Understanding personal health budgets
- What is a personal health budget?
- How do personal health budgets fit with other personalised health and social care initiatives?
- Why are personal health budgets being offered in the NHS?
- What is the aim of a personal health budget?
- How can someone get a personal health budget?
- What is an integrated personal budget?
Managing the money
- How can a personal health budget be managed?
- What can a personal health budget be spent on?
- Are personal health budgets one way to privatise NHS services?
- Can people add their own money into a personal health budget?
- How much money will someone get in their personal health budget?
- What happens if someone’s needs change, or they underspend or overspend their budget?
Understanding personal health budgets
A personal health budget is an amount of money to support someone’s health and wellbeing needs, which is planned and agreed between the person, or their representative, and the local clinical commissioning group (CCG) or NHS team.
The amount in someone’s personal health budget is based upon their personalised care and support plan. This plan helps people to identify their health and wellbeing outcomes, together with their local NHS team, and sets out how the budget will be spent to enable them to reach their goals and keep them healthy and safe.
- A personal health budget is not new money; it is about spending NHS money differently.
- They enable people to have choice and control over decisions about their care and the budget that is available to meet their needs
- Personal health budgets can be managed in different ways. No one will ever be expected to have more choice and control than they feel comfortable with.
- The NHS should work in partnership with the individual and agree together the outcomes to be achieved and set these out in a personalised care and support plan.
Personal health budgets and personal budgets in social care both aim to give people more choice and control to meet their health or care and wellbeing needs. If someone receives a personal health budget and a personal budget for social care, then it may be possible to join the two budgets together to form a joint or pooled budget. In some areas, the assessment, planning and monitoring processes may also be joined up between health and social care. The aim of this is to make the experience as straightforward as possible for the person.
Personal health budgets are one of a number of different personalised health and social care initiatives being led by the Government in England. You may also come across:
- Personal budgets in social care. In social care, personal budgets are means-tested and can be used to purchase your own care and support, including home care. For more information contact your local authority, visit the Think Local, Act Personal website or review the Care Act statutory guidance.
- The Special Educational Needs and Disability (SEND) reforms (2014). Following changes to the Children and Families Act 2014, there have been changes to the way children and young people with SEND are supported. This includes a new Education, Health and Care (EHC) plan to replace the statement of special educational needs, and parents and young people having the option of a personal budget. Local authorities must also produce a ‘local offer’, setting out the education, health and social care services they expect to be available for children and young people up to 25 years.
- Transforming Care. This is a national programme of support aimed at making improvements to health and care services so that more people with a learning disability, autism or both can get the right support, live in the community and closer to home. Building the right support is a national plan to develop community services as alternatives to inpatient facilities. Personal health budgets are an important part of the plan.
- Patient choice in the NHS. There are a range of choices that people should expect to be offered when they access NHS services. Some of these are legal rights. The Department of Health’s Choice Framework sets out the nine main types of choices that should be available.
- Other initiatives you may hear about are shared decision making, personalised care and support planning, supported self-care and self-management, patient activation, social prescribing and Integrated Personal Commissioning.
The personalised health and care webpages provide more information about the initiatives currently being led by NHS England.
Personal health budgets are one way to give people more choice and control over the services and care they receive. They are part of a wider drive to personalise health and social care which dates back to the 1970s, when disability groups campaigned for people to have more control over the money that was being spent on their care.
There is good evidence suggesting that giving people more choice and control over decisions about their care can lead to people accessing more appropriate services, improve the coordination of their care, improve their outcomes and experience, and reduce costs for the NHS. Personal health budgets are part of a growing shift towards greater personalisation and integration of services, and as people are now living longer and with more complex health needs it is increasingly recognised that new approaches to managing care are required, to ensure the health service responds effectively to people’s individual needs.
Personal health budgets build on experience of personal budgets in social care and personalised care and support planning for people with long term conditions, and start from the principle that people who need long-term support should be seen as experts in their condition and partners in their care, rather than passive recipients of services. The Next Steps on the Five Year Forward View (2017) included specific commitments to increase the choice and control people have over their care through personal health budgets, with plans to reach in excess of 40,000 people by 2019. The Mandate to the NHS also outlines the expectation that there will be a continuous increase, with 50-100,000 people with a personal health budget by Mach 2021.
