Direct Payments for Healthcare, HFMA, 2012

7/31/2019 Direct Payments for Healthcare, HFMA, 2012

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Shaping healthcare fnance

Direct Paymentsfor Healthcare

Practical Guide


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Published by the Healthcare Financial Management Association (HFMA),

Albert House, 111 Victoria Street, Bristol BS1 6AX

Tel: (44) 0117 929 4789

Fax: (44) 0117 929 4844

E-mail: [email protected]

This guide has been produced by members o the HFMAs Commissioning

Finance Group working closely with the Department o Healths personal health

budget pilot sites. The drating was carried out by Simon Stockton o Groundswell

Partnership and the editor was Anna Green.

Cover design was undertaken by YZDESIGNS, setting by Academic + Technical

Typesetting and printing by ESP Colour Ltd.

The NHS is always changing and developing this edition refects the structures

and processes in place in September 2012. We are keen to obtain eedback on

ways in which the content, style and layout can be improved to better meet theneeds o its users. Please orward your comments to [email protected] or to the

address above.

While every care has been taken in the preparation o this publication, the

publishers and authors cannot in any circumstances accept responsibility or

errors or omissions, and are not responsible or any loss occasioned to any person

or organisation acting or reraining rom action as a result o any material within it.

Healthcare Financial Management Association 2012. All rights reserved.

The copyright o this material and any related press material eaturing on thewebsite is owned by Healthcare Financial Management Association (HFMA).

No part o this publication may be reproduced, stored in a retrieval system or

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recording or otherwise without the permission o the publishers.

Enquiries about reproduction outside o these terms should be sent to the

publishers at [email protected] or posted to the above address.

ISBN 978-1-904624-75-2


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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 Page 22

ii. A checklist for what must be included in a care or support plan Page 23

iii. Example healthcare direct payment contract Page 24

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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 aremade, 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 HFMAs Commissioning Finance Group

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Acknowledgments

This guide has been produced by members of the HFMAs Commissioning Finance Group

working closely with the Department of Healths 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 thispublication.

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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 flexiblyprovided 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.

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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 isintended 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 Healths PHB web pages:

www.personalhealthbudgets.dh.gov.uk

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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 paymenton the persons 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:

. 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.

6

1 For more information on requirements for representatives, see page 17 of the Department of Healths

guidance Direct Payments for Health Care; Information for Pilot sites:

www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117477


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. 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 nominees or

representatives 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 receivingdirect 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

7

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 Margarets support needs. As Margarets

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 herparents 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

What are direct payments?


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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 givingpeople 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 servicesthen this may also not constitute a direct payment. For more on this see chapter 4 below

which looks at what direct payments can and cant be used for.

8

3 Resource Deployment Options for Personal Health Budgets, Department of Health, 2011:

www.personalhealthbudgets.dh.gov.uk/Topics/latest/Resource/?cid=3430


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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 someones 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 tohelp calculate budgets for people eligible for NHS continuing healthcare.4

3.2 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 receivinginappropriate 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.

9

4

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


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10

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 beds 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 thatnight. 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.



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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 howthe 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 individuals 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 shouldnot 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 someones health

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. 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 persons need for that service; or to

promote the welfare of a person who is a child5

. To employ people in ways which breach employment regulations or to purchaseanything 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:

.

Information about how disputes will be managed and under what circumstances apayment 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.

12

5 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



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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 exampleagreement 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 care-

coordinator 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 thereasons 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 helppeople through this process where necessary.

13

How direct payments for healthcare can be spent


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14

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 bedat 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 Johns 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 apowered 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.



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Chapter 5: Integrating direct payments between health andsocial 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 havealso 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.

15

6 Oxfordshires Support with Confidence scheme:

www.supportwithconfidence.gov.uk/


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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 directpayments 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

peoples 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 doesnt 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 approachto 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

16

7 Direct Payments and Individual Budgets: Managing the Finances, CIPFA, 2007:

www.cipfa.org/Policy-and-Guidance/Publications/D/Direct-Payments-and-Individual-Budgets-Managing-

the-Finances


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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 theyear 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 persons 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

dont 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 anindicator 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.

17

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.pdf9 Think Local, Act Personal website:

www.thinklocalactpersonal.org.uk/Browse/

Monitoring and reviewing direct payments


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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 costeffectiveness of health direct payments.

18

10 In Control: www.in-control.org.uk/



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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 directpayments 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 theoption 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

19

11 See www.cheshirecil.org and www.nw-pa.org


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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

20

12 Best Practice in Direct Payment Support: A guide for commissioners, 2012:

www.thinklocalactpersonal.org.uk/BCC/Latest/resourceOverview/?cid=9235



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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 makearrangements 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 peoples 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 Departments web pages on direct payments for

updates and guidance: www.personalhealthbudgets.dh.gov.uk

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Appendix i: Example personal health budget team financialprocess

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 office3. 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 system9. 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).

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Appendix ii: A checklist for what must be included in a care orsupport plan

[Extracted from pages 2223 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. The health needs and outcomes to be met by the services in the care or support plan

b. The services that the direct payment will be used to purchase

c. The size of the direct payment, and how often it will be paid

d. An agreed procedure for managing significant potential risk

e. The name of the care co-ordinator responsible for managing the care or support plan

f. Who will be responsible for monitoring the persons health conditiong. The anticipated date of the first review, and how it is to be carried out

h. The period of notice that will apply if the PCT decides to reduce the amount of the direct

payment.

23


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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 asdetailed 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 employers 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


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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 itemand 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

Example healthcare direct payment contract


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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 makingpayment?

FOR PCT MANAGEMENT COMPLETION ONLY:

Frequency of payment agreed

Date of first payment

Type of payment

Purchase agreed

Confirmed account is separate to

persons personal bank account

Budget holder authorisation

name and signature is required

Date

26



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Finance training or nance and non nance sta

e-learning

See the HFMA website for further details:

www.hfma.org.uk/e-learning

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Healthcare Financial Management Association (HFMA)

Albert House 111 Victoria Street Bristol BS1 6AX

T 0117 929 4789 F 0117 929 4844 E [email protected]

ISBN 978-1-904624-75-2

Healthcare Financial Management Association (HFMA) is a registered charity inEngland and Wales, no 1114463 and Scotland, no SCO41994. HFMA is also a limited

company registered in England and Wales no 5787972 Company no: 5787972

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