since April 2015 the NHS also offers PHBs more widely - for example to people with long term health conditions or people with mental health problems who could benefit.

As part of the whole systems integrated care programme, CCGs will be working towards commissioning fully integrated models of care based on the holistic needs of different population groups, encompassing both health and social care. Outcomes will be commissioned across health and social care with a combined, capitated budget. Capitation provides an opportunity to support the expansion of PHBs to meet the combined health and social care needs through the development of personalised care and support plans.

In Hounslow CCG the current PHBs are being offered or piloted:

1. NHS Continuing Healthcare

Anyone who is eligible for NHS Continuing Healthcare (CHC) is also eligible for a PHB. Everyone who is eligible for CHC is offered a PHB.

2. Children

The Children and Families Act 2014 introduces new duties, policies and procedures for Local Authorities and Clinical Commissioning Groups and the support they provide to children and young

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people (a person over compulsory school age and under 25) with Special Educational Needs (SEN) and/or disabilities including the right to request a personal budget.

3. Long term conditions

The government mandate is that ‘anyone who could benefit’ from a PHB will have a ‘right to request’ and ‘a right to have’ from April 2015, including people with long term conditions.

Capacity

The eligible budget holder is dependent on the mental capacity of the individual in need of direct payments.

Person with capacity: this can be the budget holder themselves or they can nominate a friend or relative.

Person without capacity: (as defined under the Mental Capacity Act 2005) anyone showing reasonable involvement with and commitment to the person can nominate themselves to be the budget holder. It is at the discretion of the healthcare assessors/clinicians to accept this following a risk assessment. There has to be a clear rationale as to why someone is not accepted.2

2.3 Who may not be eligible to receive Personal Health Budgets? There are several criteria that rule a person ineligible for receiving a PHB. This includes:

• those living in permanent residential care to pay for the placement (though this is currently being piloted and may be available in future); and

• people restricted by certain criminal justice legislation to arrange their own care.

3 Personal Health Budget Process 3.1 The End-to-End Process for Personal Health Budgets As part of the Continuing Healthcare Assessment process by the Multi-Disciplinary Team, a recommendation will be made whether a client is eligible for Continuing Healthcare. When a client has been assessed as eligible, the recommendation is made to the Continuing Care panel for agreement.

The Continuing Healthcare team with the multi-disciplinary team will then consider the care options with the person or their nominated representative. At this stage one of the options to be offered to the person is a PHB. If the option for a PHB is supported by the client a support plan will be developed by the Care Co-ordinator/Health Assessor with the person.

Whilst a PHB is being arranged, a care package arranged by the Continuing Healthcare team is provided, unless the individual already has direct payments from social services. If this is the case, then NHS CWHHE CCGs’ will seek to keep the existing care arrangement in place and either put in additional care, as needed, or adjust the direct payments and ensure additional care is provided, the personal budget/direct payment is converted to a PHB.

It is noted that when a person is eligible for NHS Continuing Healthcare via the fast track process, due to the timescales to set up a PHB and the volatility of the care packages, it is not usually

2 If someone lacks capacity and there is a court registered LPA deputy, they have to have both LPA for welfare and finance to be a budget holder.

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recommended that a PHB is the best care option for the client. Hounslow CCG will consider each request for Fast Track PHBs on a case-by-case basis.

The diagram below highlights the process flow for the PHB process for CHC-approved patients.

3.2 Process for Implementation Continuing Healthcare Assessment Process: 1. the Continuing Healthcare Assessment is undertaken by a Multi-Disciplinary Team where a

patient is recommended as meeting the Criteria for Continuing Healthcare; 2. the MDT recommendation is presented to panel for ratification; 3. the CHC Panel will consider:

• is the person CHC eligible; • does the person meet the eligibility criteria for PHBs; • does the person have capacity; • does the person have a nominated representative; • does the representative have a Power of Attorney in place for Finances or Health and

Welfare; and • does the person have an existing Direct Payment from the Local authority?

4. The Continuing Healthcare Team then meets with the person and/or their nominated representative to start the support planning process in regards to their assessed health care needs. If required, an interim Continuing Healthcare care package is arranged to allow time for the PHB support planning process to be completed.

