Personal Health Budget (PHB) Quality Framework

Classification: Official
Publication approval reference: PR810

Foreword

The NHS Long Term Plan recognises personalised care as one of five major practical changes to the NHS to ensure we have a service that is fit for the future. This means people will get more control over their health, and more personalised care when they need it – including access to personal health budgets (PHBs).

This PHB Quality Framework will support collaboration across integrated care systems (ICSs) to build on best practice and realise the improved outcomes and experience of NHS care and support that PHBs can offer for people. Integrated care boards (ICBs) will play a vital role in supporting partners to deliver high quality PHBs, offering strategic support to ensure PHBs are part of the solution to improve outcomes, tackle inequalities and make best use of resources.

When we really focus on what matters to people rather than what is the matter with them, we see a shift – PHBs support people to build on their strengths and develop their existing support networks, and empower staff to offer care and support that is flexible and innovative.

We continue our national commitment to deliver on the mandate expectation for 200,000 people to have a PHB by 2023/24 and hope that this framework supports ICBs and partner organisations to make this a reality.

James Sanderson
Director of Community Health & Personalised Care
NHS England

Introduction

Purpose

The PHB Quality Framework supports ICBs to create the conditions to meet PHB performance expectations, with a focus on improving operational delivery to:

  • deliver high quality care
  • improve the experience of PHB holders
  • realise the ‘life changing’ outcomes that PHBs can deliver
  • develop workforce confidence in commissioning and delivering PHBs
  • ensure value for money.

This in turn will support the four aims of ICSs:

  • improve outcomes in population health and health care
  • tackle inequalities in outcomes, experience and access
  • enhance productivity and value for money
  • help the NHS support broader social and economic development.

Scope

Both the ICS Design Framework and Thriving places: Guidance on the development of place-based partnerships as part of statutory integrated care systems outline the expectation for ICSs to work at place level, integrating and co-ordinating the delivery of health, social care and public health services around the needs of the population – including the use of PHBs.

The PHB Quality Framework focuses on PHBs, however, the principles and requirements can be applied to integration of health, social care and education needs around the individual through the provision of integrated personal budgets (IPBs). The potential to offer IPBs should be considered in all PHB offers – the key requirements for health within these remain as detailed in this document.

The PHB Quality Framework is intended to support integrated care partnerships meet the requirements for quality improvement and personalised care within integrated care strategies, and develop ICB PHB strategy, governance and processes. It can be used to self-assure quality and progress against key NHS Long Term Plan commitments and annual operational and planning guidance requirements.

The PHB Quality Framework may also be particularly helpful where PHB offers are coming together in a single ICS and best practice approaches and areas requiring further development and/or improvement need to be identified. It is not intended to be used as an external assurance tool.

Role of ICBs in supporting delivery of PHBs

ICBs must retain overall responsibility, including legal responsibility, for all decisions made under The National Health Service (Direct Payments) Regulations 2013, even where functions have been delegated to other statutory providers and organisations.

They have a broad range of responsibilities that empower them to better join up health, social care and education, improve population health and reduce health inequalities.

They can:

  • Create the conditions to fully realise the benefits of PHBs for local populations.
  • Support leaders to create sustainable PHB models across the ‘right to have’ cohorts and expand PHBs into cohorts where the local population health needs would benefit from targeted personalised care and support.
  • Support alignment and integration to improve the experience for people where two or more funding streams contribute to a PHB across health, social care and/or education.
  • Ensure the mechanisms, roles and responsibilities involved in the transfer of PHBs between ICBs are clear and promote a personalised approach, and the process is managed in a timely manner.
  • Promote a system-level approach to quality improvement that aligns to A Shared Commitment to Quality, a single vision of quality based on the need to provide high-quality, personalised care for all.
  • Support and promote the enablers of good personalised care and support and PHBs, including co production with people with lived experience, workforce development, robust governance structures, policy development and the use of digital solutions to improve the architecture for efficient delivery and use of PHBs.
  • Develop a strategic plan to support and oversee the implementation and wider expansion of PHBs.

The PHB Quality Framework should be read in conjunction with the Guidance on direct payments for healthcare: understanding the regulations which explains the regulatory requirements relating to direct payments.

Direct payments for healthcare are one way of managing a PHB. Although the regulations only apply to direct payments, the guidance provides useful information for all types of PHBs and information on implementing PHBs not included in the PHB Quality Framework.

PHBs explained

A PHB uses NHS funding to create an individually agreed personalised care and support plan that offers people of all ages greater choice and flexibility over how their assessed health and wellbeing needs are met.

The personalised care and support planning conversation identifies the care, support and services the PHB will be spent on. This can include a range of things to give people access to care, support and services that are holistic, innovative and build on their strengths.

