Practical Guide

Direct Payments for Healthcare

Shaping healthcare finance

Published by the Healthcare Financial Management Association (HFMA), Albert House, 111 Victoria Street, Bristol BS1 6AX Tel: (44) 0117 929 4789 Fax: (44) 0117 929 4844 E-mail: info@hfma.org.uk This guide has been produced by members of the HFMAs Commissioning Finance Group working closely with the Department of Healths personal health budget pilot sites. The drafting was carried out by Simon Stockton of Groundswell Partnership and the editor was Anna Green. Cover design was undertaken by YZDESIGNS, setting by Academic + Technical Typesetting and printing by ESP Colour Ltd. The NHS is always changing and developing this edition reflects the structures and processes in place in September 2012. We are keen to obtain feedback on ways in which the content, style and layout can be improved to better meet the needs of its users. Please forward your comments to info@hfma.org.uk or to the address above. While every care has been taken in the preparation of this publication, the publishers and authors cannot in any circumstances accept responsibility for errors or omissions, and are not responsible for any loss occasioned to any person or organisation acting or refraining from action as a result of any material within it. Healthcare Financial Management Association 2012. All rights reserved. The copyright of this material and any related press material featuring on the website is owned by Healthcare Financial Management Association (HFMA). No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopy, recording or otherwise without the permission of the publishers. Enquiries about reproduction outside of these terms should be sent to the publishers at info@hfma.org.uk or posted to the above address. ISBN 978-1-904624-75-2

Practical Guide: Direct Payments for Healthcare

Contents
Foreword Acknowledgements Executive summary Introduction 1. 2. 3. 4. 5. 6. 7. 8. What are direct payments? Other ways of delivering personal health budgets How to cost direct payments How direct payments for healthcare can be spent Integrating direct payments between health and social care Monitoring and reviewing direct payments The role of direct payment support services Concluding thoughts i. Example personal health budget team nancial process ii. A checklist for what must be included in a care or support plan iii. Example healthcare direct payment contract Page 2 Page 3 Page 4 Page 5 Page 6 Page 8 Page 9 Page 11 Page 15 Page 16 Page 19 Page 21 Page 22 Page 22 Page 23 Page 24

Appendices

Foreword
Evidence is building that people using direct payments to meet their health needs can lead to more effective healthcare. So far, the implementation of direct payments and personal health budgets for NHS services has been limited to relatively small-scale pilots. However we must not underestimate the potential for this policy to radically alter how spending decisions are made, and to change the way in which large amounts of NHS money are committed. There are valuable lessons to be learned both from the NHS pilots and colleagues in social care about the benets, risks and challenges that come from passing public money into the hands (and bank accounts) of individuals, and there is no doubt that this agenda will need strong nancial engagement at strategic, policy, and operational level if it is to be successfully managed. Health service nance managers have a vital role to play in managing this important transition in a way that can realise the benets we know this change can bring. This practical guide provides an overview for nance managers working in health services to help build a solid understanding of this policy area and of the practical issues entailed in rolling out direct payments as a key part of good healthcare delivery. Cathy Kennedy, Chair of the HFMAs Commissioning Finance Group

Acknowledgments
This guide has been produced by members of the HFMAs Commissioning Finance Group working closely with the Department of Healths personal health budget pilot sites. The drafting was carried out by Simon Stockton of Groundswell Partnership and the editor was Anna Green. The HFMA is grateful to all those who have been involved in producing this publication.

Executive summary
.

This guide covers the information that health service nance managers working in commissioning organisations (specically primary care trusts and in future clinical commissioning groups) need to understand in relation to direct payments for healthcare. Direct payments for healthcare are cash payments paid to people to enable them to purchase the care they need. They are an important way of supporting people to exercise more choice and control in meeting their long-term healthcare needs and agreed health and wellbeing outcomes. Direct payments are one way of delivering a personal health budget (PHB). PHBs can also be delivered as notional or third party budgets. At present, any PCT can offer PHBs as notional or third party budgets but only approved pilot sites can offer PHBs as direct payments. Subject to the results of the evaluation to be published in October 2012, people eligible for fully funded continuing NHS healthcare will have the right to ask for a PHB (which will include direct payments) from April 2014. Early evidence from the PHB pilots in England is highlighting how sites are successfully using direct payments for healthcare, sometimes in ways which would not be possible via traditionally commissioned services. There is no set amount for a direct payment. In each case the amount must be arrived at through an individual assessment. Sometimes this may be done using a specic budget setting tool or via costing of existing services. Whichever method is used the amount of money offered must be adequate to meet the eligible needs. Direct payments for healthcare can only be signed off once a care or support plan has been approved by the commissioning organisation. People can use the money exibly provided it is not used for anything illegal and that any identied risks are adequately managed. Evidence from people using direct payments in social care and from PHB pilot sites has shown that some people can nd the process of getting a direct payment stressful and confusing. Efforts should be made to keep processes quick, simple, and transparent. People should be able to access good advice, information and support to help them take up and use healthcare direct payments effectively. PHB pilot sites have found that using local direct payment support services set up for people using social care direct payments can be a very effective way of ensuring people get the help they need. Where people have both health and social care needs particular attention should be given to making the process as seamless as possible. Direct payments should be monitored in ways that are proportionate to the particular risks in each individual case. A lighter touch approach to monitoring is advised wherever possible and appropriate.

