Bristol Health & Wellbeing Board. Personal Health Budgets

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1 Bristol Health & Wellbeing Board Personal Health Budgets Author, including Jessica Harris, Bristol Clinical Commissioning organisation Group Date of meeting 4 September 2014 Report for Information 1. Purpose of this Paper The purpose of this paper is to provide information about personal health budgets (PHBs) and to inform the Health and Wellbeing Board (HWB) of the progress of Bristol Clinical Commissioning Group (CCG) on the implementation of PHBs. 2. Executive Summary This report provides information regarding the work of the Continuing Healthcare (CHC) team within the CCG following Norman Lamb s announcement on 30 November 2012 that PHBs were to be rolled out. CCGs were required to be in a position to offer a PHB to those who are eligible for CHC from 1 April The right to ask for this cohort will transform into the right to have from 1 October From 1 April 2015 the right to ask for a PHB will be extended to other groups of service users. Guidance on the particular groups is expected in Autumn The report sets out the background to PHBs and explains the framework supporting them. Information about the work that the CHC team has undertaken over the last year is outlined, including the future trajectory in relation to this particular cohort. Risks and opportunities that will PHBs will introduce, predominantly in the context of the CHC PHB cohort have been considered. 3. Context The Independent Living Movement began in the UK in the 1980 s with Project 81 being an instrumental groups in this movement. Project 81 involved a disabled group of service users who were dissatisfied with the services

2 provided. They sought change to enable them to have a greater choice and control over the services they received and they challenged the perception that an institution, rather than the community, was the only place whereby a disabled individuals needs could be met. Following much campaigning, the Community Care (Direct Payments) Act 1996 was finally implemented 1st April Local authorities were allowed to make direct payments to individuals to organise and pay for their own care. This provided individuals with choice and control over the services that were bought to meet their needs. However, it was only made available to those aged 18 to 65 who were in receipt of a community care assessment and it was not mandatory for local authorities to offer direct payments. There followed further campaigning to achieve equality of access to direct payments. Since 2003 it has been mandatory to offer direct payments to all those who can consent and manage with or without assistance under the Health and Social Care Act However, across the country there was still poor uptake of direct payments. The recognition of public and service user involvement contributed to a paper being published titled Our health, our say; a new direction for community services (2006). It described the vision for development of a personalised approach to the delivery of adult social care as a whole. In support of the personalisation agenda, the paper Putting People First: a shared vision and commitment to the transformation of adult social care (2007) was published stating that Councils were required to move to a system of personal budgets for everyone who was eligible for publicly funded adult social care support. Direct payments are one method of delivering a personal budget. Findings have shown that personal budgets provide individuals with more choice and control over the care services they received, improved outcomes and it was a better use of money. Following the drive in social care for personalisation and personal budgets, the NHS has also sought to progress this agenda. Since 2003, NHS organisations have been required to consult service users and the public about the running of local health services (Part 242 (formerly Section 11 of the Health and Social Care Act 2001) of the consolidated NHS Act 2006). Lord Darzi set out in High Quality Care for All (2008) the intention to develop the concept of personalisation in the NHS. One method of personalisation discussed was the testing of PHBs through a national pilot programme. The PHB national pilot programme was launched by the Department of Health in 2009 after the publication of the 2008 Next Stage Review. An independent evaluation was commissioned alongside a three year pilot programme with the aim of identifying whether PHBs ensured better health and care outcomes when compared to conventional service delivery. The pilot would also consider the best way for PHBs to be implemented if they ensured better health and care outcomes.

