Date published: 5 April, 2023
Date last updated: 6 April, 2023
Uncategorized

Personal health budgets: Delegation of healthcare tasks to personal assistants – March 2023

Introduction

This guidance aims to support practitioners and integrated care boards to:

  • understand the decision-making process involved in delegation of healthcare tasks from registered practitioners to personal assistants
  • establish clear protocols for ensuring safe and appropriate delegation
  • clarify responsibilities and lines of accountability.

Registered practitioners are specifically accountable to their regulatory body as well as to their employer. This guidance does not circumvent any standards for delegation set by regulatory bodies which they are required to meet.

Duty of care

Personal health budgets increase the level of choice and control that people have but do not change the statutory duty of care that the NHS has to all individuals.

Principles of delegation

Delegation is defined by the Nursing and Midwifery Council as “the transfer to a competent individual, of the authority to perform a specific task in a specified situation.” To do this means providing training but also checking that the person understands and can show that they can perform the task satisfactorily (often referred to as assessment of competence).

If you’re delegating a task, it’s your responsibility to make sure that:

  • delegation does not harm the interests of people in your care
  • the task is within the other person’s scope of competence
  • the person you are delegating to understands the boundaries of their own competence
  • the person you are delegating to understands the task
  • the person you are delegating to is clear about the circumstances in which they must refer back to you
  • you take reasonable steps to identify any risks and whether any supervision might be necessary
  • you take reasonable steps to monitor the outcome of the delegated task.

Read the Delegation and accountability supplementary information to the Nursing and Midwifery Council code of practice.

Why delegation is important

Delegation can:

  • help people get on with their lives since the personal assistant can respond to the person’s needs when and where required. This includes being flexible and responsive to cultural needs and individual lifestyles
  • enable personal assistants to develop new skills and more fully meet the person’s needs
  • help make best use of NHS workforce resources and skills.
“The person has less people involved in their care, so there is more continuity and co-ordination in their care”. – District Nurse
“I’m now capable to assist with all their needs, which allows them to be flexible to live how they want to live”. – Personal Assistant

Ensuring appropriate governance and assurance arrangements

It’s important that integrated care boards, as the responsible bodies for planning and commissioning healthcare services in their local area, put in place a clinical governance framework for delegation of healthcare tasks to personal assistants.

This might usefully include:

  • principles of delegation and clarification of roles, responsibilities and accountability
  • the process to be followed in considering delegating tasks to personal assistants and how decisions should be made
  • an indicative list of healthcare tasks that might commonly be considered for delegation to personal assistants (it must be made clear that this is indicative only and that each decision must be made in relation to individual needs and circumstances)
  • the model of training and monitoring of personal assistants who carry out delegated healthcare tasks
  • an outline of the generic training that will be provided to personal assistants in core competencies
  • an outline of the training required for each healthcare task and how competency will be assessed and signed off
  • an overview of how ongoing support and advice will be provided to personal assistants
  • the process for review and reassessment of competence.

Aligning these governance arrangements with arrangements for delegation to other care workers (for example, domiciliary care workers, healthcare assistants) can help ensure consistency, sustainability and provide value for money.

Developing a robust process for delegation

Identify the tasks to be delegated

The decision to delegate a healthcare task to a personal assistant should be made by a registered practitioner who is occupationally competent in the task and accountable in relation to that aspect of the person’s clinical care.

Delegation must first and foremost be in the best interest of the person for whom the care and support is being provided. The care plan should make clear the task that is to be delegated, the limits of the delegation and how risks will be managed. It will also need to identify contingency arrangements should there be a gap in service, for example when the personal assistant is on leave or off sick.

Identify how training and assessment of competence will be provided

For tasks that can be delegated, the personalised care and support plan needs to identify how the associated training will be provided and who will be responsible for assessment of competence, ongoing support to the personal assistant, and clinical review of the person’s needs.

“We’ve had lots of enthusiasm for training from personal assistants. This is a group of healthcare workers that can really benefit from high-quality training and formal recognition of the importance of their skills. It’s wonderful to see the personal assistants growing in confidence as they progress through training”. – Nurse Trainer for delegated healthcare tasks

Developing a robust process for delegation

Sign-off and review

The final decision to delegate a healthcare task to a personal assistant should be made by a registered practitioner who is occupationally competent in the task and is accountable in relation to that aspect of the person’s clinical care.

A three-way agreement, where all parties (the registered practitioner, the employer and the personal assistant) record that they are happy for the task to be delegated can be helpful. This can also include information about the extent and limits of the delegation, how support will be provided, competency maintained, and when and how to seek help.

Frequency of review should be documented in the care plan and should take into account the specific healthcare tasks, person’s clinical needs and changing requirements in relation to healthcare tasks. Review should also include a review of the tasks currently delegated to a personal assistant and a review of training and competency requirements.

Roles, responsibility and accountability

Accountability for delegation is a consideration for all those involved, including senior managers and commissioners.

A sound governance framework for delegation will help ensure that roles and responsibilities are understood and that systems are in place to support delegation. Understanding the responsibility to delegate appropriately and the risks both in not delegating or not delegating appropriately, along with sound protocols, will help practitioners feel confident and support safe and effective practice.

A registered practitioner who delegates a task remains accountable for the appropriateness of the delegation and ensuring that the person who does the work is able to do it. They cannot delegate that accountability. However, provided the decision to delegate is made appropriately they are not accountable for the decisions and actions of the personal assistant to whom they delegate. The personal assistant is accountable for accepting the delegated task and responsible for their actions in carrying it out.