Introduction
Personal health budgets (PHBs) are an important way of giving people more control over their health and wellbeing and, subject to the results of the national evaluation (to be published in October 2012), the government intends to roll out PHBs for people with long-term health conditions. Direct payments, which allow people to receive a PHB into a designated bank account and arrange services for themselves are a proven way of ensuring people can gain more control. The intention of healthcare direct payments is to give people control over the nancial resources available through the NHS to meet their healthcare needs. Direct payments legislation was rst introduced in 1996 following a long campaign led by disabled people to take control of the money used by local authorities and other bodies to pay for care services and to choose how to use that money to best effect. At the time of writing the full details of how PHBs will be implemented have yet to be nalised. However, the Secretary of State for Health has already announced that, subject to the results of the evaluation to be published in October 2012, by April 2014 everyone in receipt of NHS continuing healthcare will have a right to ask for a PHB, including a direct payment. As the organisations that commission healthcare services will change from April 2013, we have used the term commissioning organisation throughout this guide to refer to both primary care trusts (PCTs) and clinical commissioning groups (CCGs). This booklet is being published by HFMA with support from the Department of Health and is intended for use by health service nance managers. It focuses on the practical issues involved in the nancial management of direct payments for healthcare and explains the role of direct payments in government policy as a means of improving and personalising the delivery of certain types of health services. This guidance builds on learning from the use of direct payments in social care and from the PHB pilots. For more information about the PHB pilots and up to date learning go to the Department of Healths PHB web pages: www.personalhealthbudgets.dh.gov.uk

Chapter 1: What are direct payments?

1.1 Direct payments for healthcare are cash payments made to people to enable them to purchase the care they need. They are one way of receiving a PHB. People receiving a direct payment take on direct responsibility for purchasing support and services to meet the outcomes agreed in their care or support plan. The care or support plan can be developed by the person themselves with help from friends and family, peers or appropriate professionals. Once completed the commissioning organisation needs to agree the plan before agreeing a direct payment. A person can receive a direct payment to meet all of their assessed health needs or for part of them alongside support provided in other ways. They can be made as one off payments (for example, for items of equipment) or as regular payments to meet ongoing needs. Many people with ongoing needs use direct payments to employ personal assistants directly rather than use agency staff. This approach is illustrated in the case study at the end of this section. In order to receive a direct payment the person must be both willing and able to manage it (alone or with support). However, there is a range of ways in which a person can be supported to manage a direct payment. In addition, they can if they wish nominate someone to manage the direct payment wholly on their behalf (a nominee). A nominee must be willing to accept full responsibility for managing the direct payment. If a person does not have the capacity to consent to a direct payment, Department of Health guidance1 allows a suitable representative to receive and control a direct payment on the persons behalf, subject to certain criteria. This is similar to the suitable person process in social care. Direct payments can be managed in a number of ways:
.

1.2

1.3

1.4

1.5

Paid directly to the person, into a designated bank account, which is only used for purchasing care and support to meet the needs and outcomes specied in the care or support plan. The commissioning organisation must agree access to this money by any other person. Paid into an account managed by a third party (another person, such as a friend or relative, or a non-NHS organisation for example, a direct payment support service, user-led organisation or Credit Union) and for use solely under the direction of the person receiving the direct payment (including a nominee or a representative receiving a direct payment) in accordance with the care or support plan. In this case, the money is managed by the agency or individual; but the purchasing of care and support and therefore contracts for care and support remain ultimately the responsibility of the direct payment recipient.

For more information on requirements for representatives, see page 17 of the Department of Healths guidance Direct Payments for Health Care; Information for Pilot sites: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117477

What are direct payments?

