PERSONAL HEALTH BUDGETS GUIDE Integrating personal budgets ... · The NHS already has the necessary powers to offer personal health budgets, although only approved pilot sites can

PERSONAL HEALTH BUDGETS GUIDE

Integrating personalbudgets – early learning

Authors: Sam Bennett and Simon Stockton, Groundswell Partnership

Integrating personal budgets – early learning

1 Introduction 3

2 Setting the scene 4

3 Definitions and design principles 6

4 The six-stage customer journey 10

5 Conclusion 31

6 References 35

Contents

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A personal health budget is an amount of money to support a person’s identifiedhealth and wellbeing needs, planned and agreed between the person and their local NHS team. Our vision for personal health budgets is to enable people with long term conditions and disabilities to have greater choice, flexibility and controlover the health care and support they receive.

What are the essential parts of a personal health budget?

The person with the personal health budget (or their representative) will:

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

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

n be enabled to create their own care plan, with support if they want it

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

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

How can a personal health budget be managed?

Personal health budgets can be managed in three ways, or a combination of them:

n notional budget: the money is held by the NHS

n third party budget: the money is paid to an organisation that holds the money on the person's behalf

n direct payment for health care: the money is paid to the person or their representative.

The NHS already has the necessary powers to offer personal health budgets, although onlyapproved pilot sites can currently make direct payments for health care.

What are the stages of the personal health budgets process?

n Making contact and getting clear information.

n Understanding the person's health and wellbeing needs.

n Working out the amount of money available.

n Making a care plan.

n Organising care and support.

n Monitoring and review.

Personal health budgets

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This guide is one of two focusing on theintegration of personal budgets acrosshealth and social care.1 Improving theexperience and quality of care for peopleand supporting them to achieve betterhealth and social care outcomes are themost important aspects of integration.

The two guides are aimed at health and socialcare staff involved in the implementation ofpersonal budgets and personal health budgets,who want to develop local systems for peoplewho would benefit from an integratedbudget. They draw together learning from 14of the pilot sites2 that have been working incollaboration with the Department of Healthto explore how best to integrate budgetsacross health and social care.

This early learning guide focuses on thecustomer journey for integrated personalbudgets (section 4). It draws out the centralmessages from the pilot programme anddescribes the six stages of the journey, withpointers to support successful local delivery.Each stage also contains statementsdeveloped in partnership with the peernetwork3 to describe what people might say ifthis stage was working really well.

The learning and examples we describe areapproaches that pilot sites have found to beeffective. We advise that local monitoring andevaluation are established to ensure thatwhatever the approach, a positive outcomefor each person remains the priority.

Where no reference is given the examples listedin this guide accompany its online version at:www.personalhealthbudgets.dh.gov.uk/toolkit

1 Introduction

http://www.personalhealthbudgets.dh.gov.uk/toolkit

Personal health budgets are part of awider drive to personalise public services.Personalisation is central to the ongoingreforms under way in social care,4 isincluded in recent policy announcementson special educational needs anddisability,5 and is at the core of thegovernment’s vision for the NHS.

The push towards integration is also a recurrenttheme in health and social care. For peoplewith support needs, the divisions betweenhealth and social care can feel artificial andcan have a negative impact on theirexperience and outcomes. For people withcomplex needs, it is imperative that healthand social care organisations work together to deliver a seamless, person-centred service.

Recently, integration has emerged as a priority for the coalition government,featuring heavily in both the 2010 NHS and2012 care and support white papers.6,7

‘Equity and excellence: liberating the NHS’states that it is: essential for patient outcomesthat health and social care services are betterintegrated at all levels of the system andenvisages an enhanced role in health for localauthorities, particularly through sharing publichealth functions and through councils havinga lead role on health and wellbeing boards.

The white paper ‘Caring for our future’7

identifies disjointed healthcare and support asa driver for reform, and along with the Healthand Social Care Act 20128 sets out clearobligations for the health system, and itsrelationship with care and support.

A King’s Fund report from 20119 identifiesthree potential benefits from integration:

n better outcomes for people, such as livingindependently at home with maximumchoice and control

n more efficient use of existing resources byavoiding duplication and ensuring peoplereceive the right care, in the right place, atthe right time

n improved access to, experience of, and satisfaction with, health and social care services.

Increasingly, these benefits are being realised in areas where integrated personalbudgets are being tested. As personal healthbudgets are extended beyond the pilot sites,it is clear that there are challenges to beovercome and opportunities not to be missed to ensure personal budgets areintegrated with social care budgets anddeliver the real benefits that the growingevidence base suggests.


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2 Setting the scene


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How this guide was developed

During 2011/12, 14 pilot sites2 chose to focuson delivering integrated personal budgets,with the local authority, for at least twopeople. This part of the pilot programme wasa truly co-produced piece of work andinvolved all the main stakeholders: site leads,local authority personalisation leads, supportbrokers and other operational staff,commissioners, the personal health budgetspeer network3 and people with personalhealth budgets.

This guide focuses on understanding how theprocess can work for people end to end, fromtheir first contact with the system and theinformation that they receive, through to themonitoring and review of their integratedpersonal budget. It aims to demonstrate whata good customer journey for a person receivingan integrated budget should look like.


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Defining integrated personal budgets andmeasuring their impact

A recent King’s Fund report on integrationstated that:

The patient’s perspective is at the heart of anydiscussion about integrated care. Achievingintegrated care requires those involved withplanning and providing services to impose thepatient’s perspective as the organisingprinciple of service delivery.10

To build on this idea of a person-centreddefinition of integrated budgets, we workedwith the personal health budgets peernetwork3 to understand what would maketheir personal experience the best it could befor each stage of the journey. This has led usto a definition of integrated personal budgetsthat is less about background process andprofessional input, and more about how the

journey is felt and experienced by people withpersonal health budgets, their carers andfamilies (see box).

Defining integration in this way suggests that integrated personal budgets aresomething that can be delivered nowregardless of the prevailing staffing, financeand commissioning structures, and that they are not dependent on the perfect ITsolution, Section 75 agreement or paymentsystem being in place. While all these thingsmay ultimately be desirable, their absence is not an insurmountable barrier tomeaningful progress.

Work undertaken locally to deliver integrated personal budgets should start from the right point – what is most importantto the person, rather than what is mostconvenient and least disruptive forprofessionals and services. Delivered in thisway, the potential benefits to be derived fromintegrating personal budgets are substantial.