Support Planning with Person/Nominated Representative: 1. a meeting is arranged with the person/family/carers to start the care support planning and to

discuss the legal requirement and responsibilities in managing a PHB. It is important to allow sufficient time for this meeting to cover all the key areas of responsibilities of managing a PHB;

2. at the Support Planning Meeting the following key areas needs to be covered: • what is important to the person in ensuring their assessed care needs are met; • how they want their health needs to be met such as the frequency, time of day, who will

provide the care; • what type of PHB would they wish to consider? e.g. A notional budget, a third party, direct

payment or a mixture of the options available, including CCG commissioned care; • do they want to employ their own carers or do they have existing carers and are they being

paid legally; • support services that are available to the person in the management and setting up of their

PHB; and • sign post them to information to assist them to make an informed decision on their care;

3. complete the draft Support Plan with the person or their nominated representative including the completion of a risk assessment, allocation of responsibilities for mitigating risk;

4. plan any contingencies for complexity of conditions/health needs; and

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5. agree and ensure the final draft of the Support Plan is signed by the person or their nominated representatives.

Approval of Personal Health Budget: 1. the Support Plan and proposed package of care is presented to the Continuing Care

Commissioner for approval; 2. the proposed package of care costs is considered and approved if appropriate, in line with the

Delegated Authority levels within the CCG; 3. the Commissioner will consider the following:

• the person meets the PHB criteria (as set out in the NHS personal health budgets toolkit) • adequate support planning has been carried out; • the support plan reflects the views of the person; • both the person or their representative and the lead care co-ordinator have signed the

support plan; • the value of the indicative budget (review of the outcomes, planned activities and other

purchases and spending set out in the support plan); • determine whether the agreed outcomes will meet the needs identified in the continuing

healthcare assessment; • determine whether the support plan will deliver the agreed outcomes; • be assured that contingency plans are in place; • determine whether the final budget is the right amount to deliver the support plan and if

needed, suggest adjustments; • in cases where the value of a person’s requested care and another alternative is vastly

different, choice will not always supersede value for money; • find out whether direct payments have been requested and whether it is appropriate to

give the PHB as a direct payment; • ensure that the plans for the direct payments are in line with the NHS Direct Payments

regulations; and • check there is a review date in the support plan and it meets the requirements of the

continuing healthcare review process.

Adult Social Care Finance Process for Personal Health Budgets: 1. the Care Co-ordinator starts the completion of the Financial processes to inform the Direct

Payment Agreement, Bank Details form, and the Third Party Agreement; 2. the approved and signed Support Plan and copies of the agreements are provided to the ASC

Care Management Team and placed on their system to make and monitor payments; 3. the Care Manager sends the Direct Payment Agreement, Bank Details form, Third Party

Agreement to the ASC Finance Team and seeks confirmation of when first payment will be processed and paid;

4. the Finance Officer checks the paperwork to ensure all is complete; 5. the Finance Officer enters the person/family/carer as a payee on the corporate finance system; 6. payments are entered for monthly payment runs (unless required more frequently); 7. The Finance Officer informs the CHC Team that payments are set up and when payment will be

made; 8. the Finance Officer will request bank statements and evidence of the PHB quarterly; and 9. the Reviewing Officer will obtain copies of bank statements and evidence of PHB expenditure

quarterly from the person/family/carer/third party and when funds are not being spent, to investigate the reasons for this and to review arrangements and make recommendations.

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Review and Monitoring There are two sets of reviews for persons who have PHBs:

1. review of individual’s health needs: For continuing healthcare persons, this review is carried out in line with the Continuing Healthcare National Service Framework, i.e. three months after the person has become eligible for continuing healthcare and annually thereafter. The person or their nominated representative can request a review following a change in health needs at any time; and

2. for people who have direct payments: This is a review of how the PHB is being spent. This will vary from person to person but, at a minimum, will be in line with the NHS direct payments regulations, i.e. within three month of the first direct payment being made and at least annually thereafter.

The frequency and type of reviews will be outlined in the Support Plan and PHB Direct Payment agreement.

3.3 Further Detail Assessment No additional assessments for PHBs are required for people who meet the NHS Continuing Healthcare eligibility as the existing assessments (the Checklist, the Decision Support Tool, the London Health Needs Assessment and the Fast Track Tool) are used.

Budget-setting Under the traditional model of continuing healthcare, an assessment would be followed by the care co-ordinator producing a personalised care plan based on the person’s assessed health needs, i.e. a schedule prescribing episodes of care and defining specific tasks for the care worker to meet the assessed needs. Under the PHB approach an ‘indicative budget’ is set after an assessment. The indicative budget is a planning tool giving a financial envelope within which the individual and their planner can undertake support planning.

There are currently two methods of developing an indicative budget: a Resource Allocation System (RAS), and a ‘Ready Reckoner’ model.