Paid into a bank account held by a nominee or representative (often a friend or relative), who has an agreement with the commissioning organisation to manage the direct payment. This bank account must be separate from the nominees or representatives other accounts, and be used only for purchasing care and support to meet the needs and outcomes specied in the care or support plan. The nominee or representative is responsible for fullling all the responsibilities of someone receiving direct payments. Paid onto a pre-paid card. This is similar to a debit card. Because a pre-paid card is not wholly controlled by the individual and cannot be used as exibly as money in a bank account, this can only be regarded as a form of direct payment if the person has the free choice to alternatively receive their money in the ways described above and has chosen a pre-paid card as their preferred option. This arrangement must give the individual the necessary freedom to use the card to purchase care and support to meet the needs and outcomes specied in the care or support plan. Kent County Council has one of the longest established pre-paid card systems which is a popular option for direct payments recipients.2

Case study employing a personal assistant Margaret lives in an adapted bungalow with her parents. She has not had any formal care or support until now, as her parents have provided for all Margarets support needs. As Margarets mother is getting older and is herself no longer in good health the family have worked together to plan for the future. Following an assessment Margaret was offered a joint health and social care budget. She has used this to put in place a plan that will mean she no longer relies on her parents 24 hours per day. She employs two personal assistants for 26 hours per week. Her personal assistants provide support with personal care, attending GP and hospital appointments, shopping and other activities. Margaret says that her budget has made a big difference to her life. She did not want to use a home care agency, as this would mean a lot of different carers who did not know her well coming in and out of her parents home. Her personal assistants enable her to lead the life she wants to, without relying on her family. This makes her feel independent and in control of her life.

Kent County Council the Kent Card: www.kent.gov.uk/adult_social_services/your_social_services/your_money/direct_payments/kent_card.aspx

Chapter 2: Other ways of delivering personal health budgets

2.1 Direct payments are one way in which health and social care bodies can make PHBs available to people but they are not the only option. A parallel paper to this guidance Resource Deployment Options for Personal Health Budgets3 published by the Department of Health explains in detail how direct payments sit alongside other ways of giving people PHBs. There are two additional ways in which health bodies can deliver PHBs as notional payments or via a third party arrangement. All PCTs can offer notional or third party budgets, but only approved Department of Health PHB pilot sites can currently offer direct payments. Subject to the results of the evaluation of the PHB pilot programme it is hoped that direct payment powers will be extended across England in 2013. In some instances it may be appropriate to offer a mixture of different methods for delivering a PHB for example, if someone would like to try out a direct payment but is not yet sufciently condent to manage their whole budget in this way or where a person wishes to retain an existing NHS service to meet part of their needs, and to meet their remaining needs in a way not provided by the NHS. There are some methods of payment that appear to be direct payments but on closer inspection may not meet the criteria to count as such. For instance where direct payments are made via pre-paid cards which can only be used with prescribed providers, or where money is not held in an account which the individual has full access to. Likewise where unnecessary conditions are placed on the use of a direct payment so that the money can only be spent on specic services and/or specic providers of services then this may also not constitute a direct payment. For more on this see chapter 4 below which looks at what direct payments can and cant be used for.

2.2

2.3

Resource Deployment Options for Personal Health Budgets, Department of Health, 2011: www.personalhealthbudgets.dh.gov.uk/Topics/latest/Resource/?cid=3430

Chapter 3: How to cost direct payments

3.1 Calculating the amount of a direct payment can be achieved in a number of different ways, each of which has its own merits. There are three common ways in which this is typically done: a. By calculating how much is currently spent on services to the individual and converting this into a direct payment. This is a useful approach where people are already receiving a service and the cost of that service is easily ascertained. This method has been used successfully in pilot sites working with people with existing NHS continuing healthcare packages. b. By estimating the value of the NHS services that would normally be offered to the person, taking account of their identied health needs. This is a useful approach where people are being newly assessed and services are not yet in place. For example, if following an assessment of someones needs, a commissioning organisation judges that the cost of meeting these needs would usually be approximately 120 then the value of the direct payment can be based on that informed assumption. Such judgments can reasonably be made on a case by case basis but the rationale for the assumed cost should be documented in brief during the assessment process so that the value of the later offer of a direct payment can be understood and can stand up to challenge. c. By using an assessment tool, which looks at the outcomes to be achieved, and the likely average cost of achieving them. This is a useful approach where there is some experience of how people can meet their needs and time to develop a more outcomes based approach. For example, the decision support tool has been used to help calculate budgets for people eligible for NHS continuing healthcare.4 3.2 Most approaches to setting budgets are accurate in no more than about 80% of cases. It is always advisable to have some in built exibility whichever approach is used in order to ensure that commissioning organisations can satisfy their legal duties to ensure that people have adequate resources to meet their eligible needs. To ensure that the budget allocated is a good t for what is required to meet the needs and outcomes outlined in the plan, there should be a sign-off process to agree both the care or support plan and the budget. There should also be a review within three months of the budget being awarded (see chapter 4). This can help minimise the risk of people receiving inappropriate or inadequate amounts of money. In many cases people are able to use direct payments to meet their needs more cost effectively (as the example below shows) however, the main benet is the enhanced control and the improved outcomes people experience.