3 Definitions and design principles

An integrated personal budget is where:

n a person’s health, social care and other needs are met through a single allocation of resources

n one care plan is in place and identifies the outcomes important to the person

n processes are proportionate and the experience is as timely, straightforward and seamless as possible.


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Pilot sites, working with their local authoritycounterparts, have identified the potential

benefits that can be used as local measures of progress (see box).

Measures of progress

n Number of people with integrated personal budgets who have achieved the outcomesthey set themselves.

n Number and type of integrated systems and processes, eg finance (budgets), assessment,IT, support planning, performance management.

n Workforce measures, eg wellbeing, sickness, retention, satisfaction.

n There is one budget, one assessment, one support plan.

n Good feedback from individual outcomes to inform strategic thinking and delivery (using tools such as the POET11 questionnaire and ‘Working together for change’).12

n Integrated access routes, eg eligibility.

n Single, faster and simpler processes (more throughput).

n Increased capacity and activity.

n Reduced staff turnover.

n A better developed marketplace for care and support.

n Fewer delayed transfers of care.

n Reduced acute admission levels.

n Greater use of preventive services.

n Possible reduction in health and social care costs per head.

n Positive impact on carers’ ability to maintain caring roles.

What do we know so far?

The evaluation of the pilot was published inNovember 2012. The final evaluation reportrecommends that: Personal health budgets

should be considered as a vehicle to promote greater service integration (especiallywhere ... budgets could be integrated aroundestablished bank accounts, accounting andpayroll arrangements).

Design principles

To help explain what would support a goodcustomer journey, the personal health budgetpeer network has developed a number ofcentral design principles for integratedpersonal budgets.

A good customer journey should be:

Inclusive

People with long-term conditions anddisabilities should have the chance to shapetheir lives by making the decisions about their health and wellbeing that matter mostto them. To ensure this is possible, the process needs to be built around people and to engage them fully at all stages.

Informative

Information about what to expect from theprocess needs to be clear and wellcommunicated. The process should build up apicture of how resources can be used to besteffect in a way that suits each person.

Right first time

Health and social care staff need to worktogether to ensure activity is right the firsttime and that there is no unnecessaryduplication of work.

Person centred

Staff should be skilled in using person-centred thinking and practice in all their work with people.

Flexible and proportionate

Processes should not be one size fits all, but should work flexibly and proportionatelyin a way that reflects each person’s needs and circumstances.

Creative

People need permission to be creative in orderto use resources to best effect. Staff shouldencourage and support all those involved tothink differently.

Portable

Personal budgets should enable care and supportto follow the person, rather than prescribingwhere care and support should happen.

Impartial

The process of allocating budgets and the rulessurrounding how they can be used need to befair and rational, and clearly communicated.

Outcomes focused

A good process should be built around identifyingthe best health and wellbeing outcomes for theperson, and making sure care and support can bearranged in such a way as to offer the bestchance of achieving them.

Universal

Much of the support and advice people needto achieve good outcomes can work just aswell for people with lower level needs or withthe means to arrange support for themselves.Good advice, information and planning toolsshould be widely available for everyone whocould benefit from them.


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Transparent

Information about the process and about howdecisions are made needs to be up front, clearand transparent.

Timely

The process and opportunities for feedbackneed to be timely to build and maintainpeople’s confidence and prevent anxieties due to unexpected delays.

Empowering

People should be encouraged and supportedto co-design how to arrange services to suittheir individual requirements. People are theexperts in their own care and support needs,and should be given the confidence to play anactive role in meeting their own needs andachieving their preferred outcomes.

The six stages of the customer journey forintegrated personal budgets have beenagreed through consultation with pilot sitesand engagement with the peer network.Although the six stages are arrangedconsecutively here, they are not necessarilyexperienced as a linear journey – it is possibleto skip or repeat stages depending on aperson’s circumstances. The six stages are:

1) Making contact and getting clear information.

2) Understanding the person’s health and wellbeing needs.

3) Working out the amount of money available.

4) Making a care plan.

5) Organising care and support.

6) Monitoring and review.

‘I’ statements

Each stage of the customer journey beginswith an ‘I’ statement agreed by the peernetwork. Each statement describes how agood experience would look and feel fromthe person’s perspective – the sorts of thingsthat personal health budget holders, theircarers and families might say if an integratedpersonal budget is working really well forthem. These statements, along with thedesign principles on page 8, providebenchmarks to guide the development oflocal processes and to measure the success of the integrated customer journey. They could also be used as the starting point for discussions with local people todevelop local ‘I’ statements together.

Process diagrams

For each of the six stages, a diagramillustrates the various tasks involved – whichare undertaken by health bodies, which bysocial care, which are best done jointly andwhich can be fully integrated.


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4 The six-stage customer journey


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The separate health and social care tasksdescribed here largely reflect the duties thathealth bodies and local authorities have tofulfil to meet their statutory responsibilitieswithin the current legal framework. Jointtasks are where health and social care workin partnership to deliver an output oroutcome while retaining distinct roles, ratherthan as part of a fully integrated team orprocess. Integrated tasks are where there areexamples from the pilot areas of an output oroutcome that is delivered through a single,joined-up process.

These distinctions are changeable, prone tolocal differentiation, and likely to evolve overtime. They represent a snapshot of how theprocess can work in the here and now, rather

than a projection of how things may be in thefuture – this guide aims to support localprogress in the short to medium term, ratherthan stimulating debate about the longer-term direction for health and social care.

What works

Each of the six stages summarises what pilot areas have learned about what workswell, and what doesn’t, when integratingpersonal budgets.

Examples

For each stage, relevant examples may includepolicies, procedures, stories and research.

MAKING

CONTACT AND

GETTING CLEAR

INFORMATION

UNDERSTANDING

THE PERSON’S

HEALTH AND

WELLBEING

NEEDS

WORKING OUT

THE AMOUNT

OF MONEY

AVAILABLE

MAKING A

CARE PLAN

ORGANISING

CARE AND

SUPPORT

MONITORING

AND REVIEW


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The six stages of the personal health budgets process

I know where to go for clear and accessible information and advice and feel well informed and supported

I feel listened to, understood and involved in assessment that is proportionate and personal to me

I know how much money is available and how it was calculated, and have enough to meet all my needs

I have the support I need to develop my plan and I understand what information is needed for sign-off

I have control over organising my care and support in the ways and at the times that make sense to me

I am supported to review my plan, to see what’s working and not working, and to make any changes needed

Co

rres

po

nd

ing

‘I’ s

tate

men

ts


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Stage 1 Making contact and gettingclear information

People come into contact with health and socialcare services through a variety of differentroutes. When first contact occurs, it is commonfor people to be at a point of crisis. Oftenpeople know little about what to expect,what help is available or how to access it.