A ‘RAS’ sets an indicative budget based on an individual’s level of need – it puts a monetary value on any particular level of need. In theory a RAS is not driven by existing services and having a RAS-generated indicative budget should enable more creative care planning.

A ‘ready reckoner’ approach is one where a basic care plan is used to calculate an indicative budget. Whilst the ready reckoner approach is based on existing services, it can be simpler to use, more transparent and easier to understand.

Central London, West London and Hammersmith and Fulham CCGs’ will use the ‘ready reckoner’ to set budgets. Ealing and Hounslow CCGs will use a locally-determined model.

Once a person is assessed as eligible for NHS continuing healthcare, the Continuing Care Manager and person/or their nominated representative work together to calculate the indicative budget. This is then validated by the commissioned Local Authority Direct Payments Team in Hounslow CCG.

Support Planning Support planning (which is sometimes called ‘care planning’) is fundamentally different from traditional care planning carried out for continuing healthcare persons. A traditional care plan is a

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timetable showing episodes of care and tasks. It should be produced in consultation with the person or their nominated representative.

Whereas a care plan starts with the existing services, a support plan has the indicative budget as the starting point. In general, a support plan is a unique plan developed by the person/or their nominated representative and the care co-ordinator. It outlines how the PHB will be used to achieve people’s identified health and care outcomes. This includes who will be providing each element of support; who will be managing the budget; and action and contingency planning. Good support planning involves looking holistically at a person’s life to improve their health, safety, independence and wellbeing.

Support plans should be developed with all individuals, regardless of the PHB management option they choose, i.e. whether to take direct payments, third-party managed budgets or a notional budget.

While a support plan will be created with the individuals choices and desires held in high regard, choice will not always be prioritised if a better valued alternative is readily available.

Third sector support for support planning is available in each CCG which the person/nominated representative is able to work with/make use of.

For each person receiving a PHB the CCG must name a care co-ordinator, and this must be recorded in their care plan. The care co-ordinator is responsible for:

• managing the assessment of the health needs of the individual as part of the care plan; • ensuring that the individual, or representative and the CCG have agreed the care plan; • undertaking or arranging for the monitoring and review of the direct payment, the care plan

and the health of the person; and • liaising between the CCG and the person receiving the direct payment.

The care co-ordinator should normally be someone who has regular contact with the individual receiving care, however they do not necessarily need to have 'care co-ordinator’ in their job title – they should just fulfil the responsibilities above.

3.4 Methods and Frequency of Payments There are a range of options available to customers to receive their PHB including a pre-paid card, managed payroll and opening a bank account, ensuring maximum flexibility in managing funds.

A separate bank account or managed payroll option is essential for those customers receiving on-going support to ensure clear and transparent monitoring process.

4. Receiving Personal Health Budgets 4.1 Who is a suitable person to receive a Personal Health Budget? Hounslow CCG has a duty to consider a right to ask for a PHB to anyone who is eligible and consents to receive it. The CCG will do all it can to support customers in making their own decisions. Where possible, the PHB holder will be the individual who is eligible for direct payments. In cases where a customer lacks the capacity to consent to a PHB, a suitable person can be nominated. The suitable person will sign an agreement to receive and manage the money on behalf

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of the customer. By doing so they take on the legal responsibility related to employing and managing paid staff employed through the PHB scheme. If a suitable person is not a close friend, spouse, partner or a relative of the person receiving support, then they are required to have a police check (DBS). If applicable, they are also required to carry out a DBS check on the personal assistant (PA) they intend to employ on behalf of the customer.

4.2 Ability to manage Personal Health Budgets Hounslow CCG will ensure that there is sufficient support available to the customer to manage their PHB. Assistance with this can be arranged through the support service or a suitable person and/or a third party nominated by the customer. Additionally, spouses and other family members are often able to provide support that is sufficiently robust.

4.3 Third Party Those customers who do not wish to take on the responsibility of managing the PHB have the option of using a specialist agency or nominating a person to administer the money, e.g. a service provider. Customers still retain control over their money but they are free from the financial burden of having to manage it. A third party would be required to sign an agreement with Hounslow CCG to agree to the terms and conditions of receiving the PHB.

4.4 Pre-paid Card Customers can opt to receive a pre-paid card and pay for support by telephone or internet banking. The card option offers 24/7 access to a PHB account and eliminates time spent on completing financial returns. It is the CCG’s default position to offer the pre-paid card to those customers who are eligible to receive it and able to manage it. If a person is not able to manage their PHB through the pre-paid card, they will be offered an option of managed payroll or a bank account.