3 There were 64 pilot sites, 20 were selected to be in-depth evaluation sites with the remainder being part of the wider cohort. The evaluation included people with any of six conditions: chronic obstructive pulmonary disease, diabetes and long term neurological conditions, mental health, stroke and those eligible for NHS Continuing Healthcare. Bristol CCG was not a pilot site. An evaluation of the pilots by the University of Kent came to the following conclusions: Recipients of PHBs had a better quality of life and used health services less. Recipients reported benefits of having care and support planning. Their health status did not improve but neither did it deteriorate. Larger monetary value budgets had a significantly different impact on both cost and cost effectiveness than smaller PHBs. PHBs are best offered to people with greatest need to act as a substitute for conventional service delivery. PHBs are most cost effective for people receiving CHC and patients with mental health problems, but are inconclusive for other health conditions. Appendix A provides case examples of service users who received PHBs as part of the national PHB pilot programme. Following the PHB national pilot evaluation, the NHS (Direct Payment) Regulations 2013 and Guidance on Direct Payments for Healthcare: Understanding the Regulations (2014) was published. This provides the NHS with the power to make direct payments to service users and sets out the CCGs responsibilities in respect of direct payments. The Care Act 2014 also makes reference to the provision of direct payments. 4. Personalisation The Department of Health (2007) has provided a definition for personalisation: Personalisation means that every person who receives support, whether provided by statutory services or funded by themselves, will have choice and control over the shape of that support in all care settings. PHBs are just one method of realising personalisation in the delivery of health services. Other health personalisation initiatives include self-directed care, shared decision making, the NHS Mandate requirement for all those with long term conditions to have a personalised care plan by 1 April 2015, directed enhanced services, the Better Care Fund and the introduction of Special Educational Needs & Disabilities (SEND).

4 The personalisation agenda has been furthered by the introduction of a new duty placed on CCGs, introduced by the Health and Social Care Act 2012 that sets out the duty to promote involvement of each patient: (1) Each clinical commissioning group must, in the exercise of its functions, promote the involvement of patients, and their carers and representatives (if any), in decisions which relate to (a) the prevention or diagnosis of illness in the patients, or (b) their care or treatment. In regards to fulfilment of this duty, the CCG is currently exploring personalisation across the organisation, with an aim to set out all of the ongoing and planned personalisation projects in a personalisation strategy. 5. Personal Health Budgets 5.1 Who can have a personal health budget? Following the Department of Health s successful national PHB pilot programme, PHBs are being rolled out: 1 April 2014 Those eligible for NHS Continuing Healthcare (including parents of children/nhs Continuing Care) will have the right to ask for a personal health budget. 1 October 2014 Those eligible for NHS Continuing Healthcare (including parents of children/nhs Continuing Care) will have the right to have a personal health budget. Eligibility for CHC is based on an individual s assessed health needs and determination of a primary need for healthcare. The Decision Support Tool from the National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care (November 2012) provides the basis for decisions on eligibility for CHC funding for adults. The Decision Support Tool from the National Framework for Children and Young People Continuing Care (March 2010) provides the basis for decision on eligibility for CHC funding for children and young people under the age of eighteen. At present, it is only envisaged that PHBs will be offered to those who are CHC eligible but who are receiving a care package in their own home. National pilots are still ongoing into the use of PHBs for individuals in residential and nursing homes. Apart from exclusions by statute, service users who are in receipt of CHC funding, in principle, are eligible to hold a personal health budget. There is no

5 exclusion by diagnosis or by virtue of mental incapacity. However, PHBs are voluntary and a traditionally commissioned CHC package will remain in place if an individual chooses not to have a PHB. 1 April 2015 The right to ask for a personal health budget will be extended to those with long term conditions and mental health conditions who could benefit (although it is possible to offer this now if CCGs chose to). We are currently awaiting further guidance on the specific groups but this is not expected until Autumn This objective ties in with the NHS Mandate that states from 1 April 2015 that everyone with long-term conditions, including people with mental health conditions, will be offered a personalised care plan that reflects their preferences and agreed decisions. On 9 July 2014, the NHS England Chief Executive, Simon Stevens announced a new Integrated Personal Commissioning (IPC) programme, which will blend comprehensive health and social care funding for individuals, and allow them to direct how it is used. This extends and combines current work on year of care NHS commissioning, CHC, and the early experience of integrated care pioneers. 4.2 What a personal health budget can be used for: The aim of a PHB is to give the individual more choice and control over the money spent on meeting their health care and wellbeing needs. This means that they select treatments and services that meet their needs in a way that is most appropriate for them. The vision for PHBs is to enable people with long term conditions and disabilities to have greater choice, flexibility and control over the health care and support they receive. PHBs are one way of helping people to be more involved in discussions and decisions about their care. A PHB is an amount of money to support a person s identified health and wellbeing needs and outcomes, planned and agreed by the service user and their local healthcare professional. At the centre of a PHB is the care and support plan. This plan helps people to identify their health and wellbeing goals, together with their local NHS team, and sets out how the budget will be spent to enable them to reach their agreed health and wellbeing outcomes and keep them healthy and safe. There are certain things that a PHB cannot be used for:- alcohol or tobacco products; gambling services or facilities; a debt other than for a service agreed in the Care and Support Plan