Clear information and advice is critical to help people understand what care andsupport is available and how it can beaccessed, including through integratedpersonal budgets. This should include accessto peer support from the earliest stages.

Some people may require advocacy to ensuretheir interests are represented fairly or to negotiatewith funders and agencies, so good referralroutes to advocacy services are also needed.

MAKING CONTACT AND GETTING CLEAR INFORMATION

I know where to go for clear and accessible information and advice and feel well informed and supported

OUTCOMES:

• Person has clearinformationabout personalhealth budgets

• Person hasaccess to otherinformation and support

• Referred forassessment ifrelevant

HEALTH TASKS:

Referrals

Signposting

EXAMPLES: Derbyshire personalhealth budgetswelcome pack

SOCIAL CARE TASKS:

Referrals

Signposting

JOINT TASKS:

Joint referrals

Informationshared withother relevantparties

Developing jointinformation andadvice

EXAMPLES: Derbyshire jointproject plan

INTEGRATED TASKS:

Single, consistentpoints of contactacross health andsocial care and inthe community

EXAMPLES: Nottinghaminformation pack

Information should help frame people’s thinking,and provide reassurance and clarity about whatis possible. For instance, in some cases peoplemay mistakenly believe that adequate care canonly be provided in a residential setting, or thatcare must always be delivered by an NHS trustor other health body. Good information shouldaddress any concerns and explain the broadrange of options available.

People should be reassured early on that theywill be fully engaged in deciding how best tobalance risks and support in a way that suitstheir needs, making it clear that appropriatelyskilled people will be available to work with the person and their loved ones to explore thefull range of options available. A good firstcontact will also direct people to othersources of information and advice, includingfrom local Healthwatch services.14 Whereappropriate, it should also provide access to aquick overview assessment to understandwhat needs to be done immediately and whatfurther work may be needed to understandthe person’s needs and preferences.

What helps this stage go well?

n Strong local Healthwatch servicesembedded in local communities

From 2013, Healthwatch services should beavailable across England, replacing LocalInvolvement Networks (LINKs), to ensurepeople have access to good advice,information and representation, and that theirviews and experiences are heard and used tohelp improve local services.

n Personalisation information packs

Accessible information about what to expectshould be available online (and whereappropriate in other formats and languageseg easy read) to clarify the process andanswer frequently asked questions.

n Well trained, customer focused staff

A good first experience can set the tone forhow people think, feel and interact withhealth and social care systems andprofessionals throughout their journey. Agood person-centred approach shouldrecognise people’s anxieties, fears andfrustrations and respond to these positively,while encouraging people to retain a sense ofcontrol over the process as it evolves.

What can get in the way?

n Too much focus on the process and notenough on the person

Health and social care systems are complex,and it is easy for people to feel dehumanisedwhen sharing their story and asking forassistance. Recognising a person’s individualneeds should be a major part of training foreveryone involved at first contact.

n Poor information sharing

People do not want to tell their storyrepeatedly, so information captured at firstcontact should be entered into appropriatesystems, shared with relevant professionalsand used in subsequent planning and review processes.


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n Using jargon

Professionals working in health and social caretend to forget how much of the languagecommonly used makes little sense to peopleoutside the system. Ensuring that informationand advice uses the simplest languagepossible and avoids acronyms is an importantpart of ensuring people do not feel alienated.Engaging local people who use services, andHealthwatch, in developing literature can helpto achieve this.

Examples

n Information pack (Nottingham).

n Personal health budgets welcome pack(Derbyshire).

n Personal health budgets project plan(Derbyshire).

n Protocol for sharing personalinformation between health and social care (Devon).


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Stage 2 Understanding the person’shealth and wellbeing needs

Assessment is where health and social carebodies work with people and those close tothem to determine their health and social careneeds and eligibility for support. This caninvolve a range of different processesdepending on the person’s circumstances.Where relevant, carers should also be offeredtheir own assessment. For people with social

care needs, this is also where a financialassessment is undertaken to work out whatthey may need to pay towards the cost ofmeeting any eligible needs.

The more varied and complex a person’sneeds, the more likely it is that a number ofdifferent assessments may be needed toensure people can access the full range ofsupport available. The assessment processshould also include triggers to other fundingstreams for which the person may be eligible

UNDERSTANDING THE PERSON’S HEALTH AND WELLBEING NEEDS

I feel listened to, understood and involved in assessment that is proportionate and personal to me

OUTCOMES:

• Health needsidentified

• Social careeligibilitydetermined

• Social careneeds identified

• Contributionidentified

• Self-assessmentquestionnairecompleted

HEALTH TASKS:

Decision support tool

Clinical needsidentified

Professionalrecommendation

Specialistassessments

SOCIAL CARE TASKS:

Overviewassessment

Check for eligibility

Specialistassessments

Start financialassessment

EXAMPLES: Tees singleassessment process,NHS ContinuingHealthcare check

JOINT TASKS:

Assessment visitsby social workerand carenavigator

EXAMPLES: Doncaster self-assessmentquestionnaire

INTEGRATED TASKS:

Self-assessmentquestionnairecovering health and social care needs

EXAMPLES: Oxfordshiregrading ofhealthcare tasks


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– an initiative currently being piloted by theDepartment for Work and Pensions’ Right toControl pathfinders sites.15

At this stage the person needs support tocomplete the assessment component neededto generate an indicative budget. The processfor doing this will depend on their assessedneeds, and usually includes completion of asupported self-assessment questionnaire. Thisshould be integrated in the overall assessmentprocess to avoid duplication.