The aim of a personal health budget is to give people more choice and control over the money spent on meeting their health and wellbeing needs, in order to help meet their needs in a way that is most appropriate for them. They are one way of helping people to be more involved in discussions and decisions about their care, and they can be suitable for people of all ages, with physical or mental health conditions, or both.
If someone is interested in a personal health budget for themselves or someone they care for, they should talk to the local NHS team or health professional who helps them most often with their care – this might be a care manager or a GP. Currently only adults who are eligible for NHS Continuing Healthcare and children in receipt of continuing care have the legal right to have a personal health budget, although all areas across England are expected to offer personal health budgets to additional groups of people, based on local need, including people with a learning disability and/or autism.
Decisions about who can have a personal health budget outside of NHS Continuing Healthcare are made by local clinical commissioning groups (CCGs), who are responsible for paying and planning for most local health services. Every CCG should have information made publically available about who is able to access one locally.
An integrated personal budget is where the budget includes funding from both the local authority and the NHS. This could be for health and social care needs and where appropriate include education funding. Integrated personal budgets aim to put in place a seamless approach to care, so that people and their families have the same experience of care and support, regardless of whether their care is funded by the local authority or the NHS. An integrated personal budget, as with other personal budgets, can be managed in three ways, or a combination of these approaches. Integrated personal budgets build on work undertaken as part of the Integrated Personal Commissioning (IPC) programme, which has looked at ways of joining together a person’s health and social care.
Managing the money
A personal health budget is based upon a personalised care and support plan. This plan sets out someone’s health and wellbeing needs, the outcomes they wish to achieve, the amount of money available and how it will be spent. Once the plan and budget has been agreed, the money in a personal health budget can be managed in three ways, or a combination of these:
- Notional budget: No money changes hands. The personal health budget holder knows how much money is available for their assessed needs and decides together with the NHS team how to spend that money. The NHS is then responsible for holding the money and arranging the agreed care and support.
- Third party budget: An organisation independent of both the person and the NHS commissioner (for example an independent user trust or a voluntary organisation) is responsible for and holds the money on the person’s behalf. They then work in partnership with the person and their family to ensure the care they arrange and pay for with the budget meets the agreed outcomes in the care plan.
- Direct payment for healthcare: The personal health budget holder or their representative has the money in a bank account and takes responsibility for purchasing the agreed care and support. Budget holders must show what the money has been spent on. Further guidance is included in the Direct Payments in Healthcare Guidance.
In most cases people will need a separate bank account to receive a personal health budget via a direct payment (there are some exceptions when the money can be paid directly into someone’s existing account, for example if it is a one-off payment). The separate account must only be used for purchasing care, but it may also be used for receiving and managing a social care personal budget, if someone has an integrated personal budget.
If someone wishes to have a personal health budget but doesn’t want to manage it themselves or doesn’t have the capacity to manage the budget themselves, it may be possible for someone else to manage the budget on their behalf. This might be a family member, a close friend or representative. Regardless of who is responsible for the budget, every effort must be made to ask the person about their wishes and to keep their best interests in mind.
People’s personalised care and support plans should be regularly reviewed and updated, at least once every 12 months. The frequency of any review should be based on the needs of the individual, for example if someone has a fluctuating or degenerative condition then their plan will need to be reviewed more frequently. People will also need a review if their health needs changes or something in the plan isn’t working. No one will ever be expected to have more choice and control than they feel comfortable with.
A personal health budget can potentially be spent on a broader range of care and support than would routinely be commissioned by the NHS, if it is agreed as being appropriate to meet someone’s identified needs. This could include funding for a personal assistant to help with personal care at home, and equipment such as a wheelchair. There are a small number of exclusions that are outlined in regulation and further outlined below.
Everyone who has a personal health budget should be supported by a suitable professional to think through how they would like to use their budget in order to meet their health and wellbeing needs. It is the responsibility of local NHS teams to advise people or refer someone to a relevant local organisation who can offer the necessary support. This is often described as brokerage.
What a personal health budget will be spent on, as outlined in their personalised care and support plan, must be agreed between the person or their representative, the local NHS team and where necessary the CCG.