PHBs are flexible. They can be used to meet a variety of needs:

  • for ongoing care and support to meet people’s assessed health and wellbeing needs, eg NHS Continuing Healthcare, children and young people’s continuing care, aftercare services under section 117 of the Mental Health Act
  • for one-off budgets to support people to achieve specific goals or outcomes enabling supported self-management, eg hospital discharge, mental health recovery
  • to support children and young people with education, health and care plans aligned to expectations in the SEND Code of Practice.

And they can be:

  • pooled to support several individuals to come together to achieve a common health and wellbeing goal, eg a group health weight management programme for people with a learning disability and/or autism
  • integrated with social care and/or education personal budgets
  • used to target and address wider system priorities such as identified health inequalities.

The following groups have a legal right to have a PHB – adults in receipt of NHS Continuing Healthcare, children and young people eligible for continuing care, people eligible for aftercare services under section 117 of the Mental Health Act and people eligible for an NHS wheelchair.

The rollout of PHBs is not confined to these ‘right to have’ groups. Ensuring more people can benefit from personalised care is one of the key practical changes set out in the NHS Long Term Plan, which sets the ambition to increase the uptake of PHBs to 200,000 people by 2023/24.

PHBs can be managed in one of three ways, or a mixture of these:

1. Notional budget: The money is held by the NHS and services are commissioned by the NHS according to the agreed personalised care and support plan.

2. Third party budget (also known as an individual service fund, ISF): An organisation independent of the person, the local authority and NHS commissioners manage the budget and are responsible for ensuring the right care is put in place, working in partnership with the person and their family to ensure the agreed outcomes can be achieved. A third party budget is not a form of direct payment. They are particularly helpful when a person:

  • does not want to manage a direct payment
  • does not wish to take on employer responsibilities for personal assistants
  • lacks capacity or is otherwise not in a position to manage their own budget
  • needs specialist or very tailored support that most providers are not in a position to deliver.

3. Direct payment: A monetary payment to a person (or their representative or nominee) funded by the NHS, to allow them to purchase the services that are agreed in the personalised care and support plan. ‘Managed account’ is the term used when a direct payment is held in an account on behalf of the budget holder, by a direct payment support service, solicitor, accountant or other provider. Unlike a third party budget, the managed account provider does not take on responsibility for arranging care and support, but co-ordinates the financial elements of the budget. The budget holder is still the person who signs the direct payment agreement and retains responsibility for decisions about how the budget is spent, and in most instances is also the registered employer for any personal assistants.

Universal Personalised Care outlines the expectation that at least 40% of PHBs in a local area are managed as a direct payment or third party budget (this excludes personal wheelchair budgets).

What the person with a PHB can expect

The person with a PHB (or their representative) should:

  1. Be central in developing their personalised care and support plan and agree who is involved.
  2. Be able to agree the health and wellbeing outcomes (and learning outcomes for children and young people with education, health and care plans) they want to achieve, together with relevant health, education and social care professionals.
  3. Get an upfront indication of how much money they have available for healthcare and support. (There may be flexibility when an indicative budget is discussed as part of a one-off budget.)
  4. Have enough money in the budget to meet the health and wellbeing needs and outcomes (and learning outcomes for children and young people with education, health and care plans) agreed in their personalised care and support plan.
  5. Have the option to manage the money as a direct payment, a notional budget, a third party budget or a mix of these approaches.
  6. Be able to use the money to meet their outcomes in ways and at times that make sense to them, as agreed in their personalised care and support plan.

Several core principles and enablers should underpin all aspects of the PHB process. This will ensure people have a good experience and are supported to achieve the outcomes that are important to them and agreed in their personalised care and support plan. Principles and enablers for PHBs are outlined in the next section.

Matthew’s PHB

Matthew’s PHB allowed us to plan his life beyond school. He spends time doing things that matter to him like hydrotherapy, rolling on his in-ground trampoline and being outside – especially in the wind, snow and rain!

Matthew has a lie-in if he is unwell overnight, instead of having to fit in with transport or college schedules. He has a more comfortable wheelchair. He is calmer and sleeps better so his epilepsy and previous poor weight gain have improved dramatically, avoiding hospital appointments and intervention. This has also had huge benefits for me and his sisters as we’re less exhausted.

Matthew’s Mum

Principles and enablers for PHBs

Principles

  • NHS values and principles, including a duty of care, still hold.
  • PHBs should support people to have more choice and control, not less.
  • The process of receiving and using a PHB should be a positive experience for individuals, families and their representatives.
  • Good personalised care and support planning is key to delivering high quality PHBs.
  • PHBs should focus on the person and what matters to them.
  • PHBs are part of a wider NHS commitment to embed personalised care across all services.