A guide to setting personal health budgets for people who are eligible for NHS Continuing Healthcare, Department of Health 2012. Please note that at the time of writing, a parallel paper to this guidance was being developed by the Department: it will be available shortly at: www.personalhealthbudgets.dh.gov.uk/topics/index.cfm?tag=Good practice guides

Practical Guide: Direct Payments for Healthcare

Case study meeting needs cost effectively Annabel has muscular dystrophy and needs support with breathing, eating, moving around and continence. She has opted to manage her personal health budget as a direct payment. Her budget enables her to maintain control over her care. The budget can be used exibly, not just for personal care. Annabel has a motorised bed, which enables her to keep in the correct position to prevent muscle spasms and keep her ventilator mask in place. The exibility of her personal health budget came in handy when one of the beds three motors failed on a Friday evening. Using her personal health budget, Annabel was able to buy an ex-display model of the same bed direct from an equipment retailer, complete with warranty and maintenance contract. The bed was delivered and set up on the Saturday afternoon, so Annabel could sleep in it on that night. Annabel challenges the NHS to be able to respond this quickly. Before taking up the direct payment, Annabel lived in residential care a long way from home, at a cost of 156,000 per year. The personal health budget costs 26,000, and has enabled Annabel to live at home with her husband, to keep up with friends, and have an active social life. Annabel feels that her personal health budget is much more exible and responsive than services commissioned by the NHS could ever be.

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Chapter 4: How direct payments for healthcare can be spent

4.1 Once a care or support plan has been developed and the commissioning organisation has signed off the plan a direct payment can be made. The care or support plan itself must contain a specied set of information including how the person intends to meet their health needs and their broader health and wellbeing outcomes and what services or goods will be purchased to do so (see appendix ii for the full set of information required in a plan). In agreeing a care or support plan the commissioning organisation must be satised that the goods or services which the person intends to buy (as listed in the plan) will meet the individuals health needs and their broader health and wellbeing outcomes. They must also ensure that the amount of money offered will be sufcient to meet the costs of those goods and services. The individual receiving the direct payment or their nominee must also agree to the plan. Commissioning organisations should be open minded when reviewing plans and not look to exclude things simply because they appear unusual. Existing guidance to pilot sites points out that direct payments do not circumvent existing guidance, for example relating to National Institute for Health and Clinical Excellence (NICE) approval. Where NICE has concluded that a treatment is not cost effective, commissioning organisations should apply their existing exceptions process before agreeing to such a service. However, where NICE has not ruled on the cost effectiveness or otherwise of a specic treatment, commissioning organisations should not use this as a barrier to people purchasing such services, if it may meet their health and wellbeing needs. During the planning process it is important that people have the opportunity to make choices about the goods and services which they use and should be offered support at this time to help them explore what might be right for them. It is important that people have permission to purchase things that can achieve good outcomes for themselves even if such goods and services have not previously been provided by the NHS. See the case study at the end of this section for an example of an innovative use of direct payments. However, there are some activities/items that a person cannot use a direct payment for, specically:
.

4.2

4.3

4.4

4.5

4.6

. .

. .

To purchase primary medical services provided by GPs, such as diagnostic tests, basic medical treatment or vaccinations To purchase alcohol or tobacco or for gambling To cover urgent or emergency treatment services, such as unplanned in-person admissions to hospital To make debt repayments To purchase goods or services where the commissioning organisation believes the benets are outweighed by the possible damage to someones health 11

Practical Guide: Direct Payments for Healthcare

To purchase goods or services which are unlikely to meet the agreed outcomes, or where the cost is substantially disproportionate to the potential benet To pay a close family carer living in the same household except in circumstances when it is necessary to meet satisfactorily the persons need for that service; or to promote the welfare of a person who is a child5 To employ people in ways which breach employment regulations or to purchase anything else which is illegal. It is good practice to ensure that people taking up direct payments have access to a local direct payment support service. These services can help people to be good employers and meet their legal obligations. Disability Rights UK holds information on local services supporting people to use direct payments and produces a wide range of information for people needing advice on using direct payments or nding a local support service see its website for more information: www.disabilityrightsuk.org. More information on direct payment support services can be found in chapter 7.