6 primary medical services (such as diagnostic tests, vaccinations or medical treatment); urgent or emergency treatment services (such as unplanned hospital admissions); A PHB cannot be used for support or care provided by an individual living in the same household as the budget holder unless the CCG considers that service is necessary to: satisfactorily meet the service user s need for that service; or promote the welfare of a service user who is a child. Budget holders are not allowed to contribute to or 'top-up' the cost of care as set out in the care and support plan from their own resources. PHBs are provided so that service users may use them to meet their identified health and well-being needs and outcomes. The use of PHBs does not extend to the delivery goods or services that would normally be the responsibility of other bodies (e.g. local authority social services, housing authorities) or are covered by other existing contracts held by the CCG (e.g. community equipment via the Joint Integrated Community Equipment Service contract). However, in some cases, it may be sensible for the CCG to agree a service which would normally be funded by another funding stream if that service is likely to meet someone s agreed health and wellbeing outcomes How a personal health budget can be received: Service users will also be afforded the choice in the way in which their budget is held; notionally, by a third party organisation or paid directly to the person (or their representative). There are three ways in which a person can receive a PHB: Notional budget: Third party budget: Service users are aware of the treatment options within a budget constraint and of the financial implications of their choices. The NHS underwrites overall costs, retains all contracting and service coordination functions and manages the budget/account. There is no requirement for the service user to maintain financial records. Service users are allocated a real budget, held by a third party (e.g. a Brokerage and Support Service or independent user trust) on their behalf. The third party helps the service user choose services within the budget based on their agreed health and wellbeing outcomes. Where a third party manages a service user s budget on 1 Paragraph 29 Guidance on Direct Payments for Healthcare: Understanding the Regulations (March 2014)

7 their behalf, they will be required to maintain sufficient records to be able to demonstrate that any monies provided have been used in accordance with achieving the outcomes agreed in the individuals care and support plan. Direct Payment: Service users are given cash payments to purchase and manage services themselves, including third party organisations. If the service user is unable to manage the budget themselves a Representative or a Nominated Person may do it for them. There is a requirement to maintain sufficient records to be able to demonstrate that any monies provided have been used in accordance with achieving the outcomes agreed in their individual care and support plan. A combination of the above may also be appropriate. The key principle is that the service user knows what their budget is, the treatment or care options and the financial implications of their choices, irrespective of the way the budget is actually managed. 5. Progress of Bristol CCG for CHC PHBs Although the CCG was not part of the national pilot programme, the CHC Interim Programme Manager and Finance Officer have been proactive in developing their skills and knowledge by: attending regional events and workshops with speakers from pilot sites and the Department of Health; and utilising the PHB online learning network to track the progress of the PHB pilot sites and further build up their knowledge of PHBs. As a result of this proactive engagement with the national pilot programme, an opportunity to implement a PHB for a CHC transition case was recognised. PHB implementation for this case is ongoing but this has allowed the service user to retain their team of personal assistants that are familiar with the service users care needs and provide continuity of care. This has been an extremely valuable practical learning tool for the CHC team in implementing PHBs and the infrastructure required to support this. A PHB Lead in the CHC team was appointed in January 2014 to take forward the learning from the pilots and began setting up the framework for the provision of PHBs for CHC eligible service users.

8 5.2 PHB Accelerated Development Programme The PHB Lead and CHC Finance Officer have attended a six day NHS England PHB Accelerated Development Programme that has been aimed at providing assistance to CCGs in gearing up for 1 April 2014 PHB implementation date. Through networking at this event, the PHB Lead and Finance Officer have also engaged with existing PHB pilot sites to learn more about their processes and the practical implementation issues that have already been faced. An additional Accelerated Development Programme was launched in July 2014 that is specifically aimed at PHB implementation for children and young people who have been found eligible for Continuing Care (CC). The Continuing Health Care Nurse Manager for Children and Young People is attending this programme. 5.3 PHB joined up working approach As children and young people who meet the CC funding criteria have also been able to ask for a PHB from 1 April 2014, the CHC team have actively involved the Continuing Care Commissioning Manager and Continuing Care Nurse Manager (based at City Hall) in the CHC teams PHB planning. Regular meetings are held in order to exchange PHB learning and to share progress on the development of PHBs in Bristol. The CHC team have also linked up with the Mental Health Commissioning Manager within the CCG who has implemented two pilot PHB via a one off direct payment. The CHC team have been able to offer advice based on their knowledge and experience to date to help ensure that the proposed PHB will meet legislative requirements. The CHC team have already begun developing documentation e.g. a direct payment agreement that has been shared with the Mental Health Commissioning Manager to avoid duplication of work and to ensure that a linked up PHB approach across health areas is taken. As Bristol City Council already possesses experience of delivering direct payments through personal budgets, the CHC team has met with representatives from the Direct Payment team. They have conveyed knowledge of direct payments, shared their direct payment processes and provided templates of their existing direct payment documentation. Bristol City Council is already using a brokerage support service (WECIL) to support individuals receiving personal budgets. Discussion of a collaborative approach around brokerage support has already begun, as well discussion about the potential for a collaborative pilot on pre-paid cards which is detailed later in this paper. The CCG have joined up with North Somerset and South Gloucester CCGs in order to evaluate PHBs using a Patient Outcome Evaluation Tool (POET). This evaluation tool has been developed by In Control and Lancaster