Enablers

1. Good communication

  • ICBs actively promote a culture where individuals, families and their representatives are listened to and empowered to be fully involved in discussions about their care and support.
  • ICBs communicate clearly, effectively and appropriately on how they can work with people to achieve positive health and wellbeing outcomes through a PHB.
  • There is regular and timely communication and response throughout the process, in a way that is consistent with an agreed local process and national guidelines. The person, family and/or representative should know who their lead point of contact is and ideally this should be the same person throughout the process.
  • Where staff, individuals, families or their representatives identify situations where communication has become ineffective, they have access to informal mediation to support resolution.

2. Trained and supported workforce

  • Staff understand their roles and responsibilities in relation to PHB delivery.
  • Staff are knowledgeable about the local PHB offer and processes as well as the relevant legal frameworks, eg Direct Payments for Healthcare: Understanding the Regulations; National Framework for NHS Continuing Healthcare (CHC).
  • High quality local training and support, including mentoring, is available to staff to develop competency, values, attitudes and behaviours.

3. Understanding core responsibilities

  • PHBs are offered in the context of existing policy areas.
  • The service supports flexible budget spend to enable people to achieve personalised health and wellbeing outcomes.

4. Robust PHB decision-making

  • Delegated authority for decision-making allows as much as possible to be agreed at an early stage, with risks and benefits discussed and considered throughout the personalised care and support planning process.
  • There is a clear escalation process where required.
  • Decisions around PHBs are consistent, fair and equitable to all people receiving the service. PHBs should support health equalities, demonstrate value for money and improve outcomes.
  • Every request is considered by taking a personalised and positive approach to risk management that is outcome driven.
  • Where a request is reasonably declined the reasons for this are explained clearly to the individual, family and their representative and alternative solutions to achieve outcomes are supported where possible.
  • Decisions are recorded and shared to facilitate staff learning, promote best practice and ensure a consistent and personalised approach.
  • Clinical and financial governance processes include quality assurance of decisions made, including through feedback from individuals, families and their representatives.
  • There is transparency in:
    • who makes decisions (named decision-maker)
    • response times and how decisions will be communicated
    • the information considered
    • the rationale for decisions made
    • the process for appealing a decision and where individuals, families and representatives can go to for support, including the process for making a formal complaint.

Definition of quality

This diagram shows 3 concentric circles. 

The inner circle reads 'high quality, personalised and equitable care for all. The two outer circles illustrate how this can be effectively delivered through ICSs. Care should be safe, effective, a positive experience for people, well-led, sustainably resourced and equitable.

Steps of the PHB process and quality standards

The process of setting up and using a PHB has six key steps.

Each step is explored in detail in the next section, setting out:

  • what this means for people, in the form of ‘I statements’
  • quality standards
  • additional information
  • links to useful resources
  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. Developing a personalised care and support plan
  5. Organising care and support
  6. Monitoring and review

What this means for people

Developed by people with lived experience of PHBs, the I statements represent what good care and support through PHBs looks like at each step. They provide a framework for systems to continually review and improve their PHB offer, alongside the quality standards.

The NHS England Personalised Care Strategic Co-production Group and the City and Hackney Place Based Partnership co-production group have been instrumental in supporting the development of these I statements. Their experience crosses a broad range of services and support through which PHBs can be accessed, including those for adults and children and young people, and physical and mental health services.

The PHB I statements complement the Think Local Act Personal (TLAP) Making it Real resources which aim to support change and improvement by setting out what good personalised and community-centred care and support looks like, and National Voices: A narrative for person-centred co-ordinated care.

PHB 6 steps

Step 1: Making contact and getting clear information

What this means for people

  1. I know where to go and who to contact for clear, accessible and timely information and advice about PHBs and the three different ways I can choose to manage the budget – notional budget, direct payment and third party budget.
  2. I feel well informed and supported to think about the choices available to manage my health and wellbeing.
  3.  I have the option to have support from advocacy services or to speak with other people who have experience of receiving a PHB.
  4. I have enough time to think about the choices available to me to help manage my PHB.
  5. I understand the responsibilities of the different ways to manage my budget and can explore which option works best for me, with my NHS team.

Quality Standards: what is expected from systems / organisations

The ICB PHB strategic plan needs to ensure:

  1. A plan is in place to implement the rollout of PHBs to people with a legal right to have one. It includes the expansion of PHBs across local populations, and considers opportunities for integration with social care and education.
  2. Oversight and alignment of PHB offers and messaging across systems, taking into account the priorities and needs at place level.
  3. Consistent and good quality information about PHBs is available across the ICS.
  4. Advocacy support across the system is understood – ICBs consider supporting the development of independent and accessible advocacy services to ensure people have independent support and advice if they need it.