4.7

Where the commissioning organisation is not satised that a plan is suitable for sign off it should inform people why that is the case and offer them support to review and amend their plan or to appeal the decision should they wish. The plan is the key document which both the direct payment recipient or their nominee and the commissioning organisation must agree and sign off before a direct payment can be made. It is therefore vital that it contains all the information required. Plans must also be reviewed at appropriate intervals starting at three months and then at least annually. In taking the direct payment, the recipient or their nominee must agree to the review and understand that part of that process may include a reassessment of their needs. In addition to the care or support plan, it has been common practice in social care to have a separate direct payment agreement.

4.8

4.9

4.10 If such an agreement is required it is important to keep it as simple as possible. Most of the information needed for sign off should be gathered by a care or support plan. The additional items which direct payments agreements have typically included which may not be in a care or support plan are:
.

. .

. . .

Information about how disputes will be managed and under what circumstances a payment may be withdrawn Details of how any unused money will be dealt with Details of how the direct payment will be delivered, how often and by what means (for example, via direct debit to a specied bank account) The bank account details which the money is to be paid into (this must be set up for the person to receive the payment into a personal bank account) If the direct payment is a one off payment, how it will be paid What other monies can be put into a direct payment bank account Under what circumstances money will be reclaimed.

Paragraph 83, Direct payments for healthcare: information for pilot sites, Department of Health, July 2010: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117477

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How direct payments for healthcare can be spent

4.11 Commissioning organisations should consider having one process for signing off a direct payment ensuring that any additional information required over and above the care or support plan is introduced in a simple agreement at the same time and that the process of agreeing the payment is as seamless as possible. Where people have a mix of health and social care funding, a single direct payment agreement is preferable and efforts should be made to merge the sign off requirements into a single document. An example agreement is included in appendix iii. The process that one pilot site uses to set up a healthcare direct payment is also included as appendix i. The process for signing off a direct payment should be clearly documented and communicated to people so that everyone understands what is expected of them. 4.12 Commissioning organisations should consider keeping the sign off process as simple as possible. Many organisations have developed panel arrangements to sign off care and support plans and agree direct payments. These involve bringing together key staff and stakeholders with knowledge and expertise of direct payments to agree sign off and ensure decisions are recorded and explained. This can be a useful approach and learning tool, particularly when key staff are new to working with direct payments. However, although such panels can be useful in the early stages of developing a direct payments infrastructure, they can also be very resource intensive and bureaucratic and slow down decision making they should therefore be used judiciously. It should not be necessary for all direct payments to be signed off by a panel. Instead, the person acting as carecoordinator or a team manager may be best placed to do so. Where there are queries over whether plans are suitable, panels can be helpful in ensuring that responsibility does not rest with a single person. Panels making decisions should operate in line with clear pre-set governance rules and ensure that decisions are recorded along with the reasons behind them and that these are communicated promptly to the people requesting the direct payment. Commissioning organisations should also ensure that people have an opportunity to have their views heard in the decision making process. 4.13 During the approval process a date should be agreed for when payment needs to begin and when payment will actually be made. Once approved, commissioning organisations need to ensure that direct payments can be paid on time to avoid the risk of people being left without access to essential support. Payments can be made in a number of ways (see chapter 1). Delays can sometimes happen if the person is setting up a bank account to receive payments. Direct payments support services can offer support to help people through this process where necessary.

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Practical Guide: Direct Payments for Healthcare

Case study innovative use of direct payments John has been a wheelchair user for some 15 years following a motorcycle accident. He has used a direct payment from social services to employ personal assistants. This means he can arrange support at times that suit his lifestyle such as getting up at 11am, and going to bed at 1am. John has tried using chairs provided by the NHS and those available using the NHS voucher scheme. However none of the chairs has stood up to the demands of Johns active lifestyle for more than a few months. Over 7 years ago John decided to build his own wheelchair, using his engineering skills and money from his state benets. This left John short of money, so his house began to fall into disrepair. John was offered a one-off personal health budget, equivalent to the value of an NHS wheelchair. He took this as a direct payment and has used the money to buy parts to build a powered wheelchair that he can use outdoors. He can now take his dog for walks on the beach and through the woods, without fear of getting stuck. His chair can also get past obstacles such as the ramp into his local pub that defeated the NHS chairs. Having the personal health budget has also meant that John can use his own money to replace torn carpets with lino and get his skirting boards repainted. His personal health budget has cost the NHS 6,000 over 3 years. The previous cost to the NHS of the many replacement wheelchairs is not easy to estimate, but is likely to be more.