9 University as a way for personal budget holders and carers to report their experiences of personal budgets. It has now been adapted so it is relevant for people using personal health budgets, and their carers. Once 100 PHBs have been implemented as a collective, In Control will produce a local evaluation report. 5.4 PHB Service User involvement The PHB Lead has liaised with a brokerage support service and met with a direct payment recipient to obtain a service users views about the practicalities of receiving a personal budget, specifically in respect of receiving direct payments. Valuable service user feedback was obtained on the potential pitfalls that, as a service user, they may have faced during the setting up of the personal budget. The following table provides a report on the number of personal health budgets to date: Service User Cohort Monthly Direct One off Direct Payment Payment CHC 4 1 Mental Health 2 Exceptional Funding 1 case is currently being considered for a PHB. All have been provided via the direct payment method. Throughout the implementation of the above PHBs, service user feedback has been sought and recorded at key stages in the process. This has allowed the PHB Lead to amend the PHB process as appropriate. To date feedback has been received about brokerage support services used, the patient information available and the CCGs website. 5.5 PHB Leaflet An introduction to personal health budgets leaflet has been produced utilising the CSU Communications. A separate leaflet has been produced for adults and children and young people using the same style of template. These leaflets are now available in hard copy. North Somerset CCG has been granted permission to use the leaflet templates for their PHB provision. This will help to ensure wider continuity of PHB patient information in the locality and neighbouring CCGs. 5.6 PHB Newsletter A PHB Newsletter has been developed that provides information about CHC, CC, and PHBs along with notification of the intent to extend the availability of

10 PHBs to long term conditions and mental health as of 1 April This newsletter was included in the GP bulletin on 9 April 2014, sent to Healthwatch and has been sent to a direct payment contact at Bristol City Council for circulation. It has also been circulated to the CCG in the staff update. The CHC team plan on issuing quarterly newsletters to inform service users and stakeholders of the CCG s PHB progress. This newsletter has received recognition from NHS England s PHB delivery team via Twitter: The CCG are now considering the creation of a BCCG PHB twitter account. Please see Appendix B and Appendix C for the first and second editions of this newsletter. These are also available on the CCGs PHB web page. 5.7 BCCG Website On 1 April 2014, the CCG s website had information posted about CHC and CC. Information relating to the introduction of PHBs for both CHC and CC eligible patients was included along with copies of our leaflets and My personal health budget journey (Appendix F).There is also a link to the NHS England PHB website that includes YouTube videos of the experiences of service users and staff involved in the national PHB pilot. Feedback on the web text has been received from Bristol Parent Carers and the text has been amended to reflect this. 5.8 PHB Networking Brokerage support is required to ensure that individuals are supported throughout the PHB implementation process and make the most out of their budget. The PHB Lead and Finance Officer have scoped out the brokerage support service available in the locality and beyond through internet research and asking pilot CCGs about the brokerage support services that they already use. The PHB Lead and Finance Officer have met with brokerage support services to find out what support they are able to offer PHB service users. Consideration has been given to the capacity and experience of these