During the assessment, practitioners need towork together with the person to identify anyrisks that need to be taken into account andto engage them in deciding how risks shouldbe managed.


n Accessible information about personal budgets and what to expect from assessment

Information should be available to peoplefrom the earliest stage. Jointly developedinformation and guidance is useful so thateverything a person needs to know is in oneplace and provided consistently, regardless oftheir route into the system. Informationshould be developed with people with healthand support needs and their carers to ensureit strikes the right tone and explains things inways people understand.

n Using a single supported self-assessment document

Covering both health and social care needscan make life easier for everyone wherepeople’s needs are straightforward. This maynot be possible where people have morecomplex or varied needs.

n Appointing a single person to co-ordinate the assessment process

This can significantly improve people’sexperience of assessment, and is particularlyhelpful where a single assessment tool is notpossible. Keeping the number of professionalsinvolved in assessment to a minimumstreamlines the process and is less dauntingfor the person being assessed.

n Sharing information between health and social care

It is important to share information to makesure that the assessment process is robust andkept simple for the person. Where it is notpossible for a single practitioner to take aperson through the assessment process,making sure that appropriate information canbe shared between professionals helps toprevent people from having to give personalinformation repeatedly.

n Ensuring staff take a person centred approach

Personal budgets are about real changes inculture and practice, not just new systems and processes.


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Assessment should be an actively engagingand inclusive process, rather than one ledsolely by professionals. Practitioners shoulduse the best tools available to enable peopleto take part in decisions about risk and tocontribute to a rounded understanding oftheir needs.


n A long and complex assessment process

This can be confusing and stressful for peopleand their carers. Evidence suggests that a complexand confusing process is the major factorhaving negative impact on people’s experienceand outcomes from personal budgets.

n A lack of joined up working

This can have a very negative impact onassessment. People should not have to telltheir story more than once, or be confusedabout who to speak to if they have questionsor concerns.

n Burdensome validation requirements

This can mean that decisions aboutassessment take longer to complete andcommunicate, and can slow down the processof moving to care planning. The validation ofassessments should happen as close to theperson as possible, and should beproportionate to any risks identified.Remember that there will be further validationat later stages of the process as personalbudgets are agreed and plans signed off.

n Not engaging people in understandingand managing risks

This can undermine the principles behindpersonal budgets. People should beempowered to work with practitioners aspartners during assessment, rather thanreceiving professional advice to which theymust adhere. For example, many people mayneed support to understand how their careneeds can be safely met at home rather thanin a residential environment.

n IT systems that do not talk to each other

This can make assessments more cumbersomeand resource intensive. There is a lot that canbe done without waiting for the idealintegrated IT system, from using secure emailto share information, to linking local healthand social care IT systems via the NHS spine.

Examples

n Public leaflet on personal healthbudgets (Derbyshire).

n Example of a single assessment processdocument (Doncaster).

n Referral consent form (Tees).

n Protocol for sharing personalinformation between health and social care (Devon).

n Pan-Hampshire information sharing protocol (Hampshire).

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Stage 3 Working out the amount of money available

An important outcome of the assessmentprocess is an understanding of the resourcesavailable to meet a person’s health and socialcare needs. At this stage the resources

available need to be confirmed andcommunicated clearly, ahead of careplanning, so that a person knows the amountof money they are working with andunderstands any rules regarding how it can beused. After the assessment is completed, anumber of questions need to be clarified toturn the output of the assessment into anestimated budget.

WORKING OUT THE AMOUNT OF MONEY AVAILABLE

I know how much money is available and how it was calculated, and have enough to meet all my needs

OUTCOMES:

• Indicativebudgetcalculated

• Indicativebudgetcommunicated

• Calculation andany fundingsplit explained

• Budget known beforeplanning starts

HEALTH TASKS:

Apply relevantestimatedbudget setting tool

EXAMPLES: Nottinghampersonal healthbudgets flow chart

SOCIAL CARE TASKS:

Apply resourceallocation system

Apply fairercharging

EXAMPLES: Doncaster carersself-assessmentquestionnaire

JOINT TASKS:

Agree healthand social carefunding split

EXAMPLES: Doncaster jointself-assessmentquestionnaire

INTEGRATED TASKS:

Confirm the overallamount of moneyavailable, includingany contribution,and how this hasbeen calculated

Communicate anyrules governingexpenditure

EXAMPLES: Oxfordshireguidance on howbudget can be spent


n Being clear how much money is available

The results of both the health and social careelements of an assessment need to beconverted into a monetary value. Whatevermethod is used, there must be a rationalcorrelation between the estimated budgetand what it would reasonably cost tocommission services adequately to meeteligible needs, taking into account localmarket conditions. Long-term health and careneeds can be offered as a personal budget,but some specific needs for acute services orspecified treatments may not be included.

n Being clear what the offer means

Once the estimated budget has beencalculated, it needs to be communicated well in order to manage expectations. The offer made at this stage is often referred toas an indicative budget, which reflects the possibility that it could change during the planning process as new informationbecomes available. The important thing is forpeople to understand as early as possible in theprocess the money that is available to developtheir care plan, and to know that this is not setin stone. It will be useful to clarify that if theamount begins to look inaccurate duringplanning, it can be altered upwards if it proves

inadequate, or downwards if a person meetshis or her needs within the available resource.

Part of managing expectations is making itclear what their budget can and cannot beused for, and what other conditions may needto be met in order for the money to changehands. It is important to communicate assimply as possible what is permissible for eachportion of the budget (health and social care).This should be provided in a concise, easyread format that sets out what the budget isfor, how it can and can’t be used, and anyrequirements for monitoring and review.

n Being transparent about how thebudget was calculated

People may want different levels of detailabout how the offer was calculated, but ingeneral they will want to know thecalculation method is fair and makes rationalsense. Training for frontline staff in how tocommunicate this well can help improvepeople’s confidence in the process.

n Supporting people to see the potentialbenefits of using a personal budget

Sharing real-life stories and communicatinghow having a personal budget can offergreater choice and control and betteroutcomes helps people and professionals torelate positively to the offer.


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n Bureaucracy

Making decisions quickly and communicatingthem well should be a priority forcommissioning organisations.

n Lack of consistency

Decisions about funding need to be consistentin order to be fair and defensible. Regularaudits of decision making can be helpful inensuring this happens.

n Unclear process

Although consistency may exist in policyterms, it still needs to be communicated wellso that people are kept informed of what toexpect, and staff understand how to followthe process. Joint training for health andsocial care staff, and easy read explanations ofthe process, can help make the journey easierto understand for everyone involved.

Examples

n Outcome-based budget-setting tool(Department of Health).

n Joint supported self-assessmentquestionnaire (Doncaster).

n Personal health budgets flow chart(Nottingham).

n Carer-supported self-assessment(Doncaster).

n Guidance for getting a personal healthbudget (Oxfordshire).