A personal health budget cannot be used to pay for alcohol, tobacco, gambling or debt repayment, or anything that is illegal.
A personal health budget cannot be used to buy emergency care – for example if someone in receipt of a personal health budget had an accident, they would go to A&E like everyone else.
A personal health budget also cannot buy primary care services such as seeing a GP or buying medication. . For a full list of exclusions please see the Direct Payment in Healthcare guidance.
No, personal health budgets are about people getting care that’s right for them, which is funded by the NHS and provided free at the point of contact. Currently CCGs commission a range of services from both the NHS, the voluntary and community sector and private providers, based on the needs of the people in their area. The use of personal health budgets does not change this practice of choosing the right provider for the need identified.
In nearly all cases, people cannot add their own money into a personal health budget, and the budget should meet all the identified health and wellbeing needs of the person. The exceptions to this rule include people accessing wheelchairs and some dental and ophthalmic services, where under existing legislation people can add their own money to NHS funds in order to purchase a different service or product. In these situations the NHS must still ensure the NHS funding covers the service or product that meets someone’s identified needs, as agreed in the care and support plan, so that any contribution is paying for any additional extras or changes that an individual wants outside of the agreed need.
In all other situations, if someone wants to access more services than those being provided by the NHS to meet their assessed needs, then they can do so. They would need to organise and pay for this, and it would be separate to the personal health budget.
The amount that someone receives in their personal health budget will depend on the assessment of their health and wellbeing needs and the cost of meeting these needs.
Once someone’s health and wellbeing needs have been assessed, a personalised care and support plan is developed in partnership with their NHS team, outlining the health and wellbeing outcomes someone wants to achieve and how the budget will be used to meet these. Some care may still continue to be arranged by and commissioned from the NHS, and may not be included in the budget. People should know in advance what their indicative (estimated) budget is, which will help them to plan how the money should be spent. This budget will usually be based on the current cost of the NHS meeting those identified needs.
Once the plan has been agreed the final budget is confirmed, which may be more or less than the indicative budget, depending on the agreed plan. A personal health budget will not cover all the NHS care a person may need, and things like attending A&E, hospital stays, GP appointments or medication, which are out of the scope of a personal health budget, would not be included.
Personal health budget holders should have regular contact with their NHS team, so if their situation changes the care plan is reviewed and budget adjusted accordingly.
There may still be times when people underspend or overspend their budget. If someone has underspent, the NHS should discuss with the individual what will happen with the money. Depending on the circumstances, it may be kept for future health needs, or returned to the CCG.
If someone thinks that they may overspend or fears that their personal health budget is running out they should inform their NHS team as soon as possible. Budgets may run out for a variety of reasons, requiring different responses. Higher than expected spend may be as a result of perfectly legitimate reasons, such as a crisis period. If large amounts of additional costs have been incurred that were either unforeseen or higher than expected, the care and support plan should be reviewed to ensure the individual’s health and wellbeing needs are adequately represented, with sufficient funding provided to meet those needs in full.
A review can be requested at any time by an individual or an NHS team if circumstances have changed.
If someone has deliberately spent their budget in ways not agreed with the NHS team, they can be asked to repay the money to the CCG.
No-one should ever be denied essential treatment via normal NHS services as a result of having a personal health budget.
Personal health budgets were piloted between 2009 and 2012 by around 70 primary care trusts. People offered budgets in the pilot included those receiving NHS Continuing Healthcare, people using mental health services and people with a range of long-term conditions. 20 in-depth pilot sites took part in an independent evaluation. This was a controlled trial involving over 2,000 people, of whom around half had a personal health budget and the remainder were in a control group. The evaluation looked at outcomes, costs and cost-effectiveness.
The main findings from the evaluation include:
- People’s quality of life and wellbeing improved
- People benefited more when personal health budgets were implemented in a way that gave them more choice and control
- People with high levels of need benefited more than those with relatively mild needs
- Total spending fell for people with high levels of need
- People in receipt of NHS Continuing Healthcare or with mental health needs spent less time in hospital when they had a personal health budget.
The evaluation report is available at www.phbe.org.uk.