11 brokerage support services to support children with PHBs and service users from the long term condition and mental health groups. A document has been compiled to hold all of the information gleaned from the meetings held with the above brokerage support services. This document includes: An overview/summary of the brokerage support service; Types of services that are offered; Pricing lists for the services offered to service users and the CCG; Any development areas that the brokerage service is working on; Key points of meetings/conversations held with brokerage support services; Feedback on information provided; and Record of performance where the broker has been used e.g. a CHC eligible service user and the CHC team has just used a brokerage service to facilitate a one off direct payment by providing employment advice and a payroll function. This has been circulated to relevant professionals within the CCG and Bristol City Council. Discussions have taken place between the CHC team and the Council s Direct Payments team around how brokerage support services could sit between the two organisations. Both teams are currently seeking management approval to set up a working group to further plans for this. The PHB Lead is taking point on a regional piece of work to develop a set of quality standards for brokerage support. This is currently in the initial stages but it is envisaged that this will be utilised across the region for continuity of standards expected in PHB brokerage. 5.9 PHB supporting documentation/information PHB papers and information sharing opportunities having been undertaken: Discussion paper about PHBs presented to the Quality and Governance Committee on 18 March An equality impact screen and equality impact assessment conducted for PHBs. A paper providing information about PHB implementation progress made to date, potential financial risks to the CCG and the CHC s draft CHC (adults only) PHB three year strategy. A three year PHB CHC (adults only) strategy. The Governing Body approved the strategy in July 2014 for consultation with Healthwatch. A separate strategy for PHB CC (children and young persons) is also in development.

12 Direct Payment Legal Agreement and One off Direct Payment Legal Agreement for service users. First draft PHB Policy which applies to CHC and CC with the principles to apply to PHBs for long term conditions and mental health introduction in April A draft Operational Guide for CHC (adults only) with supporting template documentation. A separate Operational Guide for CC (children and young persons) is also planned. The PHB Lead presented on PHBs to the PEC (PPI, Equalities and Communications) team at the CCG on 10 June The PHB Lead presented on PHBs during the CHC presentation for the CCG s staff meeting on 19 June PHB Finance On 21 May 2014 the CCG provided the venue for discussion about a pre-paid cards pilot. Pre-paid cards would be another way of the service user receiving their budget and would limit some of the financial risks associated with direct payments. Representatives from Bristol CCG, Kernow CCG, Wiltshire CCG, North Somerset CCG, South Gloucestershire CCG and Bath County Council attended. An invitation to attend was also sent to Bristol City Council Direct Payment team. Following this, the CHC team wish to implement a pilot for pre-paid cards. The CHC and CCG Finance teams have received presentations from two leading pre-paid card providers and are scheduled to visit Birmingham CCG in October for learning on how they have implemented the pilot. Following discussion with Bristol City Council s Direct Payments Team about the intention to set up a pre-paid cards pilot, they have expressed an interest for a number of their direct payment recipients to be involved in the pilot. Both organisations are in the process of seeking senior management approval to add this agenda to set up a collaborative pilot. The CHC team submitted an expression of interest for funding from the Patient Voice South Development Fund. The aim of this was to provide funding for personalisation. Although the proposal on how to use the funding was unsuccessful, we have been encouraged to revise our proposal and resubmit during the next round of applications. The PHB Lead has also explored an offer of human resources from Kent and Medway CSU on a patient in control initiative they are working on.

13 5.11 Planned work The CCG has further PHB development planned: The PHB Lead to deliver presentations to the Partnership Boards and Carers Steering Group. PHB Lead attendance at Westminster Health Forum Seminar Next steps for rolling out personal budgets in health and care: integration, commissioning and long-term conditions in Central London on 27 January Finalising the PHB policy, CHC (adults only) three year strategy and CHC (adults only) PHB Operational Guidance. Further development of the CCGs PHB website. Wider training for the Provider on delivery of PHBs. To build on the number of CHC PHB holders. Exploration of a the potential to become a first phase site as part of Proposed support network for Personal Health Budgets (PHBs) and Integrated Personal Commissioning Programme (IPC) accelerated roll out in the South West. This would involve identification of a range of practitioner champions who have the goal of supporting these ten PHBs for ten service users with long term conditions. 6. Key risks and Opportunities 6.1 Clinical Risk PHBs will have clinical risk attached to them due to the shift in NHS culture to risk enablement and shared decision making: PHBs will bring an additional risk to the CCGs Providers. The CCG recognises that the implementation of PHBs may be more resource intensive for clinicians to the current model during the implementation phase. Therefore this could impact on Providers capacity to implement and monitor PHB holders. However, other CCGs have realised the benefits of this investment at the implementation stage in avoiding packages of care breaking down and better service user outcomes. PHBs bring the opportunity for service users to spend the NHS budget on non-traditionally commissioned services or equipment in order to meet their health and wellbeing needs and outcomes. This may mean that choices on how to use the budget may not be supported by NICE

