Practical Guide
Direct Payments
for Healthcare
Shaping healthcare finance
Published by the Healthcare Financial Management Association (HFMA),
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E-mail: info@hfma.org.uk
This guide has been produced by members of the HFMA’s Commissioning
Finance Group working closely with the Department of Health’s personal health
budget pilot sites. The drafting was carried out by Simon Stockton of Groundswell
Partnership and the editor was Anna Green.
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ISBN 978-1-904624-75-2
Practical Guide: Direct Payments for Healthcare
Contents
Foreword
Page 2
Acknowledgements
Page 3
Executive summary
Page 4
Introduction
Page 5
1.
What are direct payments?
Page 6
2.
Other ways of delivering personal health budgets
Page 8
3.
How to cost direct payments
Page 9
4.
How direct payments for healthcare can be spent
Page 11
5.
Integrating direct payments between health and social care
Page 15
6.
Monitoring and reviewing direct payments
Page 16
7.
The role of direct payment support services
Page 19
8.
Concluding thoughts
Page 21
Appendices
Page 22
i. Example personal health budget team financial process
ii. A checklist for what must be included in a care or support plan
iii. Example healthcare direct payment contract
1
Page 22
Page 23
Page 24
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 benefits, 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 financial
engagement at strategic, policy, and operational level if it is to be successfully managed.
Health service finance managers have a vital role to play in managing this important transition
in a way that can realise the benefits we know this change can bring. This practical guide
provides an overview for finance 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 HFMA’s Commissioning Finance Group
2
Acknowledgments
This guide has been produced by members of the HFMA’s Commissioning Finance Group
working closely with the Department of Health’s 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.
3
Executive summary
.
.
.
.
.
.
.
.
.
.
.
This guide covers the information that health service finance managers working in
commissioning organisations (specifically 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 specific 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 flexibly
provided it is not used for anything illegal and that any identified risks are adequately
managed.
Evidence from people using direct payments in social care and from PHB pilot sites has
shown that some people can find 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.
4
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 financial
resources available through the NHS to meet their healthcare needs.
Direct payments legislation was first 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
finalised. 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 finance managers. It focuses on the practical issues involved
in the financial 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 Health’s PHB web pages:
www.personalhealthbudgets.dh.gov.uk
5
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.
1.2
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.
1.3
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.
1.4
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 person’s behalf, subject to certain criteria. This is similar to the ‘suitable person’
process in social care.
1.5
Direct payments can be managed in a number of ways:
.
.
1
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 specified 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 Health’s
guidance Direct Payments for Health Care; Information for Pilot sites:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117477
6
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 nominee’s or
representative’s other accounts, and be used only for purchasing care and support to
meet the needs and outcomes specified in the care or support plan. The nominee or
representative is responsible for fulfilling 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 flexibly 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 specified 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 Margaret’s support needs. As Margaret’s
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.
2
Kent County Council – the Kent Card:
www.kent.gov.uk/adult_social_services/your_social_services/your_money/direct_payments/kent_card.aspx
7
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.
2.2
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 sufficiently confident 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.
2.3
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 specific services and/or specific 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 can’t be used for.
3
Resource Deployment Options for Personal Health Budgets, Department of Health, 2011:
www.personalhealthbudgets.dh.gov.uk/Topics/latest/Resource/?cid=3430
8
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 identified 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 someone’s 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
4
Most approaches to setting budgets are accurate in no more than about 80% of cases. It
is always advisable to have some in built flexibility 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 fit 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 benefit 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
9
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 flexibly, 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 flexibility of her personal health
budget came in handy when one of the bed’s 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 flexible and responsive than
services commissioned by the NHS could ever be.
10
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.
4.2
The care or support plan itself must contain a specified 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).
4.3
In agreeing a care or support plan the commissioning organisation must be satisfied that
the goods or services which the person intends to buy (as listed in the plan) will meet
the individual’s health needs and their broader health and wellbeing outcomes. They
must also ensure that the amount of money offered will be sufficient 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.
4.4
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 specific treatment, commissioning organisations should
not use this as a barrier to people purchasing such services, if it may meet their health
and wellbeing needs.
4.5
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.
4.6
However, there are some activities/items that a person cannot use a direct payment for,
specifically:
.
.
.
.
.
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
benefits are outweighed by the possible damage to someone’s 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 benefit
To pay a close family carer living in the same household except in circumstances
when ‘it is necessary to meet satisfactorily the person’s need for that service; or to
promote the welfare of a person who is a child’5
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 finding 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 satisfied 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.
4.8
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.
4.9
In addition to the care or support plan, it has been common practice in social care to
have a separate direct payment agreement.
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:
.
.
.
.
.
.
.
5
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 specified 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
12
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.
13
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 John’s 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 benefits. 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.
14
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 Confidence’.6
5.2
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 finding ways of merging and streamlining these processes will
be necessary for dealing with larger numbers of people.
6
Oxfordshire’s Support with Confidence scheme:
www.supportwithconfidence.gov.uk/
15
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
people’s health outcomes.
6.2
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.
6.3
People can get much added value from using money flexibly to meet outcomes in ways
that suit them as an individual and prohibiting flexibility compromises the purpose
behind health direct payments.
6.4
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 doesn’t to influence future plans as
to how a direct payment can be most effectively utilised.
6.5
In addition, it is important when deciding how payments should be monitored to take a
proportionate approach, which takes account of the specific risks relating to each
particular individual and situation. CIPFA guidance 7 issued in 2007 supported this
approach, but beyond the need to reflect good practice there is also a financial
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 inefficient 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 significantly 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 office systems and frontline staff time
7
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
16
Monitoring and reviewing direct payments
were significant 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 person’s identified 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
6.7
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
don’t 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.
6.8
If someone is holding a significant 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.
6.9
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.
6.10 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.
8
Practical approaches to improving productivity through personalisation in adult social care, Putting
People First, December 2010:
http://www.puttingpeoplefirst.org.uk/_library/Practical_Approaches_doc.pdf
9
Think Local, Act Personal website:
www.thinklocalactpersonal.org.uk/Browse/
17
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 specific 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/
18
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
specific 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 qualified staff. As mentioned earlier, Disability Rights UK can
provide details of local support schemes: www.disabilityrightsuk.org.
7.3
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 finances; bespoke training
courses delivered in employers own homes and a North West Personal Assistant Register
delivered in partnership with Age UK Cheshire.11
7.4
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.
7.5
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
11
See www.cheshirecil.org and www.nw-pa.org
19
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
20
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.
8.2
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 benefits of healthcare
direct payments to improve people’s health and wellbeing.
8.3
At the time of writing, the detail of how direct payments and PHBs will be rolled out is
yet to be finalised with the results of the evaluation due to be published in October
2012. Readers are advised to check the Department’s web pages on direct payments for
updates and guidance: www.personalhealthbudgets.dh.gov.uk
21
Appendix i: Example personal health budget team financial
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 office
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 office 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 22–23 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 significant potential risk
The name of the care co-ordinator responsible for managing the care or support plan
Who will be responsible for monitoring the person’s health condition
The anticipated date of the first 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.
23
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 _____________ financial monitoring policy, I agree to open a
dedicated, separate bank account for the payments and send copies of bank statements
to the PHB programme office every 3 months. For a one-off purchase I will send the
receipt or invoice to the same office.
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 office every
3 months. For a one-off purchase I will send the receipt or invoice to the same office.
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 office 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 employer’s 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 confidence 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 first payment
Type of payment
Purchase agreed
Confirmed account is separate to
person’s personal bank account
Budget holder authorisation –
name and signature is required
Date
26
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