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Chapter 5: Integrating direct payments between health and social care

5.1 A number of PHB pilot sites have undertaken focused work around integration, with the aim of testing out ways of merging health and social care budgets to improve the user experience and to simplify and join up systems and processes. Some of these sites have also delivered direct payments for people with a mix of health and social care funding. Approaches to integrating direct payments have been varied but a common feature has often been the shared use of existing direct payment support services. All areas where sites are operating have some history of delivering support services to people using direct payments for social care. For example, Oxfordshire has developed a service aimed at supporting the employees of people using direct payments with a programme of workforce development called Support with Condence.6 Some PHB sites are moving towards integrating support planning and review functions, and are aiming to develop single support planning and review tools which can support integrated working between social care and healthcare professionals and provide joined up information to people using direct payments. Although at an early stage, there is a common recognition that nding ways of merging and streamlining these processes will be necessary for dealing with larger numbers of people.

5.2

Oxfordshires Support with Condence scheme: www.supportwithcondence.gov.uk/

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Chapter 6: Monitoring and reviewing direct payments

6.1 Direct payments are public money and commissioning organisations have a responsibility to ensure they are used to meet the health needs and the broader health and wellbeing outcomes of those to whom they are given. Commissioning organisations also have a responsibility to effectively manage the risks associated with people using health direct payments including minimising the risk of fraud and the risk of money being used in ways that are either illegal or otherwise prohibited or do not work towards meeting peoples health outcomes. In managing these risks it is important that the uses of direct payments are not overly prescribed and that as far as possible people are supported in the choices they make. It is important to make clear from the start what people can and cannot spend their money on and to ensure that people receiving direct payments understand these rules. People can get much added value from using money exibly to meet outcomes in ways that suit them as an individual and prohibiting exibility compromises the purpose behind health direct payments. Where people have tried things that may not have been as effective as intended it is important that the commissioning organisation does not automatically assume that the direct payment is not working. Care co-ordinators should work with people to learn and adapt and to use experience of what works and what doesnt to inuence future plans as to how a direct payment can be most effectively utilised. In addition, it is important when deciding how payments should be monitored to take a proportionate approach, which takes account of the specic risks relating to each particular individual and situation. CIPFA guidance 7 issued in 2007 supported this approach, but beyond the need to reect good practice there is also a nancial incentive to ensure monitoring processes do not take up disproportionate amounts of time and resources. Many local authorities have developed a proportionate approach to monitoring direct payments because it has proved costly and inefcient to collect routine monthly or quarterly returns for large numbers of people. In 2009, Lincolnshire County Council decided to move to a lighter touch and outcomes focused approach to monitoring, allowing them to more accurately identify and quantify risks. They found an outcomes approach required signicantly less detailed information across the board and were able to reduce the frequency of monitoring for people who were considered to be low risk. The savings to back ofce systems and frontline staff time

6.2

6.3

6.4

6.5

Direct Payments and Individual Budgets: Managing the Finances, CIPFA, 2007: www.cipfa.org/Policy-and-Guidance/Publications/D/Direct-Payments-and-Individual-Budgets-Managingthe-Finances

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Monitoring and reviewing direct payments

were signicant and as a result of this move the council reported cashable savings of 130,000 in the following year.8 6.6 Traditionally monitoring direct payments has tended to focus on whether the money is being used in ways that are outlawed, so as to guard against fraud, and whether there is any money which is unused, so as to ensure money can be recouped at the end of the year if it is not needed. It is good practice to carry out an outcome-focused review after three months, and then at least annually, which looks at how the PHB has been used to meet the persons identied health needs and achieve the agreed outcomes. Financial monitoring should take place at the same time, rather than as a separate process. Joining up the two processes can save time and give a more rounded picture of whether resources are being used effectively. Advice on how to carry out outcome-focused reviews is available on the Think Local, Act Personal website.9 Where it is found that people appear to have wilfully made inappropriate use of the money a care-coordinator should work with the person to understand why this has happened and to consider whether further action needs to be taken to recoup monies. The commissioning organisation should develop a clear process for setting out how and under what circumstances money would be reclaimed from people making sure they dont penalise those who have made a genuine mistake. In addition, where people still need services, a decision will need to be made as to whether those needs should be met through notional or third party arrangements rather than via a direct payment. If someone is holding a signicant amount of unused money from his or her direct payment and where this is not allocated for a particular purpose, this may be an indicator that a reassessment is appropriate. However, it is important that people are allowed to hold a certain amount of money for contingencies. It is also important to take account of the potential for people to suffer from neglect or abuse. Although there is little evidence to suggest so far that people using direct payments are more at risk than people receiving direct services, it is important that the planning process explores what needs to happen to keep someone safe and how risks will be monitored over time. A good review process is an important safeguard against abuse.

6.7

6.8

6.9

6.10 It is also important to understand whether outcomes have been met and to gather information about this during the review stage. This should be the primary focus of the review and provides a platform for understanding how plans may need to change and adapt to be effective.