14 guidance, or be considered to be less orthodox, causing concern in professionals trained to adhere to evidence based practice. If finances are not efficiently delivered to the service user to allow them to meet their health needs and outcomes, this could impact on the service user s outcomes and could increase healthcare intervention required. If sufficient time and detail is not provided at the outset of the care and support planning then there is a real risk that the person s health and wellbeing outcomes will not be met. This will also lead to a new or increased need for primary care services and have financial implications for the CCG. PHBs offer the opportunity to employ personal assistants to be trained in the delivery of clinical tasks; this raises the issue of delegation of accountability and competence. The NHS England PHB delivery team are currently working with the RCN and Scils for Care regarding this issue. There is a clinical risk if PHB clinical and financial reviews are not conducted in line with service users needs and the NHS (Direct Payment) Regulations The CCG recognises the above risks and is working through these issues to ensure clinical risk is minimised. 6.2 Financial risk A comprehensive paper on the financial risk that PHBs will bring to the CCG has been conducted and included in the paper titled Personal Health Budgets: CHC Progress, Financial Risk and CHC PHB Three Year Strategy which was presented to the CCGs Quality and Governance Committee on 20 May This paper predominantly focused on the financial risk of PHBs where the service user is eligible for CHC funding. This identified the main areas of financial risk: Resource Allocation for PHBs The Resource Allocation Tool that is being used in Bristol is one that has been developed by Manchester CCG. Going forward, the CCG will need to evaluate the performance of the Resource Allocation Tool. It will be necessary to develop other versions for long term conditions and mental health so that resource allocation is accurate for these groups and to ensure that PHBs are sustainable

15 Misuse of money/fraud by service users or their representative/nominated person Of the three ways of receiving a PHB, a direct payment represents the biggest financial risk to the CCG; therefore it is essential that quarterly financial reviews are conducted. This will mean additional administrative resources may be required to oversee this dependant on the uptake and this has prompted consideration of the introduction of pre-paid cards as way of reducing the administrative resources required. In addition, a PHB Legal Direct Payment Agreement has been devised to ensure that the individual and CCGs duties and responsibilities around having a PHB are clearly set out in order to minimise the risk of misuse of the budget. Associated financial risks with the use of personal assistants The use of personal assistants can bring financial advantage to the CCG and the service user through lower hourly rates compared to a care agency. However, other financial considerations such as pension (where there is more than five PA s employed a stakeholder pension may be required), long term sickness and maternity cover all become the responsibility of the employer. These employer issues and the associated financial impact would be covered by the agency rather than the CCG through the usual commissioning process of CHC care packages. A PHB will need to cover these eventualities and this will result in a financial risk to the CCG. Potential increases in service costs due to private paying individuals Where a service user receives a direct payment, they will be directly commissioning care services. This could result in the individual receiving a less preferential rate than what the NHS could obtain through the traditional commissioning process. However, Guidance on Direct Payments for Healthcare: Understanding the Regulations 2014 provides that PHB must still follow the NHS principle of providing value for money. Brokerage support services Brokerage support services will be required to assist individuals to plan and buy services within their allocated budget. There will be a cost associated with this. Research has already been undertaken in the varying costs and experience of brokerage support services in the locality. The CHC team and Bristol City Council s intend to carefully plan how any brokerage support service/s will sit between the two organisations in order to