4.5 Managed Payroll A managed payroll service is available to those customers who do not wish to manage their PHB or have difficulties with it. The customer does not have to hold the PHB funds; payments are made to a separate bank account held by an independent organisation who then makes payments on the customer’s behalf. Managed payroll providers are only authorised to make payments as per the customer’s instructions. The PHB recipient retains control over their care and is responsible for managing the funds.

4.6 Bank Account If a customer is not able to manage the PHB using the pre-paid card or managed payroll, a separate bank account can be opened. It is essential that the bank account is separate from the customer’s personal account for monitoring purposes. The account must also have a cheque book facility as most payments for services should be made by cheque or bank transfer. In exceptional

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circumstances, the CCG can agree for a customer to make cash payments for services. This is authorized only where there is no other way that the service can be purchased.

4.7 Enduring and Lasting Power of Attorney Enduring power of attorney (EPA) has been replaced with the lasting power of attorney (LPA) in the 2005 Act giving a person who has a LPA the power to make not only decisions relating to finances but also those concerning personal welfare and care arrangements. A court-appointed deputy or a donee of lasting power of attorney can act as a suitable person to receive a direct payment on behalf of a customer who lacks capacity. In accordance with section 57 of the Health and Social Care Act 2001 to receive a direct payment the attorney under EPA would have to agree to it on behalf of the person lacking capacity.

5. Terminating Direct Payments 5.1 Excess Funds As previously mentioned, it is recommended that customers should hold sufficient funds in their direct payment account to cover any bills relating to their service. Hounslow CCG allows customers to hold up to the equivalent of six-weeks’ worth of funding as a contingency fund. If a customer holds more than six-weeks’ worth of funding the CCG will reclaim the funds in excess of their contingency fund.

If a person is receiving a Personal Budget from the Council, further guidance should be sought from the relevant Council’s Personal Budget Policy.

5.2 End of a Direct Payment Service Direct Payments will end if one of the following occurs:

• the Personal Budget Holder no longer has the capacity to consent - in this situation the CCG can look for a suitable person to receive the payments on behalf of the person concerned;

• conditions outlined in the Direct Payment Agreement are not met; • support for which the direct payments were made is no longer needed; • support for which the direct payment was paid is not needed for a short period of time

(for example, through admission to hospital); or • the PHB is placed under a condition or requirement by the courts relating to drug or

alcohol dependency.

Depending on the circumstances the individuals Care Manager will advise the customer or their next of kin of the end of the direct payment. The customer or their next of kin should then give notice to any employed workers and calculate the outstanding bills. If necessary they can contact their support service for assistance with settling these matters. A closing audit will be carried out and any unallocated direct payment funds that remain will be reclaimed. In addition, if the PHB moves out of the borough, direct payments will be stopped once adequate provision is established in the new borough.

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If the individual receiving the direct payment dies, the CCG will cease the payments as soon as possible. Any outstanding payments for support will be paid by the CCG and the residual funds in the account must be returned to the CCG. Where direct payments are stopped, NHS CWHHE CCGs’ will give notice to the person or their representative in writing. There is no fixed notice period for stopping direct payments. The time taken before stopping direct payments will depend on any contractual obligations the direct payments user may have entered into.

Direct payments are not a welfare benefit and do not represent an entitlement to a fixed amount of money. Direct payments are paid to meet assessed health and care needs. Where individuals’ needs change, this needs to be reflected in the value of the direct payments.

5.3 Settling the final costs and returning remaining funds For customers using a pre-paid card, their card will be frozen following the end of the direct payment. Once the customer or their next of kin has calculated the final costs they should let their support service or the monitoring team know. Funds will then be made available in order for the final costs to be settled. If the final costs are greater than the funds the client held on their pre-paid card Hounslow CCG will need to look into exactly what the additional costs relate to before considering any additional funding.

Customers using a bank account or managed payroll should settle their bills and then arrange for any remaining funds to be returned to Hounslow, either by cheque or bank transfer. The CCG will require a final financial return from customers who were using a bank account. A final return will automatically be supplied by the managed payroll service for customers using that payment method. As above if there is need for additional funding Hounslow will require details of the additional costs before considering any additional funding.

5.4 Repayment of direct payments and debt recovery In addition to when a client holds excess funds or when a direct payment service ends there may be other circumstances where Hounslow CCG requires repayment of a customer’s direct payments. For example:

• where there has been an overpayment to the customer; • the direct payment has been used for other purposes than identified in the support plan; and • where the direct payment has been used to pay a relative or person living in the same address

without prior agreement to such an arrangement.