What this means for NHS and related organisations (operational delivery)

  • The local PHB offer is published on the relevant health body’s website, and a local PHB policy is available.
  • Information on PHBs, including about the three different options for managing the money, is available in a variety of accessible formats to meet the needs of all people.
  • A single point of contact is available for people to discuss PHBs with; typically this would be a care coordinator or case manager.
  • A range of support services are available including information and advice, independent advocacy, direct payment support, brokerage (the help and support people may need to spend their PHB) and peer support.
  • Staff are able to articulate what PHBs are and are not and how they can be used. They can provide information on the care and support that will continue to be available through commissioned services and not included in the PHB.
  • Information and support is available that is comprehensive, relevant, up-to-date and accessible and responsive to diverse individual and community needs.

Additional information for step 1

The first step in the PHB process aims to ensure that both staff delivering PHBs and people who have requested or are offered a PHB receive appropriate information about them, including what a PHB is, how PHBs can be used and the support available to receive and manage one. People need the right information and support throughout the process to achieve good outcomes.

As set out in Responsibilities and Standing Rules Amendment (2013) and Amendment No.2 (2019), for those groups who have the right to have a PHB, responsible health bodies have a legal duty to:

  • publicise and promote the availability of PHBs
  • provide information, advice and support to those eligible, their representatives, families and carers, to help them decide if a PHB is right for them
  • ensure they have the systems and processes in place to be able to make this provision.

Where another organisation provides information and support, the relevant health body should work in partnership with that organisation to ensure messaging is comprehensive, relevant, up-to-date and accessible.

What are PHBs?
Information for people, families and carers
Accessible Information Standard
Guidance on the legal rights to have PHBs and personal wheelchair budgets
Guidance on Direct Payments for Healthcare: Understanding the Regulations
The National Health Service (Direct Payments) Regulations 2013

Step 2: Understanding the person’s health and wellbeing needs

What this means for people:

  1. I understand the process of how my needs will be assessed.
  2. I have time and information to allow me to prepare for this.
  3. I feel listened to, understood and involved in an assessment that is personalised to me.
  4. I have an equal voice in the assessment process, and my expertise about my own health and wellbeing needs is valued and respected.
  5. I can involve others to support me if I want them to be included.

Quality standards

The ICB PHB strategic plan needs to ensure:

  1. PHB development is informed by population health management approaches and improvement, and better understanding of current health and care needs/predicted future needs for local populations – in particular the groups with the worst health outcomes.
  2. Joint Strategic Needs Assessments (JSNA) and joint health and wellbeing strategies are used to support and inform PHB expansion planning, to meet the needs of whole communities.
  3. Integrated care partnerships work together to identify opportunities for PHBs to enable people’s care and support to be better integrated and their outcomes improved.
  4. A consistent approach to assessment of health and wellbeing needs for people who access PHBs is in place across the ICS.

What this means for NHS and related organisations (operational delivery)

  1. PHB policies outline clinical governance processes for assessing needs.
  2.  A personalised approach is used to assess needs – focused on the whole person and providing an accurate reflection of current needs.
  3. Accessible and transparent information is available about the assessment process so people understand how their needs will be assessed and when their needs will be reviewed.
  4. Clear information is available about where the assessment will be conducted, eg face-to-face, supported self-assessment (questionnaire), online or phone assessment.
  5. A fair and equitable approach is used to assess needs across all three budget deployment options – notional budget, direct payment, third party budget.
  6. A clear and timely process is in place for approving the needs assessment.

Additional information for step 2

This step involves a detailed discussion with the person about their specific health and wellbeing needs. These needs should be determined before the indicative budget setting process which calculates the amount of money available for the PHB.

All approaches to understanding needs should be underpinned by the following principles:

  • personalised
  • timely
  • equitable and consistent
  • focused on the whole person – all their health and wellbeing needs.

The discussion should explore:

  • the outcomes that matter to the person
  • the person’s health needs and how they impact on their wellbeing
  • the person’s strengths and circumstances including home, interests, work and family.

The aim is to capture a full picture of the person and what needs and goals they may have.

Where unpaid carers are identified they should also be offered an assessment of their needs.

Care Act 2014: Promoting wellbeing

Step 3: Working out the amount of money available

What this means for people:

  1. I know how much money is likely to be available within my budget and how it was calculated.
  2. I have enough money to help me start to plan for how I will meet all my agreed needs.
  3. I have contingency funding in my budget (where appropriate) so I can plan for unforeseen circumstances.
  4. I understand how to ask for a review of my budget if it is insufficient to meet all my agreed needs.