Stage 4 Making a care plan

At this stage, people are supported to explorehow they can use their personal budgetalongside the other resources available tothem to meet their needs and achieve theirhealth and wellbeing outcomes. Developing a

care plan should be a meaningful andengaging exercise for the person and thosethey choose to involve, and it should helpthem to explore a wide variety of options.

A plan starts from what is important to theperson, and uses person-centred approachesto enable them to build up a picture of how


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MAKING A CARE PLAN

I have the support I need to develop my plan and I understand what information is needed for sign-off

OUTCOMES:

• Plan developed

• Individualoutcomesidentified

• Informationcollected forsign-off

• Plan signed offand personinformed

• Review dateagreed

HEALTH TASKS:

Record decisions made

Completerelevant riskassessments

EXAMPLES: Derbyshire clinicalgovernancepolicy

SOCIAL CARE TASKS:

Record decisions made

Complete relevantrisk assessments

EXAMPLES: Doncaster care plan

JOINT TASKS:

Refer to supportand adviceservicesPersonal plansign-off

EXAMPLES: Norfolk onlinesupport plan

INTEGRATED TASKS:

Communicateoutcome of sign-off and anyprocess for appeal

Agree review date

EXAMPLES: Derybshireguidance onagreeing a plan


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their care and support should look. In order toengage in the process, people may need avariety of information, advice and support,ranging from materials needed to develop aplan for themselves, through to peer supportand/or paid support from a professional. Theyalso require good information about what isavailable, a variety of options for how theycan manage their care and support, and anunderstanding of what is required for sign off.See ‘Implementing effective care planning’ formore information about care plans.

The process for sign off should be kept assimple as possible. Recourse to panels shouldtake place only where necessary, and with theoutcome communicated in a clear and timelyfashion.


n Having a clear understanding of what isrequired to sign off the plan

People should begin planning with a clearunderstanding of what needs to be in theplan to ensure it is signed off. This will help toavoid wasted time in the planning processand reduce the prospect of plans moving backand forth before sign off.

n A range of care planning options

Many pilot sites have drawn on the expertiseof existing local services and peer supportnetworks to support people using personal

budgets for social care. The best exampleswork with people in an empowering andsupportive way, and share information so thatpeople can plan for themselves with supportfrom friends and peers.

n Making the plan a living document

Where appropriate, plans should be flexibleenough to accommodate changes withouthaving to go through a reapproval process. Insome cases, keeping the detail of the planfairly high level can help to ensure reapprovalis not required if people need to adjust theirapproach to meeting agreed outcomes.

n Devolved decision making

While the use of panels has beencommonplace during the pilot programme(with joint panels for integrated packages), in the long term this will not be a sustainable use of staff time and resources. As the number of personal budgets increases,and people develop more confidence in the systems that support their delivery, it will be helpful to ensure decision makinghappens as close as possible to the person,with sign off devolved to lead professionalsand minimal recourse to panels. The healthelement of a support plan should alwaysinvolve lead clinicians to ensure health needsare met and to provide people with the rightinformation and evidence so they can makean informed decision.


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n Not knowing the budget availablebefore starting to plan

Although some forward planning can be very useful, an understanding of the moneyavailable is essential if realistic plans are to be developed.

n Not having clear criteria for signing off a plan

Failure to sign off a plan should be rare. If this is not the case, it is likely that theplanning process is not working well and that information about what is required is not being communicated. People should be given clear information about what willand won’t be approved so that they can plan with confidence and have a timelyresponse at sign off.

n The plan is service rather than outcome focused

The benefits of personal budgets can be lost ifpeople are constrained to using them for thesame types of service that typically would becommissioned to meet their health and wellbeingneeds. A positive approach that encouragesand supports people to find innovativesolutions to meeting needs and achievingoutcomes is essential for good care planning.

Examples and other useful resources

n Policy on clinical governance and risk(Derbyshire).

n Decision making guidance – agreeing a care plan (Derbyshire).

n Care plan approval policy (Nottingham).

n Online care plan (Norfolk).

n Care plan (Doncaster).


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Stage 5 Organising care and support

At this stage the care and supportarrangements outlined in the person’s planare put into effect. The tasks involved andwho completes them can vary significantlydepending on whether or not the person istaking some of their integrated budget as adirect payment.

Where this is the case, a direct paymentagreement will need to be set up. As thereare two funding streams involved, and a directpayment may potentially cover one or bothfunding streams, there is potential for thepaperwork to become onerous for all involved.

Adopting a single direct payment agreementthat can be used for both health and socialcare direct payments is highly recommended.Although some terms and conditions are

ORGANISING CARE AND SUPPORT

I have control over organising my care and support in the ways and at the times that make sense to me

OUTCOMES:

• Decision madeabout how to manage the money

• Care andsupportidentified and organised

• Care andsupport in place

HEALTH TASKS:

Commissionand/or deliversupport asappropriate

EXAMPLES: Norfolk directpaymentagreement

SOCIAL CARE TASKS:

Commission and/ordeliver support asappropriate

JOINT TASKS:

Release funds fordirect payment

Refer to directpayment supportservices asappropriate

Signpost torelevant training

EXAMPLES: Hull guidance on employment)

INTEGRATED TASKS:

Provide informationabout care andsupport services,including personalassistants

Ensure contingenciesare in place andpeople know whereto go if things change

EXAMPLES: Nottinghaminformation pack

slightly different for health and social caredirect payments (eg it is not possible to top upa healthcare direct payment), a single formwith optional parts to complete – dependingon which funding source(s) are being utilised –is a useful and important way of streamliningprocess and minimising duplication.

People using direct payments to employpersonal assistants will need access to payrollsupport and assistance to help them meettheir legal and tax obligations as an employer.The efforts involved in ensuring people canachieve this can sometimes be moreoffputting for frontline staff than for peoplewith support needs. People with supportneeds have been successfully employing staffusing direct payments for over 15 years, andthere is a wealth of expertise and peersupport available, often from clusters aroundlocal direct payment support schemes thatspecialise in making the process simple.Making sure people have access to suchsupport is a vital component of this stage forthose considering a direct payment.