16 Resources and Training The will utilise existing staff resources (Bristol Community Health, CHC Health Assessment and Review Team for adults and Sirona s Lifetime Service for children and young people) to implement and manage PHBs. However, the HART service specification has been revised to factor in PHB clinical support and will have a financial implication in the commissioning of this revised service specification. The PHB Lead will continue to attend NHS England PHB learning events and increase knowledge of PHBs. This learning will be shared with other professionals. Potential for double funding through block contracts Traditionally commissioned CHC care packages are through a spot purchasing basis due to the varying needs of each eligible service users. However, PHBs will be extended form 1 April 2015 to groups of long term condition service users where block contracting is used. This creates a substantial risk of double funding. The CCG will also face the challenge of unpicking existing block contracts to avoid double funding for those who request a PHB, with the risk of destabilising services in the process. This will be a national risk. Paying for social care services in addition to health care PHBs take a holistic approach. This has the potential side effect of the CCG beginning to fund services that would traditionally be funded through the Local Authority. However, this also provides the opportunity to pool budgets in order to minimise this risk. The CCG recognises the above risks and is working through these issues to ensure that financial risks are minimised. 6.3 Litigation Risk As a result of introducing PHBs, the CCG could face legal challenges which would also result in financial consequences. Therefore PHBs must be implemented with clearly defined processes for decision making and risk management. Without a robust decision making process and an adequate framework to manage risk then the CCG may be liable to legal challenge where a PHB is declined or if any significant harm is caused to CHC patients who receive a PHB. The statutory instrument The National Health Service (Direct Payments) Regulations 2013 which came into force on 1 August 2013, provides a legal framework for the delivery of direct payments by the NHS. Supporting guidance (Guidance on Direct Payments for Healthcare: Understanding the Regulations) issued April 2014 is also relevant to the delivery of PHBs. The CCG will need to ensure compliance with these provisions to minimise the

17 litigation risk. Particular areas of legal challenge which the CCG could face in relation to PHBs include: Service Users employing Personal Assistants Where PHBs are implemented through a direct payment, this creates the opportunity for people to employ their own staff e.g. personal assistants. This will mean that service users would become the employer and they will be subject to the legal implications that being an employer brings. However, the CCG will still retain a duty of care. The introduction of PHBs will allow delegation of clinical tasks to personal assistants. At present, CQC registration is not required for this. This may bring legal implications for the CCG if a clinical task is inappropriately delegated and/or a personal assistant undertake a task but does not possess the requisite competency. Challenge under the Equality Act 2010 If there is not sufficient support from healthcare professionals and brokerage support services to ensure equality of access to PHB provision then the CCG could face legal challenge. Clinical Negligence The CCG will continue to have a duty of care towards an individual who has a PHB. Human Rights PHBs will naturally cause clinicians and the CCG concern about the level of control that is passed to the individual and the risks attached. This may result in frequent reviews which are not proportionate and interfere with respect for private and family life. 6.5 Opportunities The introduction of PHBs provides the following opportunities: A shift in NHS culture. PHBs provide a stronger focus on commissioning for outcomes. For successful implementation of PHBs there is a need for NHS staff culture to move towards a collaborative, risk enablement and shared decision approach. This will involve combining the healthcare professional s expertise (learned) and the service users experience (lived). PHBs also reflect a shift towards health prevention and increased promotion of health and wellbeing rather than reactive healthcare system.

18 Service User Involvement PHBs allow service users to become the commissioner and buy their own care. This provides valuable service user input and the potential for more cost effective and appropriate services. Another potential byproduct of personalised care planning is exclusion of inefficient and unused services. Care coordination and personalised care planning There are many variations of personalised care planning that is currently undertaken by the CCG and its Providers. Bristol City Council also implements personalised care planning in their support plans. This has prompted the need to consider a strategic view around care coordination and personalised care planning. Furthering the personalisation agenda in the CCG As already highlighted in this paper, PHBs are just one method of introducing personalisation into the delivery of healthcare services. It has prompted the CCG to analyse and link up all of the existing personalisation initiatives that are currently ongoing or which are planned. Integration and collaborative opportunities As already highlighted in this paper, PHBs offer an opportunity to collaborate and integrate processes with Bristol City Council. Where opportunities are being recognised, these are being considered and acted on where possible. Due to the similarities between personal budgets and PHBs, there is an opportunity to provide pooled budgets for service users who receive both. This is currently being piloted by PHB Go Faster Further CCGs. Help to reduce health inequalities A national and local Equality Impact Assessment conducted demonstrates that PHBs and the overall movement to personalise services could be a powerful tool to address inequalities in the health service. Growth of Providers and a support and independent living network in the locality Service users may want to use their budget for innovative services which will require a sufficient marker to support this. Service users receiving a PHB, especially those who chose to receive their budget through a direct payment, will need a good support network to ensure sustainability. This offers an opportunity for the localities voluntary and community sector. 7. Implications (Financial and Legal if appropriate) 7.1 Financial Implications