In such circumstances, Hounslow CCG will write to the customer and explain the need to reclaim funds and the amount to be repaid. If the customer is unable to repay the total funds the case will be passed onto the credit control team to set up a repayment plan. If a customer fails to return these funds Hounslow CCG may decide to take legal action to reclaim the money.

6. Financial Contribution 6.1 Paying customer contributions towards the cost of care In accordance with the CCG’s contributions policy a customer’s contribution will be deducted at source. This means that those customers, who are assessed as having to pay a financial contribution towards their care, are obliged to pay the requested amount of their contribution in to their direct payment account either weekly or monthly. This could be done in a number of ways: the customer

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can set up a standing order with the requested contribution amount to be transferred from their personal account to the direct payments account, or they can make a payment by bank transfer. Compliant with section 17 of the Children’s Act 1989, Hounslow CCG will not carry out a financial assessment and seek contribution from a person with parental responsibility for a child aged 16 or 17 eligible for CCG-funded support. In the same way and in line with section 117 of the Mental Health Act 1983 (after-care) the contribution will not be required from customers receiving services under the aforementioned section.

7. Monitoring Direct Payments Hounslow CCG’s approach to establishing a direct payment for a PHB considers a range of things, including:

• the person’s wishes and feelings in relation to their care and support and receiving direct payments;

• their capacity to consent to the making of a direct payment and where appropriate the provision of support in the form of a nominee or representative;

• the benefits to the individual of having a direct payment for healthcare in both the short and longer term;

• whether the benefits of receiving a direct payment represent value for money and, where applicable, outweigh any direct additional financial costs;

• whether a person’s PHB would be affordable across a much wider proportion of the Hounslow population;

• whether it is clear where the money for the direct payment will come from and when it will be available; and

• the availability of appropriate support for the individual (or their representative or nominee) to be able to plan and manage direct payments.

7.1 What direct payments can be used for With a direct payment customers are in control of their care; they choose who supports them and how the support is provided. Direct payments can be used to pay for any care or support option providing it’s legal and meets the outcomes as identified in the support plan. The care plan must be agreed by both the CCG and the person receiving care, or their appointed representative. Before signing off the care plan, the CCG must be satisfied that the health needs of the patient can be met by the services specified in the care plan. The following support may be purchased thought direct payments:

• a personal assistant (PA), support worker or a care agency; • activities in the local community; • attending a day centre; • equipment that the council has assessed the customer as needing; • some aspects of residential support though not the accommodation costs; and • respite care for unpaid carers providing a substantial amount of support to a person with

disabilities or an older person.

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7.2 What direct payments cannot be used for Direct payments for healthcare will not be appropriate for all aspects of NHS care an individual may need. A direct payment cannot be used to purchase primary medical services provided by GPs, as part of their primary medical services contractual terms and conditions, nor is a direct payment suitable for the following public health services:

• vaccination or immunisation, including population-wide immunisation programmes; • screening; • the National Child Measurement Programme; or • NHS Health Checks.

A direct payment cannot be used for urgent or emergency treatment services, such as unplanned in-patient admissions to hospital or A&E. This is because they are, by their nature, unplanned and thus not within the care plan’s ambit. A direct payment can also not be used for surgical procedures. There are a number of other things that direct payments cannot be used for, including:

• alcohol, cigarettes and anything involving gambling; • debt repayment; • any activity which is against the law (this includes not paying people a minimum wage, not

registering an employee with Revenue and Customs, giving someone ‘cash in hand’ and not complying with other employment regulations);

• paying for those things which other sources of income would normally pay for, like day-to-day food bills, rent or utility bills;

• any treatment which CWHHE have a policy not to fund or which NICE recommends should not be funded, because it is proven not to be effective;

• any treatment that would be in conflict with another treatment; • enablers to care as opposed to direct care itself; • anything that has previously been turned down by an exceptions committee; • anything that is deemed unreasonable by the Multi-Agency Panel/Complex Cases Board, or

which would potentially bring the NHS into disrepute; • equipment that has been purchased from an auction, including online sites like eBay,

equipment that doesn’t meet the required standards or using equipment where the people who are required to use it are not trained in such;

• things that could place people at risk of serious harm, including employment of improper / inapprpropiate carers and the funding of activities or situations that expose one to potential significant harm; and

Any use of direct payments towards these inappropriate purchases may result a termination of direct payments.