Where all or part of an integrated budget isbeing arranged by the commissioningorganisation, rather than the person via adirect payment, efforts should be made toensure people can make informed decisionsabout which services are most appropriate tomeet their needs, and that they still have adegree of control over who provides theirsupport, when and where it happens, andhow it is carried out. Good information aboutlocal care providers and the level of choiceand control they can offer should be made

available before a final decision is made. Forinstance, if a particular provider is usingindividual service funds as a model of servicedelivery, this would be a good indicator thatthe degree of choice and control on offer tothe person was high.

What helps this stage go well

n Training for frontline staff in supportingpeople to take up direct payments

Often frontline staff have little experience ofencouraging and supporting people to employstaff and make use of direct payments. Goodtraining should help staff feel safe inencouraging people to use direct payments,directing people to specialist advice services,and understanding the value people get fromusing them.

n Good local direct payments support services

Most local areas have an existing directpayments support service. It is vital to ensurethese are well resourced and able to providethe full range of support and advice thatpeople need. Taking stock of what is on offerlocally, and engaging people using directpayments in ensuring local services are fit forpurpose, is a worthwhile investment.

n Good person-centred information aboutapproved care providers

People can exercise choice meaningfully only when they know which services will suitthem best. Having information about how


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much choice and control different providers offer, and what their specialities are, is vital in helping people make gooddecisions for themselves.


n Not having enough time to make arrangements

In some cases, short-term support may helpto ensure people have the time they need toorganise long-term support. It may takepeople some time to recruit staff and set upemployment contracts.

n An undeveloped local market

Where local services under contract to thecouncil and/or the NHS do not understand theneed to personalise services, or to make effortsto be accountable to people using services, theoptions on offer are likely to be poor.Commissioning organisations should work withlocal providers to help them understand how topersonalise services.

n Being overly prescriptive in how peoplecan use their budget

Although it is important to be clear what it isand isn’t possible to do with a personalbudget, too many rules can prevent peoplefrom gaining the benefits that integratedpersonal budgets can offer. Provided theymeet their legal obligations and do not putthemselves at undue risk of harm, peopleusing direct payments should be able tochoose who to employ and how they aretrained to carry out tasks.


n PA contract of employment (Hull).

n Using personal health budgets to fundemployment (Hull).

n Healthcare direct payment agreement(Norfolk).

Stage 6 Monitoring and review

Monitoring and review is a periodic process.

To meet legal requirements, reviews for peoplereceiving health and social care budgets needto be carried out within 3 months of a careand support package being initially set up,and at least annually thereafter.

Monitoring may take place more frequentlythan this depending on individualcircumstances, but the frequency and degree of monitoring should be directly related to anunderstanding of the risks associated with theparticular situation. Where risks are consideredto be low, or can be managed safely and donot require regular checks, monitoring need notbe any more frequent than the review intervalsand should be integrated into a single process.


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MONITORING AND REVIEW

I am supported to review my plan, to see what’s working and not working, and to make any changes needed

OUTCOMES:

• Reviewcompleted

• Outcomecommunicated

• Any necessarychanges made

• Plan updated

• Referral for re-assessment if needed

HEALTH TASKS:

Identify anyrequirement forreassessment

Record outcomeof review

EXAMPLES: Norfolk purchaseledger

SOCIAL CARE TASKS:

Identify anyrequirement forreassessment

Record outcome of review

JOINT TASKS:

Collectinformationabout outcomes

Monitor direct payment(light touch)

EXAMPLES: Tees reviewtemplate

INTEGRATED TASKS:

Ensure peopleknow what toexpect and what informationthey need

Communicate the outcome of the review

EXAMPLES: Oxfordshire reviewguidance


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For people receiving integrated budgets, ajoined-up approach to monitoring and reviewis particularly important. Ideally this wouldinvolve a single review and a single agreedapproach to monitoring, which is agreed withthe person when the plan is signed off so thatpeople know what to expect, what if anyinformation they are expected to keep andsubmit, and who will carry out future reviews.

Both monitoring and review should focus onoutcomes rather than whether or not serviceshave been delivered. To achieve this requiresboth health and social care staff to have ajoined-up understanding of what needs to bemonitored and why, and of how to useinformation arising from monitoring andreview to help ensure people can use theirbudget effectively over time.

To be effective, people need to adapt howthey use their budget over time, for instancethey may find a particular provider is notdelivering the care and support they hadhoped for, and may wish to try anotherorganisation or switch to employing staffdirectly. It should be made clear to peoplewhat changes to a plan need to becommunicated and to whom, and whatchanges people can make without involvinganyone else. It should be possible for peopleto make reasonable changes to the way theirsupport is organised without recourse to alengthy process and without the need forspecific approval. People should have theability to update rather than rewrite their planat review to reflect changes, so long as theoutcomes remain constant.


n A joint person-centred approach tomonitoring and reviewing

Even if the process up to this point has been person centred and outcome focused,all this can be undermined if the review and monitoring processes are notpersonalised. Training for health and socialcare staff in taking the right approach isessential to keep the integrity of a person-centred approach. Where a person has a joint direct payment, a single approach tomonitoring, with one organisation taking the lead, is strongly advised.

n Clear instructions about whatinformation to keep and how to get support to gather it

People need to know what information they are expected to keep, and to have access to support and advice to help themcollect and prepare the information required. Making sure this is clearlycommunicated and that appropriateassistance is available is an essential part of the initial review and of all subsequentreviews and monitoring interventions.

n A light-touch approach

Monitoring and review should beproportionate to each situation and not overly bureaucratic. Keeping the processsimple makes it easier for people tounderstand and can save valuable staff time.


n A process that is not joined up

People receiving an integrated budget should not have to undergo two separatereviews. This can lead to confusion andincrease anxiety as well as being a waste ofresources. Where staff are not empowered toundertake reviews of both the health andsocial care elements of a person’s budget,efforts should be made to ensure joint reviewsare arranged and the process is made to feelas seamless as possible.

n Requiring too much detailed information

Understanding whether outcomes are beingachieved does not need a large quantity of detailed information. The informationrequired should be just enough to answer thecentral questions – are people remaining inbudget, are outcomes being met, and whatgoods and services are being purchased?Keeping the information requirements to aminimum can save staff time and help fostertrust and confidence in people usingintegrated budgets.

n Lack of clarity about reviews

People can often find reviews stressful andanxiety provoking. In a climate of shrinkingresources, people can be suspicious that areview will be focused on trying to withdrawresources and services. Clear informationabout the aims of a review and a joint andpublic commitment to an outcome-focusedapproach can help to reassure people.


n Support plan review template (Tees).

n Guidance for getting a personal healthbudget (Oxfordshire).

n Purchase ledger (Norfolk).