Practical approaches to improving productivity through personalisation in adult social care, Putting People First, December 2010: http://www.puttingpeoplerst.org.uk/_library/Practical_Approaches_doc.pdf Think Local, Act Personal website: www.thinklocalactpersonal.org.uk/Browse/

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Practical Guide: Direct Payments for Healthcare

6.11 In addition to the review, there are a number of tools that can be used to look at aggregate information about how far and how effectively people are managing to achieve outcomes. The national charity In Control10 is working with a number of PHB pilot sites to develop a specic outcomes evaluation tool, which can capture information from people using PHBs (including direct payments) about their experiences. Such information will be considered an invaluable asset in any analysis of the cost effectiveness of health direct payments.

10

In Control: www.in-control.org.uk/

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Chapter 7: The role of direct payment support services

7.1 The National Health Service (Direct Payments) Regulations 2010 state that a PCT (in future CCGs): Must make arrangements for a person, representative or nominee to whom direct payments are made to obtain information, advice or other support in connection with the making of direct payments. 7.2 In addition it lists some of the types of information, advice and support which may need to be provided including advocacy services, support to commission services for an individual and employment related advice and support such as payroll services for those people who may wish to use their direct payment to employ staff directly. Collectively these are referred to as direct payment support services. In practice, many PHB pilot schemes making direct payments are using the often well-established support services which exist for social care direct payments users, many of which also provide support to people with a wide variety of support needs. Others are supplementing these with specic training services to ensure that where people recruit staff directly to support them with their health needs, such staff have quick access to relevant training from suitably experienced or qualied staff. As mentioned earlier, Disability Rights UK can provide details of local support schemes: www.disabilityrightsuk.org. The learning from the PHB pilot sites suggests that it makes sense to use existing local direct payment support schemes. There may be a need to work with the local authority to invest in building the capacity of the direct payment support service. If this is done, there is no reason why such services cannot provide support to health direct payments users just as well as they do to social care direct payments users. For example, Cheshire Centre for Independent Living offers an extensive range of support to existing and potential direct payments and PHB recipients, including a managed account service to assist people who may have trouble looking after their own nances; bespoke training courses delivered in employers own homes and a North West Personal Assistant Register delivered in partnership with Age UK Cheshire.11 Direct payment support services can also help with the practicalities of setting up bank accounts for people. Many local authorities offer people using direct payments the option of a pre-paid card, which can make setting up accounts much simpler. Commissioning organisations should consider how they can work with their local authority partners to offer the same options and support for people in setting up banking options for direct payments. A recent paper published by the Think Local Act Personal Partnership Best practice in Direct Payments Support: A guide for Commissioners explores what an ideal

7.3

7.4

7.5

11

See www.cheshirecil.org and www.nw-pa.org

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Practical Guide: Direct Payments for Healthcare

support service should provide for people using or thinking of using direct payments. The paper was developed with commissioners, people using direct payments and user-led organisations and offers a useful template for benchmarking local support services.12

12

Best Practice in Direct Payment Support: A guide for commissioners, 2012: www.thinklocalactpersonal.org.uk/BCC/Latest/resourceOverview/?cid=9235

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Chapter 8: Concluding thoughts

8.1 Direct payments are here to stay. In social care they have proven to be a highly effective way of increasing the choice and control people can have over their care and support. Evidence from the PHB pilot sites is already showing that the same is true for healthcare direct payments. When people are supported to take a direct payment and make arrangements to meet their health and wellbeing needs they typically get better outcomes at least as cost effectively. Evidence from people using personal budgets, their carers and from frontline staff also tells us that the process of getting a direct payment can often be overly complicated and off-putting. To make a success of healthcare direct payments, all stages of the process need to be simple and transparent and assessment, monitoring and sign off processes need to be proportionate and straightforward. Finance managers have a key role to play in making sure this happens and helping realise the potential benets of healthcare direct payments to improve peoples health and wellbeing. At the time of writing, the detail of how direct payments and PHBs will be rolled out is yet to be nalised with the results of the evaluation due to be published in October 2012. Readers are advised to check the Departments web pages on direct payments for updates and guidance: www.personalhealthbudgets.dh.gov.uk

8.2

8.3

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Appendix i: Example personal health budget team nancial process

1. Person approved for PHB by PCT and PHB team (PHB team members and Programme Director) 2. Person completes direct payment contract and returns to PHB team ofce 3. PHB team verify direct payment contract and bank account details with person (PHB team member to phone person) 4. PCT section completed by PHB team ofce and signed by PHB team budget manager (Programme Director to sign) 5. Contract/bank details scanned and copied on the system via PHB team administrator 6. Completed bank account form/contract 7. Emailed to PCT accounts team and PHB team to set up dummy invoice 8. NHS Shared Business Services (SBS) scans in and sends invoices on Oracle for Programme Director to sign off on Oracle system 9. Invoice is then processed to be paid by SBS on every Thursday. Should be paid within three working days 10. Person receives payment via BACS into their separate bank account or a bank account established to receive SSD direct payment funds 11. Copied bank statements and proof of purchased services received from person (monitored by PHB team) 12. Person is followed up at 6 week/6 month and annual review (PHB team member).