7.3 Balancing patient choice and value for money A growing number of patients are expressing their desire to remain at home for as long as possible for their care, a move supported by the efforts to better integrate acute and community services across Hounslow CCG.

Where possible, patients in Hounslow are supported to remain independent and at home for as long as it is safe to do so. However in cases where a patient receives a PHB to manage the services for their care plan, a patient’s choice to remain at home will not in all cases eclipse value for money for the CCG.

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Hounslow’s PHB policy stance in relation to balancing patient choice and value for money is set out below:

‘There may be cases where the best place to care for a person is identified as being in a Care or Nursing Home, however the patient’s preference is to remain at home at a significantly greater cost. In such cases, the PHB allocated will only cover the cost of the Care or Nursing Home identified.’

7.4 Monitoring direct payments Direct payments recipients take on the responsibility for designing and managing their care. They can make changes to their care arrangements providing that those changes meet the outcomes identified in their support plan.

For those customers using a pre-paid card, information on use of the card is provided to the Council by the card company, so there is no need for customers to submit returns. Please refer to the Council’s Personal Budget policy for further information on how these are monitored. Customers who use bank accounts are asked to send the following information to the Direct Payments Monitoring Team (for the first three months this is on a monthly basis):

• annotated copy of monthly bank statements; • carer’s payslips (if a care component is involved); and • receipts, invoices etc. for any other payments made e.g. payroll fees, agency invoices.

After the initial three months, the frequency of monitoring is reviewed in light of a risk assessment. Customers will be asked to supply the following information depending on whether they are to be monitored on a quarterly, six-monthly or annual bases.

Quarterly monitoring

• Annotated copies of three months of bank statements; • carer’s payslips (if a care component is involved); and • receipts, invoices etc. for any other payments made. For example payroll fees, agency

invoices.

Bi-annual monitoring

• Annotated copies of three months of bank statements.

Annual monitoring

• Annotated copies of three months of bank statements.

Those customers who are using the pre-paid card to hold their direct payment, will not be required to complete financial returns as above. The monitoring team has an online access to all pre-paid card accounts and is able to carry out the appropriate checks.

When carrying out a review of a person’s PHB the CCG may:

• re-assess the health needs of the person; • review receipts, bank statements and other information relating to the use of direct

payments; and

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• consider evidence around whether direct payments have been effectively managed, including evidence as to whether service providers have or had appropriate indemnity and registration.

8. Employing a Personal Assistant or Support Worker 8.1 Employing a personal assistant Direct payments give customers flexibility and choice about who they want to employ and how the support is provided. They can employ a worker of their choice (see exceptions in section 7.1) providing the person is eligible to work in the UK. Direct payment support services can support a customer with choosing a personal assistant (PA) or support worker; they can place an advert and help with shortlisting and interviewing. However, the customer ultimately decides who to employ. Direct payment recipients are required to sign a contract with their carer(s). They are also required to purchase employer’s liability insurance to protect themselves and their carers in case of an accident. The insurance should be purchased prior to the personal assistant starting employment. Hounslow CCG will pay for the first year of the insurance policy. The customer is required to cover the cost of the insurance from their direct payment in the subsequent years. In addition to the above, there are a number of requirements that must be followed for a PA to be employed: 1. the personal budget holder must meet all legal responsibilities as an employer if they opt to

directly employ a PA; 2. all employees paid or involved in a person’s care must meet all legal conditions of employment

outlined by existing legislation (including the Modern Slavery Act 2015); 3. all employed PAs (as a minimum) must have a written job description and contract of

employment outlining their core duties and entitlements; 4. PAs must be paid via a payroll service, and that the personal budget holder must advise their

payroll service as and when they employ new personal assistant – the costs of which are to be met from their allocated PHB;

5. appropriate employer and public liability insurance must be obtained when employing a PA – the costs of which are to be met from their allocated PHB after the first year;

6. it is not permissible to pay ‘cash-in-hand’; 7. all records pertaining to the employment of a PA must be retained, including copies of all:

• pay-remittance advice slips; • payroll service invoices; • HMRC tax and national insurance payment remittance slips; • employer-related insurance certificates; • holiday and leave records; and • sickness absence records;

8. the personal budget holder must ensure that PAs are eligible to work in the UK; 9. the NHS strongly recommends that appropriate staff checks are undertaken through the

Disclosure & Barring Service (DBS) for all prospective employees – the costs of which are to be met from allocated PHBs. A support broker can help organise a DBS check on the budget holder’s behalf; and

10. the personal budget holder must confirm that self-employed care are registered for business and tax purposes with HMRC, and that they have the necessary insurances required to operate as a bona fide business. A support broker can assist the budget holder in checking someone’s employment status.