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What should the customerjourney look like?

A single approach to information and advice

Getting things right from the first point ofcontact, and concentrating on what and howpeople hear about personal budgets, can helpto improve the quality and consistency ofpeople’s experience. Some pilot areas haveagreed a single approach to information andadvice across health and social care.Nottingham City has recently developed asingle information brochure, which is given topeople at the point when they are offered apersonal budget. Another aspect ofinformation and advice that works well formany pilot areas is the development of peersupport so that people can hear from otherswith direct experience of using personalbudgets in health and social care.

Not being overambitious

It is clear from the pilot areas that integratingpersonal budgets across health and social careis complex and takes time. Joining up processesand ways of working across multipleorganisations with different structures andcultures can be a daunting prospect. Startingsmall, and with a shared commitment to

learning by doing, can pay dividends. Whilesome pilot areas have been advancing work inpartnership with the local authority to mapout a comprehensive customer journey for thefuture, they have chosen to do this alongsidedelivering integrated personal budgets now,making the pragmatic decisions needed totweak or circumvent existing processes tomake progress.

Pooled funding arrangements areworking well

While Section 75 agreements are not aprerequisite to delivering integrated personalbudgets, it is clear from the experience ofseveral pilot areas that they can make thingseasier. NHS Oxfordshire uses a pooled budgetunder Section 75, which is working well andmakes the financial process of delivering jointbudgets more straightforward and lessbureaucratic. They have found that this allowstime and energy to be dedicated to careplanning, arranging services and outcomes-focused reviews rather than managing day-to-day discussions about who pays for what.Similarly, NHS Nottingham City is currentlyworking to develop a Section 75 agreementwith Nottingham City Council with the explicitaim of promoting increased opportunities forpeople to plan their own care and provide asingle access route for direct payments. For

5 Conclusion

more detail see the Finance and legal sectionin ‘Integrating personal budgets – myths andmisconceptions’.1

Making pragmatic funding decisionsfor joint packages

There is a natural temptation, whenimplementing a new way of allocatingresources, to focus considerable time andenergy on new systems, particularly thoseperceived as important to ensuring financialsustainability. However, a balance needs to bestruck between this kind of front end processdesign and the benefits that can be gainedfrom learning by doing. The experience frompersonal budgets in social care demonstratesthe inertia that can result from well meaningefforts to get resource allocation 100 percentcorrect. Personal health budget pilots havelargely avoided the worst elements of this byusing the most straightforward processavailable, and using tools consistently todetermine people’s estimated budgets (see‘How to set budgets’).16

The same approach has been applied tointegrated personal budgets. Most pilot siteshave been using parallel systems for settingbudgets and working hard to make themwork as seamlessly as possible. In Doncasterthe NHS uses an indicative budget-setting toolfor fully funded Continuing Healthcare. Forpeople with only social care needs, the localauthority has its own resource-allocationsystem. Where there is a joint responsibility tomeet needs, staff from both organisations

work out how best to meet their respectiveresponsibilities and the most appropriate splitof funding in order to provide as seamless aservice as possible. This has generally meantagreeing to fund packages 50/50 or 70/30rather than attempting to calculate individualpercentage points. In this way it should bepossible to refine an approach over timethrough its application, rather than delayingprogress to wait for the ideal system.

Co-located teams can be helpful

A number of the pilot areas have found thatmany of the perceived benefits of integrationcan be achieved through co-location of staffteams (eg mental health and NHS ContinuingHealthcare). Where local authority and NHSstaff share the same office space, this canhelp to build an understanding of each other’srespective roles and overcome challenges thatmight otherwise remain difficult. While co-located teams can help staff to becomefamiliar with each other’s systems andprocesses, they are not the only way, andtheir absence should not prevent progress. Formore detail see the section on Joint workingin ‘Integrating personal budgets – myths andmisconceptions’.1

The importance of co-production

Co-production is a critical element in thesuccessful delivery of integrated personalbudgets. To work at scale across health andsocial care, personal budgets need inclusiveand effective relationships between


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commissioners, providers, and people withhealthcare needs, their representatives andfamilies, with all parties working together toimprove health outcomes. A number of pilotshave involved people with care and supportneeds through project boards and in localdecision making, and developing links withestablished user-led organisations and newpeer networks. For more detail see the sectionon Co-production in ‘Integrating personalbudgets – myths and misconceptions’.1

Joint health and social care plans and reviews are working well

Although pilot areas have found it difficult tofully integrate some stages of the customerjourney for personal budgets, particularlyaround assessment and resource allocation,they have achieved far greater success withsupport planning and review. A number ofareas are working with a single support planto meet health and social care needs, and arelooking at what it will take to bring togetherthe review, working in partnership. In otherareas this has been facilitated by theinvolvement of independent third parties assupport planners and brokers, usually fromthe voluntary and community sector.Doncaster has a joint care plan across thelocal authority and NHS, and NHS NottinghamCity has developed a joint support plantemplate and guidance document. For moredetail see the section on Assessment and careplanning in ‘Integrating personal budgets –myths and misconceptions’.1

Making use of local authority directpayments support systems

Pilot areas have powers to deliver personalhealth budgets as direct payments directly to people or nominated third parties. Giventhe long history of direct payments in socialcare, pilots have found it helpful to useestablished local authority support servicesand payment systems, rather than reinventingthe wheel. Direct payments support servicesrange from local authority in-house teams to services commissioned from the voluntaryand community sector and user-ledorganisations. When delivering integratedpersonal budgets, local authorities havetended to make the full value of the paymentand then charge the NHS for the value of the health contribution. Some pilot areas have also begun to establish preferredprovider lists for budget managementservices, payroll and employment advice, in partnership with the local authority.