19 PHBs do not introduce new funding, but are a way of using existing resources in a different way. Whilst the pilot sites have shown no direct cost savings to the NHS, they have shown that the quality of life and psychological wellbeing for people with PHBs has significantly improved with some seeing a drop in their attendance to hospital. Overall, cost savings were seen for PHBs introduced for CHC service users and service users with mental health problems and were cost neutral for other cohorts. Findings show that PHBs are most cost efficient for high need, high cost packages of care. A clearly defined PHB budget for each individual is set during the assessment process. This is determined and agreed before any funds are made available. The cost of care packages for people receiving PHBs is determined within the CHC funding allocation that is currently in place. Resource allocation for future PHB cohorts is likely to be challenging due to the use of block contracting. There will be an associated cost for brokerage and CCG commissioning, mainly to train, expand its staff team in order to safely and effectively implement this government policy. The first year set up costs is likely to be higher than subsequent years due to the need to set up the PHB infrastructure required. 7.2 Legal Implications Please see that describes the litigation risks/implications that PHBs pose to the CCG. 8. Conclusions PHBs are important tool for furthering the personalisation agenda. They will provide more choice and control for individuals over the services that are bought to meet their health needs. PHBs also have the potential to facilitate better service user outcomes and cost efficiencies for service users in Bristol. Whilst PHBs will bring risks to the CCG, particularly in relation to clinical and financial risk, the CCG has plans in progress to mitigate these risks. Opportunities to collaborate and integrate with Bristol City Council have been highlighted along with plans to act on these. The CCG has made good progress on the PHB agenda and is committed to further development of PHB practice. The CCG hope to increase the number of service users receiving budgets as experience of implementing and sustaining PHBs increases.

20 9. Recommendations This paper is for information at this stage. However, it is also hoped that it will provide assurance to the HWB regarding the progress that the CCG has made on the agenda. 10. Appendices Page 21 Page 22 Page 24 Page 26 Appendix A PHB National Pilot Programme Case Stories Appendix B First edition PHB Newsletter Appendix C - Second edition PHB Newsletter Appendix D My Personal Health Budget Journey

21 Appendix A Case Studies Nikki, 35 and from Dorset, has childhood onset rheumatoid arthritis with severe flare-ups. Normal NHS services were often unable to provide immediate care, so Nikki had frequent prolonged stays in hospital. Nikki uses her personal health budget to employ three carers on a flexible basis. When a flare-up occurs they are able to reach her within 30 minutes, and between them can provide 24 hour care for several weeks if needed. Nikki's medication can be administered at home by the NHS. Nikki's flare-ups are much shorter, she has fewer hospital admissions, and a better quality of life. Anita, 58 and from Hull, has the degenerative condition Huntington's Disease. Two years on from first receiving her personal health budget, we revisit Anita and her husband Trevor. Having personal assistants to care for her at home has improved Anita's quality of life, and reduced her need to go to hospital. Care for Anita was stepped up when Trevor's health declined and he was unable to look after her at night. The plan identified other ways to personalise Anita's care, like training Trevor to change Anita's feeding tube in an emergency. Pete, 20 and from Nottingham, has autism and type I diabetes. The move from children's to adult services was made easier for Pete because of an integrated personal budget for health, social care and education. Pete and his mum Michelle chose carers that he has known since childhood. Pete's blood sugar levels need frequent testing so his carer attends college with him to do this, enabling him to continue his education. Pete has also been able to stay living at home rather than entering residential care; he has more opportunities for social interaction and is a happier young man. Roger, 58 and from Dorset, has chronic obstructive pulmonary disease. His breathing problems required him to be admitted to hospital regularly. He is on steroid medication, and needs oxygen support indoors. Roger's personal health budget helps him manage his condition better. He has a portable nebuliser so he can lead a normal life and manage any attacks in situ. Roger is rehabilitating through exercise, attending a local gym, using a Wii Fit at home and gardening, as he breathes better outdoors. Roger's health has greatly improved and he is able to take less medication Mary, 55 and from Northamptonshire, has depression, anxiety and a personality disorder. She has accessed mental health services for 10 years. Mary overdosed 18 times last year, requiring crisis intervention, paramedic and hospital involvement. She decided to use her personal health budget for ongoing twice-weekly psychotherapy sessions with a therapist she trusts, and is now far less reliant on other mental health services. Mary's self-harming behaviour has greatly reduced, she has been able to lower her medication and she has a much better relationship with her family.

22 Appendix B - First edition PHB Newsletter

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24 Appendix C - Second edition PHB Newsletter

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26 Appendix D - My Personal Health Budget Journey

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