“Delegation can offer more flexibility, independence and control for people in managing their care package”. – Senior Matron for Community Nursing

1. The integrated care board

The integrated care board has the overall responsibility to ensure that the system commissioned for delegation, training, competency assessment and review is safe and robust, including:

  • commissioning the appropriate staff for care coordination and delegation with a service specification which details the roles and responsibilities of the commissioned provider
  • commissioning an appropriate system for training and assessment of competence, including ongoing support and supervision of personal assistants in carrying out delegated tasks
  • maintaining effective contract management oversight of providers and complaints to ensure the service specification continues to be met throughout the contract
  • being clear about who the accountable healthcare practitioner is for reviewing the person’s clinical needs.
“Ultimately that’s what it’s all about, keeping people safe in their own homes and ensuring good practice to increase quality of life and reduce hospital admissions”. – Clinical Matron

2. The care coordinator

Everyone with a personal health budget should have a named care coordinator. While they may arrange with others to undertake actions, the care coordinator should be the primary point of contact between the person and the integrated care board and ensure that everything necessary for satisfactory delivery of the care plan and to support appropriate delegation is in place.

In relation to delegated healthcare tasks, the care coordinator is responsible for ensuring that:

  • a registered practitioner with relevant occupational competence in relation to the specific area of clinical care for the person (in some instances this may be the care coordinator) makes a more detailed assessment and decision in relation to the suitability to delegate the identified task
  • arrangements for training and assessment of competence are clearly specified in the personalised care and support plan
  • the person requiring the care or their representative has been consulted as to whether they are happy in principle with the task being delegated to their personal assistant
  • funding is included in the plan to cover the cost of training and assessment of competence, ongoing support and related insurance
  • support is available locally for personal health budget holders acting as individual employers to support them in their employer responsibilities, including writing job descriptions and person specifications, interviewing and identifying appropriate personal assistants for their needs
  • review and support arrangements are identified, communicated and recorded.

3. The registered practitioner

The registered practitioner with the relevant occupational competence is responsible for the decision in relation to the delegation of the specific task. They should:

  • fully identify the healthcare tasks that require delegation
  • formally assess that delegation of the task is in the best interest of the person
  • ensure that there has been a comprehensive risk and benefit assessment completed around the proposed delegation, including an assessment of the stability of the person, the complexity of the task being delegated, and the expected outcome of the delegation
  • provide appropriate task-specific training and assessment of competence, which should include ensuring that the personal assistant recognises the limits of their competence and authority and knows when and how to seek help
  • identify clinical supervision and support requirements and record and update clinical care plans, escalation plans, risk assessments and training as appropriate. The name of the clinical review contact person should be clearly recorded, and it should be clear who is accountable for the clinical care needs of the person.
“When he had a hospital admission his personal assistants were able to support him. They stayed overnight, which was a huge benefit because he felt confident in their ability to care for him”. – Community Children’s Nurse

4. The personal health budget holder, nominee or representative acting as employer

Employers are accountable for the actions of their personal assistant when the personal assistant is working within their sphere of competence and in connection with their employment (vicarious liability). The personal assistant’s employer should:

  • check that the job description and person specification reflect requirements in relation to delegated healthcare tasks
  • when recruiting, think about the candidate’s confidence and ability to learn the required skill
  • check that each personal assistant has received training from a registered professional and both the registered professional and personal assistant have signed to say they are satisfied that the personal assistant has the competence and confidence to deliver the delegated healthcare task
  • not ask the personal assistant to go outside the scope of their training
  • seek advice from the care coordinator or relevant practitioner if concerned about a personal assistant’s ability to deliver the delegated healthcare tasks
  • check that appropriate insurance is in place in relation to the personal assistant carrying out delegated healthcare tasks and consult with the care coordinator or support organisation if there are concerns.
“Delegating healthcare tasks to my personal assistants is a relatively small change yet it’s made a significant positive difference to my whole life. I have complete freedom to get on with a life worth living, rather than endlessly feeling like I’m being kept alive by the system”. – Personal health budget holder and personal assistant employer

5. The personal assistant

The personal assistant has a duty of care and is accountable for accepting the delegated task and responsible for his/her actions in carrying it out. The personal assistant’s responsibilities include:

  • taking part in training and signing to acknowledge competence and confidence to accept the delegated tasks
  • seeking advice and support from the employer and delegator if concerns arise or they come across something not covered in training
  • not undertaking tasks that they have not been trained for or exceeding the limits specified in the delegation of the task
  • seeking retraining for delegated tasks within a reasonable timescale prior to expiry.
“I can help my employer and complete the tasks myself rather than feeling like a bystander, unable to help when they need it most”. – Personal Assistant

Delegation of healthcare tasks – checklist

  • Is delegation in the best interests of the person and have they given their consent?
  • Is there a named person or team who has agreed the task can be safely delegated to a personal assistant?
  • Is there a process in place to ensure knowledge, skills and training can be provided to the personal assistant?
  • Is the personal assistant confident and competent to carry out the task?
  • Has the personal assistant been provided with documented procedures to support performance of the task?
  • Does the personal assistant know who to contact in an emergency and for general support and guidance?
  • How and when will refresher training be provided and competence reviewed?
  • Is there a process in place to review the clinical needs of the person receiving care and support?

Additional resources

Additional resources to support professionals working to deliver personal health budgets is available on the Personalised Care Collaborative Network (login required), including opportunities to share learning and discuss issues with colleagues across the country.
Date published: 5 April, 2023
Date last updated: 6 April, 2023