Quality standards

The ICB PHB strategic plan needs to ensure:

  1. Financial planning and sustainability of PHB offers across the ICS for ‘right to have’ and wider expansion areas, including the use of PHBs as a cost-effective approach to hospital admission avoidance, step-down and discharge, and alignment to wider system transformation funding to create new PHB offers.
  2. PHBs are included in long-term financial planning to enable as much of the budget as possible for an individual’s care and support to be offered as a PHB.

What this means for NHS and related organisations (operational delivery)

  1. Sustainable funding is available for PHBs in ‘right to have’ areas.
  2. Clear and timely governance processes are in place for calculating and approving indicative and final budgets.
  3. Fair and equitable budgets are offered across all three budget deployment options – notional budget, direct payment and third party budget – consistent across the ICS.
  4. Budget setting approaches ensure the indicative budget is clear, upfront, transparent and enough to meet assessed needs.
  5. Sufficient funding is available in PHBs to cover the additional necessary costs of employment, if required, such as tax, National Insurance, training and development, pension contributions, any necessary insurance such as public liability, emergency cover, etc, and this is clearly explained to people before they recruit personal assistants.
  6. The approach for agreeing personal assistant pay rates is realistic and equitable, and ensures the PHB is sustainable, including where joint-funded budgets are offered.

Additional information for step 3

If PHBs are to meet ongoing care and support needs, working out the amount of money and identifying the indicative budget must be done after assessment of health and wellbeing needs (step 2). However, there may be flexibility in when an indicative budget is discussed as part of a one-off budget.

The indicative budget is a realistic estimate of how much money the person is likely to need to meet their needs. It is important the person has a clear understanding of this when developing their personalised care and support plan and considering how they will prioritise and achieve the agreed outcomes.

NHS care is free at the point of delivery – the final budget must be sufficient to meet all the assessed needs that will be supported by the PHB.

Responsible health bodies will have local approaches for setting budgets, aligned to the commissioned service. Budget setting models should be reviewed at regular intervals to ensure they comply with statutory requirements, take account of local audits and learning, and are financially viable for the local marketplace. There should be alignment with social care approaches for joint-funded budgets where possible.

All approaches to budget setting should be underpinned by the following principles.

Transparency: The person and their family should be made fully aware of what their budget is and how it has been calculated. A person-centred approach to budget setting must be transparent to fully involve the person in the process.

Timeliness: An indicative budget needs to be known before the detailed personalised care and support planning process for people with complex needs, to enable the person to plan how their needs and outcomes can be met.

Sufficiency: The final budget must be sufficient to meet the assessed needs and intended outcomes of the person. In the NHS, funding must be sufficient to fully meet all identified health needs in the personalised care and support plan – this may be through a mixed model of notional budget, third party budget or direct payments. Access to NHS services is based on clinical need, not an individual’s ability to pay. Therefore it is not permissible for individuals to be asked to make any payments towards meeting their assessed needs (except in a small number of areas where regulations permit this eg personal wheelchair budgets).

Finance Commissioning and Contracting Handbook for Personalised Care

Step 4: Developing a personalised care and support plan

What this means for people

  1. I have the support I need to prepare and plan how to achieve what matters to me.
  2. I have choice, flexibility and control over how and when my care and support happens.
  3. I can make decisions about my care and support, with my NHS team, through open conversations and positive approaches to managing risk.
  4. I understand how my budget can be used.
  5. I understand my plan and am involved in agreeing it with my healthcare team.

Quality standards

The ICB PHB strategic plan needs to ensure:

  1. Clear clinical and financial governance processes, and management of risk and decision-making, are enabled at place level.
  2. The workforce are empowered and supported to make decisions as close as possible to the person receiving the PHB.
  3. There is a system-level approach to workforce training in delivering personalised care and support plans.

What this means for NHS and related organisations (operational delivery)

  1. Staff are provided with training that supports them to develop an understanding of how to have proactive, personalised conversations that focus on what matters to the person and agreeing the health and wellbeing outcomes they want to achieve.
  2. There is training and clear guidance available to enable staff to understand what needs to be included in a personalised care and support plan for PHBs, how the budget will be used, management of risk and contingency planning, as well as training for personal assistants.
  3. People who receive a PHB give staff the opportunity to hear their experiences, so that staff can understand the difference good personalised care and support planning can make.
  4. There is support at organisational level and from managers to enable positive approaches to risk and decision-making that encourages innovation and new approaches.
  5. Clinical and financial governance processes support timely sign-off of personalised care and support plans.
  6. The organisation models the behaviour and culture that it would like to see, and provides supervision sessions that offer staff a safe supportive space to reflect on experiences of personalised care and support planning in their practice.
  7. A values-based approach is used in recruitment to ensure that people’s values align to personalised care values. This is also a requirement in external provider contracts.