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Failure to comply with these requirements may result in the termination of PHBs. 8.2 Relatives living in the same household Recipients of direct payments choose their own support staff. For example, they may want to employ a friend, family member or neighbour. If, however, the customer lives in the same household as a relative they intend to employ, further authorisation must be requested from the allocated care manager. The care manager will take into consideration the customer’s individual circumstances when making a decision about whether a direct payment can be used for paying a close relative living in the same household. The care manager will consider the following matters:

• the customer’s view and consent to employing a relative who lives in the same household; • the customer’s needs; • support offered by the relative i.e. level of care provision and whether a relative has given

up work to provide paid work for the direct payment recipient; • whether the customer has additional or specific needs e.g. cultural needs that will be best

met by a relative; and • any potential risk factors. As part of this there is an obligation to undertake DBS checks for

the employment of staff, which is factored into the PHB calculation.

Additionally, when employing their staff (regardless of the relationship between the customer and the carer) the customer is obliged to sign a contract of employment with each employee they intend to offer a job.

8.3 Relatives/carer’s receiving direct payments in their own right Unpaid carers are entitled to receive direct payments to support them in their caring role. An assessment will be carried out to establish whether the carer has an eligible need for support. If the carer is eligible to receive a direct payment, consents to it and can manage it (with support if necessary) then the allocated provision should be used for services to relieve them in their caring role.

8.4 Contract of employment Direct payment recipients employing a carer(s) are legally obliged to sign a written contract of employment with their carer within two months of commencement of employment. The contract will outline the terms and conditions of the carer’s work including all the statutory entitlements (e.g. maternity leave) and the carer’s job description. The employer and employee should both sign the contract and keep copies for future reference. The essential terms that must be included in the contract include:

• the date when the employment commenced / will commence; • job title; • place of work; • hours of work; • details of remuneration (which meets the national minimum wage); • statutory entitlements; • the nature of the job i.e. fixed-term or permanent; • pension scheme provision (if applicable); and

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• notice requirements. The employer should notify their employees of any changes to the terms and conditions of their work in line with the legal framework and in writing.

8.5 Hospitalisation Customers who are admitted to a hospital are obliged to continue to pay their carer for up to maximum 4 weeks after their admission. The amount/retainer will be 80% of their wages and during the time that the customer is in the hospital, the carer must be available for work.

9. Direct payments for equipment and minor adaptations 9.1 Eligibility Customers might be eligible to receive additional funds to purchase a piece of equipment and/or minor adaptations from their direct payments. Further eligibility criteria may apply if there is a need to employ a PA.

It is usually the responsibility of the Council to provide funding for equipment and minor adaptions from an individual’s Personal Budget. For further information please see the Council’s Personal Budget Policy.

9.2 Training for PA(s) Some customers using their direct payments for equipment and/or minor adaptations may need to employ a PA to support them with using the equipment. In cases where a specialist piece of equipment is required, the PA may need to be trained in the appropriate use of the equipment.

10. Review Direct payments recipients will undertake annual reviews in the same way as those customers who are receiving council-commissioned services. However, if the recipient’s needs change before they are due a review, they are encouraged to contact their care manager or social worker to arrange a reassessment. It is possible to either increase or decrease the direct payment allocation; this would be based on the customers’ needs and required support. Any changes to the direct payment allocation will be discussed with the customer.

The frequency and type of reviews will be outlined in the Support Plan and PHB Direct Payment agreement.

10.1 Increase in level of support If following an assessment the customer’s needs increase they will still be entitled to receive a direct payment and the level of direct payments will increase accordingly. The frequency and method of payment should remain the same. If there are changes to the above, the customer will be advised by their allocated care manager of those prior to receiving their direct payment. Changes to any payments affecting the PA’s terms and conditions of work such as wages, hours of work, statutory entitlements etc., should be discussed with the staff prior to implementing those changes. It is the customer’s responsibility to ensure that staff are informed of these changes.

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10.2 Reduction in level of support If following an assessment the customer’s needs decrease they will still be entitled to receive a direct payment. They will be advised by the team of their new allocation and changes to the financial contribution they may be required to pay towards their care. It may be necessary to reduce future payments if a customer has been overpaid following a decrease in their service.