22

Appendix ii: A checklist for what must be included in a care or support plan
[Extracted from pages 2223 of Direct Payments for Health Care: Information for pilot sites, Department of Health, 2010] Before a direct payment can be made, the PCT must ensure a care or support plan is developed and that the plan sets out: a. b. c. d. e. f. g. h. The health needs and outcomes to be met by the services in the care or support plan The services that the direct payment will be used to purchase The size of the direct payment, and how often it will be paid An agreed procedure for managing signicant potential risk The name of the care co-ordinator responsible for managing the care or support plan Who will be responsible for monitoring the persons health condition The anticipated date of the rst review, and how it is to be carried out The period of notice that will apply if the PCT decides to reduce the amount of the direct payment.

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Appendix iii: Example healthcare direct payment contract

Person agreement (personal health budget/direct payment contract) v I agree to only use my personal health budget/direct payment to buy the services as detailed in my support plan, and any related expenses that have been agreed with _______________. I will not misuse the money in any way. The product or service as agreed is for ________________________________________________________________ and the money to be paid is ______________________________ which is a one-off payment and/or ongoing payment of ___________ [delete as appropriate]. v I understand that my support plan and direct payment will be reviewed every 3 months, and if I am assessed for different services I may be re-assessed for direct payments. v In accordance with _____________ nancial monitoring policy, I agree to open a dedicated, separate bank account for the payments and send copies of bank statements to the PHB programme ofce every 3 months. For a one-off purchase I will send the receipt or invoice to the same ofce. Or v I will use a bank account already set up to receive direct payments from _____________ Council and send copies of bank statements to the PHB programme ofce every 3 months. For a one-off purchase I will send the receipt or invoice to the same ofce. Or v I will ask a third party ____________________________________ to act as my agent by holding the money on my behalf. ( Please delete as applicable) v I agree that I (or my agent) will send ___________ , PHB programme ofce details of how the money has been spent at intervals of ___________ or otherwise as requested. This refers to ongoing payments and not one-off payments. v I agree that I will meet all legal requirements and obligations relating to the services I pay for using my direct payments. v I agree to take out employers and public liability insurance if I am employing my own staff. The direct payment will cover this cost. v I agree that I will not use my direct payment to employ my partner (married or not) or any of my close relatives who live with me. This means a parent, parent-in-law, aunt, uncle, grandparent, son, daughter, son-in-law, daughter-in-law, step son or daughter, brother, sister, or the spouse or partner of any of these. (In exceptional 24

Example healthcare direct payment contract

circumstances, relatives may be employed, but only by prior agreement with ___________________ ) v I understand that _______________ strongly recommend that I should ask for appropriate checks to be made through the Criminal Records Bureau on all my prospective employees.

I intend to seek CRB Checks for my employees

OR
I do not intend to seek CRB Checks for my employees ( Please delete as applicable)

v I understand that _______________ has the right to stop my direct payment if they decide that my employee or care provider is unsuitable. v I understand that I can stop my direct payment by giving four weeks notice and agree to repay any unspent money. v I will be given at least 4 weeks notice by _______________ of any suspension or stoppage of my direct payments and advice about what I can do to prevent this happening. v In the case of equipment or products, I agree to maintain and safely look after the item and insure as necessary to prevent from theft or damage. I understand that if I do not keep to the above terms and conditions _______________ may stop the payments and I may be required to return all or part of the money I have received. Signed: ______________________________________________________ Print name: ___________________________________________________ Dated: _______________________________________________________ Bank account details Persons approved for a healthcare direct payment must complete the following bank account details form to ensure prompt payment can be made. Please note: this information will be stored in the strictest condence and in accordance with the Data Protection Act, 1998.

25

Practical Guide: Direct Payments for Healthcare

Person name Person address Account number Sort code Bank account name/address Is this account separate to your personal bank account? Is this account set up to receive social care direct payments from your council? Do you consent to the PCT making payment? FOR PCT MANAGEMENT COMPLETION ONLY: Frequency of payment agreed Date of rst payment Type of payment Purchase agreed Conrmed account is separate to persons personal bank account Budget holder authorisation name and signature is required Date

26

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