Additional information for step 4

Personalised care and support planning is central to the delivery of PHBs. It is about having a different kind of conversation with the person about their health and care. This supports the person to identify how they wish their needs to be met and their outcomes achieved in ways that work best for them as an individual or family. It focuses on working with the person and the people around them to agree solutions, and how the budget will be used based on their agreed outcomes to provide the optimum management of their health and wellbeing.

The process recognises the person’s skills and strengths, as well as their experiences and the things that matter the most to them. It addresses the things that are not working or need to change in the person’s life and identifies outcomes (including learning outcomes for children and young people with education, health and care plans) and actions to resolve these.

The services and support that will be purchased through the PHB to meet the agreed outcomes are discussed, agreed and set out in the plan. This then forms the PHB agreement between the ICB and the person drawing on care and support or their representative.

There are a small number of restrictions on how a PHB can be spent as set out in the Guidance on Direct payments for healthcare: understanding the regulations.

Think Local Act Personal personalised care and support planning tool
Personalised Care Institute e-learning
NHS England personalised care and support planning

Step 5: Organising care and support

What this means for people:

  1. I understand what I will need to do to make my plan happen.
  2. I have control and flexibility over organising my care and support to achieve what matters to me.
  3. I have appropriate support available to me, including support to manage the budget and any additional responsibilities.

Quality standards

The ICB PHB strategic plan needs to ensure:

  1. A system-level approach to market development based on population health needs to ensure appropriate services and support are available to PHB holders – including market development for personal assistants and third party budget providers, aligned with local authority market development approaches where possible.
  2. A joined-up approach is in place to commission direct payment support services across the system to achieve better value for money.
  3. Options for commissioning for individual outcomes are shared across the system, including approaches for the delegation of healthcare tasks, training and competency sign-off.

What this means for NHS and related organisations (operational delivery)

  1. Clear processes are in place for organising care and support across all budget deployment options, including clear roles and responsibilities for staff.
  2. Support to employ personal assistants and/or manage the PHB is available.
  3. Ongoing good quality support is offered to people to implement the care and support agreed in their personalised care and support plan.
  4. Good quality training and support for PHB holders as employers and for their personal assistants is available and accessible.
  5. It is clear who will take on the role of care coordinator for the NHS and the responsibilities of this role are understood.

Additional information for step 5

Once the personalised care and support plan has been approved and signed off, the care and support can be arranged.

For notional budgets, the NHS commissions care and support on behalf of the person. Processes to support third party budgets (also known as individual service funds, ISFs) are managed between the NHS and the third party. For both these budget management options, the person should be included in discussions about set-up of care and support, even though they are not directly involved in the administrative aspects of the care and support arrangements.

For direct payments, the relevant NHS body is responsible for ensuring the person or their representative has as much support as they need or want to make the plan happen.

Options for managing the money
Delegation of healthcare tasks to personal assistants
Skills for Care Information hub

Step 6: Monitoring and review

What this means for people:

  1. I have accessible information about my PHB review and what is expected, including timescales.
  2. I can arrange an earlier review if I feel my circumstances have changed.
  3. I have time to prepare for my PHB review and can include the people I choose, including support from an advocate.
  4. I am supported to focus on how my PHB is working for me, and any change in my needs or support will be reflected in an updated plan and budget.
  5. I can have a conversation about any aspect of my budget before changes are made as part of my review.

Quality standards

The ICB PHB strategic plan needs to ensure:

  1. A process is in place for the systematic collection of all relevant information that can contribute to system-level understanding of the benefits and challenges of working in a personalised way and inform future strategic commissioning decisions.
  2. Alignment of statutory reviews is supported and enabled where two or more funding streams contribute to PHBs across health, social care and/or education.

What this means for NHS and related organisations (operational delivery)

  1. A proportionate governance process is in place that includes timely monitoring, review and evaluation of individual PHBs.
  2. Monitoring, review and evaluation processes are established within local processes for delivering care and support, to minimise duplication and to reduce the burden on individuals.
  3. Accessible information is provided about the PHB monitoring and review processes, including what people can expect at the review:
    • the personalised care and support plan review identifies how well the PHB is meeting assessed care and support needs and agreed outcomes
    • the budget review identifies any changes required to meet the cost of purchasing the care, support and services agreed in the plan
    • the financial audit provides information on how the budget has been used and identifies any underspend or budget misuse.
  4. Reviews are aligned with the Guidance on direct payments for healthcare: understanding the regulations and aim to strengthen people’s ability to achieve their agreed outcomes.
  5. Evaluation of the effectiveness of the PHB both for the individual and for the organisation is embedded, including the direct and indirect impact of the PHB.
  6. Evaluation takes account of the person’s, and/or their representative’s, experience of receiving and using the PHB.
  7. Financial monitoring of service expenditure includes total spend on PHBs to ensure this is within the expected range and enables the organisation to forecast and manage future expenditure on PHBs.
  8. Audit of third party providers is carried out at regular intervals to ensure they are fit for purpose.