If the direct payments recipient employs a PA or support worker the CCG would strongly advise the employer to consult with support services any changes to their staff’s terms and conditions of work e.g. hours of work and rate of pay. Any contractual changes to the PA’s terms and conditions of work may have legal implications for the employer and should be discussed with the PA prior to making these changes.

11. Safeguarding 11.1 Safeguarding adults from abuse - legal framework Safeguarding adults is governed by statutory guidance – No Secrets (DH 2000) – which places a duty on Local Authorities to coordinate multi-agency adult safeguarding processes in their area.

11.2 Safeguarding and mental capacity Current legislation and statutory frameworks in relation to safeguarding and the Mental Capacity Act 2005 (MCA 2005) must be adhered to at all times.

All staff involved in the PHB offer and assessment must be up to date with training for safeguarding and the MCA 2005. They should also be in receipt of safeguarding supervision either as a standalone or within their clinical supervision.

Service users must be supported to ensure that any carer they employ meets the standards required regarding safe recruitment and practice.

Duty of care can be said to have reasonably been met where an objective group of professionals considers:

• all reasonable steps have been taken; • reliable assessment methods have been used; • information has been collated and thoroughly evaluated; • decisions are recorded, communicated and thoroughly evaluated; • policies and procedures have been followed; and • Practitioners and their managers adopt an investigative approach and are proactive.

The government has agreed principles that shape adult safeguarding. These provide a foundation for achieving good outcomes for patients:

• empowerment involves a presumption of person-led decisions and consent; • protection includes support and representation for those in greatest need; • prevention of harm and abuse is a primary objective; • proportionality involves the least intrusive response appropriate to the risk presented; and • partnerships offer local solutions through services working with communities.

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The Department of Health has provided a range of resources, guidance and toolkits to support professionals in enabling people to have greater choice and control, and a range of toolkits to support professionals to think through and manage risks, including clinical, financial and legal risks.

11.3 Assessing risk (taking risk) and preventing abuse Direct payment recipients are entitled to make their own decisions and to take risks in the same way that any other person is entitled to make choices involving risk. It is however essential to put safeguards in place to prevent any potential abuse and to support direct payment recipients with making potentially hazardous decisions. Safeguarding is everybody’s business and therefore it is essential that the CCG’s staff, staff and volunteers of partner organisations and agencies, and members of the public remain alert and vigilant to the potential for abuse. As with other customers, direct payment recipients may be at risk of abuse from family members, friends, carers, neighbours, professionals and strangers. Direct payment recipients employing PAs may be at greater risk of abuse depending on the level of rigour and pre-employment checks undertaken during the PA recruitment process.

11.4 Safeguards that are designed to reduce risk to direct payment recipients There are a number of provisions in place to protect customers from potential risks. These include: Support Plans – customers eligible for CCG-funded support will complete a support plan (with assistance if necessary). The support plan will enable customers to set out how they intend to use their Direct Payment, reducing the risk of misuse of the allocated funds. Contingency planning – support services will assist the customer with any contingency planning, including a backup care provision and ensure that there are sufficient funds in the direct payment account to cover expenses and bills related to the provision of direct payments. Reviews – direct payment recipients will be reviewed annually in the same way as those customers who receive commissioned services. If the customer’s needs change they will be reassessed and their Direct Payment allocation may change. Pre-paid card – this enables customers to make payments for services over the telephone or internet banking giving them more flexibility in managing their allocated budgets. Managed payroll – this is an option for those customers who struggle to manage their direct payment. A nominated third party organisation will receive the direct payment funds and make payments for services based on the client’s instructions. Financial returns – direct payment recipients managing their funds through a separate bank account are required to complete financial returns demonstrating how they used their direct payment so that any potential misuse of the allocated funds can be picked up at the early stage. Contract of employment – direct payment recipients will sign a contract of employment with their staff. The contract will highlight terms and conditions of the personal assistant’s work and should include a detailed job description so that the carer’s role and responsibilities are clear at an early stage of the care provision.

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Support with the recruitment process – direct payments support services will support the customer with identifying a suitable personal assistant or support worker. They will be able to assist with all stages of the recruitment process; advertising, shortlisting and interviewing.

11.5 Disclosure and Barring Service A suitable person who is not the spouse, civil partner, partner, close relative (or spouse or partner of a close relative) or friend of the Direct Payments recipient who lacks capacity is required to have a Disclose and Barring Service (DBS) check completed prior to taking on the responsibility of managing the allocated funds. It is also required that a PA who is employed by a suitable person who is not the spouse, civil partner, partner, close relative (or spouse or partner of a close relative) or friend of the Direct Payments recipient has a DBS check.