There needs to be greater emphasis onbuilding up nonemployment options, such asusing direct payments to pay for support froman agency, if they are to be available to morepeople in the future. There are opportunitiesfor a shared approach across health and socialcare to develop a comprehensive range ofdirect payment support services that can workfor a broad range of people with diverseneeds. See ‘Practical guide – direct paymentsfor healthcare’.17

Focusing on outcomes

A focus on outcomes encourages different useof resources and clinical engagement, and mayhelp to overcome funding disputes forintegrated packages. For personal healthbudgets this means, rather than simplyidentifying health needs that should be funded,starting from consideration of whether asuggested intervention will help meet a healthoutcome and might therefore be funded, evenwhere it looks different from traditionalhealthcare (eg alternative treatments fordepression or diabetes). Similarly, for jointlyfunded packages, a focus on outcomes meansthat health and social care professionals startfrom the perspective of asking if the overallpackage of care and support meets the agreedoutcomes, rather than seeking to track theirspecific contribution back to the health andsocial care need identified. A number of pilotareas use the Personal Outcomes EvaluationTool (POET)11 to build a local evidence base.This straightforward survey tool is commonlyused for personal budgets in social care, and sowill be useful for understanding the impact ofintegrated packages. For more detail seesections on Clinical engagement, Performanceand Outcomes in ‘Integrating personal budgets– myths and misconceptions’.1

Lack of clarity around expenditure canget in the way

Personal health budget pilot sites have beentesting a range of new approaches and findingtheir way in relation to some central policy andpractice issues. One important piece of

learning is that if people do not have clearguidance around rules governing expenditure,this can be disruptive and may cause lengthydelays and confusion. This can be furtherexacerbated for integrated personal budgetswhere there are different rules aroundexpenditure across health and social care. Aclear understanding of the rules governingexpenditure for each part of the budget is vitalto avoid confusion for staff as well as peoplewith support needs. For more detail seesections on Different funding streams andClinical evidence in ‘Integrating personalbudgets – myths and misconceptions’.1

Final thoughts

Developing a good customer journey forintegrated personal budgets is an iterativeprocess. Experience from the pilot sitesindicates that it takes good leadership, timeand sustained effort to get a broad range ofstakeholders engaged in developing the joined-up approach necessary to deliver integratedbudgets well. The ability to engage people withcare and support needs, their carers andfamilies in determining how local systems canbest deliver outcomes is fundamental.

This guide illustrates what we have learnt sofar, and shows that by keeping the processsimple, transparent and person centred,considerable progress can be made in thehere and now. We hope the information inthis guide, together with the other resourcesin the Personal health budgets toolkit, will behelpful in developing effective local systems todeliver integrated personal budgets.


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1 Department of Health. Integratingpersonal budgets – myths andmisconceptions. 2012www.personalhealthbudgets.dh.gov.uk

2 Personal health budgets website. About the pilot programme. 2009www.personalhealthbudgets.dh.gov.uk

3 The national peer network is made up ofpeople who have a personal health budgetand family members. Some members havefounded the the peoplehub personalhealth budgets networkwww.peoplehub.org.uk

4 Department of Health. A vision for adultsocial care: capable communities andactive citizens. 2010www.dh.gov.uk

5 Department for Education. Support andaspiration: a new approach to specialeducational needs and disability –progress and next steps. 2012www.dh.gov.uk

6 Department of Health. White paper:Equity and excellence: liberating the NHS. 2010 www.dh.gov.uk

7 Department of Health. White paper:Caring for our future: reforming careand support. 2012 www.dh.gov.uk

8 Department of Health. Health and SocialCare Act explained. 2012 www.dh.gov.uk

9 Humphries, R. and Curry, N. Integratinghealth and social care: where next?The King’s Fund. 2011 www.kingsfund.org.uk

10 Goodwin, N., Perry, C., Dixon, A., Ham, C., Smith, J., Davies, A., Rosen, R. and Dixon, J. Integrated care forpatients and populations: improvingoutcomes by working together. The King’sFund. 2012 www.kingsfund.org.uk

11 In Control and Centre for DisabilityResearch, Lancaster University. POET – the Personal Budgets Outcomes and Evaluation Tool. 2011 www.in-control.org.uk

12 Department of Health. Working togetherfor change: using person-centredinformation for commissioning. 2009www.challengingbehaviour.org.uk

13 Personal Social Services Research Unit(PSSRU). Personal health budgetsevaluation. 2012 www.phbe.org.uk


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6 References

http://www.personalhealthbudgets.dh.gov.uk/Topics/Toolkit/MakingPHBshappen/Integrating/

http://www.personalhealthbudgets.dh.gov.uk/About/aboutPilots

http://www.peoplehub.org.uk

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_121971.pdf

https://www.education.gov.uk/publications/standard/publicationDetail/Page1/DFE-00046-2012

http://www.dh.gov.uk/health/2011/07/liberating-the-nhs/

http://www.dh.gov.uk/health/2012/07/careandsupportwhitepaper/

http://www.dh.gov.uk/health/2012/06/act-explained/

http://www.kingsfund.org.uk/publications/integrating_health.html

http://www.kingsfund.org.uk/publications/integrated-care-patients-and-populations-improving-outcomes-working-together

http://www.in-control.org.uk/what-we-do/research-and-evaluation/poet.aspx

http://www.challengingbehaviour.org.uk/learning-disability-files/Putting-People-First.pdf

<http://www.phbe.org.uk

14 Healthwatch Englandwww.healthwatch.co.uk

15 Department for Work and Pensions. The Disabled People’s Right to Control(Pilot Scheme) (England) (Amendments)Regulations 2012 www.dwp.gov.uk

16 Department of Health. How to setbudgets – early learning from thepersonal health budget pilot. 2012www.personalhealthbudgets.dh.gov.uk

17 Healthcare Financial ManagementAssociation. Practical guide – directpayments for healthcare. 2012www.personalhealthbudgets.dh.gov.uk


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http://www.healthwatch.co.uk

http://www.dwp.gov.uk/consultations/2012/right-control.shtml

http://www.personalhealthbudgets.dh.gov.uk/Topics/Toolkit/HowPHBswork/Budget/

http://www.personalhealthbudgets.dh.gov.uk/Topics/Toolkit/HowPHBswork/Options/

Gateway Ref No. 18274

Personal health budgets team

Websites: www.personalhealthbudgets.dh.gov.uk/toolkitwww.nhs.uk/personalhealthbudgets

Email: [email protected]

Department of Health customer service centre: 020 7210 4850

http://www.personalhealthbudgets.dh.gov.uk/toolkit

http://www.nhs.uk/personalhealthbudgets

mailto:[email protected]

PERSONAL HEALTH BUDGETS GUIDE Integrating personal budgets ... · The NHS already has the necessary powers to offer personal health budgets, although only approved pilot sites can

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