Additional information for step 6

Reviews that focus on outcomes rather than processes can be the most effective way of identifying what works well and what does not for a person. A clear and effective process for monitoring, reviewing and evaluating the effectiveness of PHBs at appropriate intervals identifies:

  • any changes in needs and circumstances
  • whether agreed outcomes are still appropriate
  • any changes in risks or safeguarding needs
  • if the budget is adequate and being appropriately used.

In addition, a local process will provide an effective feedback loop for the individual’s experience helping to inform and influence how services and support are shaped going forward.

Case study 1: One-off PHBs to support mental health recovery, City and Hackney Place Based Partnership, NEL ICB

City and Hackney Place Based Partnership co-produced a recovery pathway with people with lived experience of mental health services where PHBs could be used to support and achieve recovery goals in conjunction with commissioned services, or as a stand-alone resource enabling individuals to be discharged from secondary mental health services to primary care.

The vision for PHBs is that they help achieve a specific mental health recovery goal rather than offering long-term support.

The pilot has led to:

  • recurrent funding being identified via transformation funds
  • the PHB offer being widened and extended to 400 people per year
  • the provision of a digital support offer helping people ‘stay connected’ during the Covid-19 pandemic and beyond.

For individuals this has resulted in:

  • successful discharge back to their GP/home enabling them to get on with their best lives
  • increased confidence in identifying their own health and support needs and the ability to access help in ways that work for them
  • decreasing reliance on secondary mental health care as people have developed skills to self-manage their mental health and wellbeing
  • hospital admission avoidance, the journey from homelessness to rehab, employment opportunities through qualifications achieved, empowerment to stay connected through the provision of digital devices.

Key design features for implementation

Step 1: Making contact and getting clear information

  • Simple clear information is available, co-produced with people with lived experience, including case examples to help people think about how a PHB could support their mental health recovery.
  • Training is provided for staff, using examples from experience and a clear learning loop to identify re-occurring challenges, with guidance and training available to address these.

Step 2: Understanding the person’s health and wellbeing needs

  • Conversations focus on what matters to the person with recovery goals agreed based on these conversations.
  • Understanding health and wellbeing needs is the start of this process no matter where the person starts their journey.

Step 3: Working out the amount of money available

  • Indicative value ranges for budgets are agreed collaboratively at the outset with a
    wide range of stakeholders, with a tiered approach to value and authorisation.
  • Direct payments are issued as single value payments, to be used for one-off payments or over a longer time (eg for an ongoing fee to access a resource or service such as relevant training opportunities).

Step 4: Developing a personalised care and support plan

  • All conversations focus on what matters to the person and recovery goals are agreed based on these conversations – a simple personalised care and support plan is developed, outlining their goals and the item and/or activity identified to support these goals.
  • Training helps staff to understand the importance of the ‘what matters to me’ conversation and how outcomes are set that lead to the PHB.

Step 5: Organising care and support

  • As the PHB offer is focused on small budgets that have a big impact, agreement for requests go through a governance process that is proportionate to the cost and/ or perceived risk.
  • People sign a co-produced direct payment agreement which outlines how the PHB must be used.
  • People are given copies of the information about their PHB and can choose to sign up to an online system (Patient Knows Best) to access this information.

Step 6: Monitoring and review

  • A comprehensive system for monitoring and reviewing plans and budgets is in place and information from this is collated and analysed to provide feedback to inform how provision should be commissioned in future.
  • The review provides an opportunity for the person to discuss the impact of the PHB for them.
  • People can choose to sign up to the Patient Knows Best system and have access to their impact questionnaire responses to self-monitor and track changes.

Case study 2: Ongoing PHBs to support long-term health and care needs, NHS Lancashire and South Cumbria ICB (Blackpool)

Blackpool’s PHB offer allows people to manage their own health and wellbeing outcomes which has a positive impact on both PHB holders and the NHS CHC team. PHBs are the default operating model for everyone in receipt of a homecare package, and through the process of regular reviews, staff identify what’s working or not working with existing arrangements, and discuss with people the options to manage their care and support differently.

PHB holders are empowered, through the personalised care and support planning process, to be part of the decision-making process to meet their needs in more creative and flexible ways than those offered by traditional care arrangements.

The NHS team have worked in partnership with Blackpool Council since 2014 to successfully provide PHBs in NHS CHC. Blackpool Council’s long-standing experience in delivering direct payments enabled the NHS to offer this option to people (along with notional and third party budgets) when the legal right to have a PHB in this area was introduced.

NHS CHC nurse advisors work closely with Blackpool Council’s dedicated PHB officers to support people and families with their PHBs. The emphasis is on ensuring positive outcomes for people’s health and wellbeing whilst managing the financial aspect to deliver value for money.

Nurse advisors and PHB officers share case management responsibilities. Nurse advisors provide clinical oversight on all aspects of care and support arrangements with PHB officers offering expert support in areas including recruitment, budget setting, mandatory personal assistant (PA) training, budget management and financial audit.

Both the nurse advisors and PHB officers undertake home visits as needed to help set up PHBs, and subsequently complete joint reviews aligned to the NHS CHC National Framework guidance or on request from people and families.

NHS Lancashire and South Cumbria ICB (Blackpool) and Blackpool Council have noted benefits for both people and the system since the introduction of PHBs, including:

  • increased satisfaction of people in receipt of care and support from NHS CHC
  • a reduction in case management input required from the NHS CHC team as people self-manage their own care and support
  • reduced hospital admissions as a result of people receiving bespoke and tailored care that successfully meets their needs
  • the employment of PAs via direct payments adding value to the local economy and creating exciting employment opportunities.

Key design features for implementation

Step 1: Making contact and getting clear information

  • People are provided with clear information about PHBs once they become eligible for NHS CHC funding.
  • In addition to information available in a local PHB information leaflet, the allocated nurse advisor discusses PHBs with people in more detail and provides support to help them choose the most suitable budget deployment option for them.
  • PHB officers provide training to nurse advisors, ensuring quality and consistency in the information and support provided.

Step 2: Understanding the person’s health and wellbeing needs

  • Conversations with people help to determine their health and wellbeing needs, what is important to them and the support they require to meet their identified needs.
  • Any recently completed assessments (including the NHS CHC Decision Support Tool) can also be used to help identify specific needs.

Step 3: Working out the amount of money available

  • An indicative budget is set based on hours of care and support required and people are provided with an upfront allocation which includes contingency funds, costs associated with training for PAs (if required) and additional support for unpaid carers.
  • The combined expertise of PHB officers and nurse advisors ensures that the indicative budget is sufficient to meet all the assessed needs.
  • PHB officers provide further information on budget deployment options.

Step 4: Developing a personalised care and support plan

  • People are offered support from the PHB officer or nurse advisor to develop their personalised care and support plan.
  • They are encouraged to document what is important to them, their goals and aspirations and how they are affected by their health condition.
  • The type of support required to meet assessed needs and agreed outcomes and how this will be provided is clearly documented, along with contingency and risk management plans.

Step 5: Organising care and support

  • The ICB’s PHB Group in Blackpool have delegated authority for budget approval up to a certain value; PHBs that exceed this value are presented to the Senior Individual Patient Panel for consideration.
  • The person is informed of the outcome of the decision and supported to respond to any queries regarding the personalised care and support plan or budget.
  • Help to arrange the care and support agreed in the plan is provided by PHB officers and/or nurse advisors, including support to access training for delegated healthcare tasks.

Step 6: Monitoring and review

  • PHB reviews (including review of people’s needs) are undertaken alongside NHS CHC reviews, and also on request in the event of any changes required to the personalised care and support plan or budget. Three-monthly financial audits are undertaken for direct payments, with underspend recovered following a conversation and in agreement with the person.
  • Both formal and informal feedback from people on their experience of receiving care and support through PHBs is used to continually improve the local process and offer.

Additional resources

Workforce development

The Care Act (2014) guidance: personal budgets

Support for systems

Additional resources to support professionals working to deliver PHBs is available on the Personalised Care Collaborative Network (login required), including opportunities to share learning and discuss issues with colleagues across the country.

Support for systems to aid critical thinking, reflection, problem-solving and decision making for PHBs is available through In Control and the National Children’s Bureau. This support will help to:

  • use shared experiences and learning to produce positive practical actions
  • support the development of governance frameworks that facilitate decision-making close to the person
  • embed a culture of positive risk management and positive conversations with people and families.

Further information and details of how to access this support can be found on the Personalised Care Collaborative Network.

The PHB Quality Framework was extensively co-produced with members of the NHS England Strategic Co-production Group alongside key partners from Association of Mental Health Providers, In Control, National Children’s Bureau, National Development Team for Inclusion and Skills for Care.

Logos: Assoication of Mental health Providers, inControl, National Children's Bureau, NDTi, NHS, Skills for Care