PERSONAL HEALTH BUDGETS GUIDE

Integrating personal budgets– myths and misconceptions

Authors: Sam Bennett and Simon Stockton, Groundswell Partnership

Integrating personal budgets – myths and misconceptions

1 Introduction 3

2 Finance and legal 5

3 Culture change 16

4 Workforce 26

5 Information and data 33

Contents

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Integrating personal budgets – myths and misconceptions

A personal health budget is an amount of money to support a person’s identifiedhealth and wellbeing needs, planned and agreed between the person and their local NHS team. Our vision for personal health budgets is to enable people with long term conditions and disabilities to have greater choice, flexibility and controlover the health care and support they receive.

What are the essential parts of a personal health budget?

The person with the personal health budget (or their representative) will:

n be able to choose the health and wellbeing outcomes they want to achieve, in agreement with a healthcare professional

n know how much money they have for their health care and support

n be enabled to create their own care plan, with support if they want it

n be able to choose how their budget is held and managed, including the right to ask for a direct payment

n be able to spend the money in ways and at times that make sense to them, as agreed in their plan.

How can a personal health budget be managed?

Personal health budgets can be managed in three ways, or a combination of them:

n notional budget: the money is held by the NHS

n third party budget: the money is paid to an organisation that holds the money on the person's behalf

n direct payment for health care: the money is paid to the person or their representative.

The NHS already has the necessary powers to offer personal health budgets, although onlyapproved pilot sites can currently make direct payments for health care.

What are the stages of the personal health budgets process?

n Making contact and getting clear information.

n Understanding the person's health and wellbeing needs.

n Working out the amount of money available.

n Making a care plan.

n Organising care and support.

n Monitoring and review.

Personal health budgets

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Integrating personal budgets – myths and misconceptions

This guide is one of two focusing on theintegration of personal budgets across healthand social care.1 Improving the experienceand quality of care for people andsupporting them to achieve better healthand social care outcomes are the mostimportant aspects of integration work.

The two guides are aimed at health and socialcare staff involved in the implementation ofpersonal budgets and personal health budgets,who want to develop local systems for peoplewho would benefit from an integratedbudget. They draw together learning from 14of the pilot sites2 that have been working incollaboration with the Department of Healthto explore how best to integrate budgetsacross health and social care.

Integrating personal budgets presents majorcultural, technical and structural challenges,and there are a number of genuine barriers to overcome to make them a success.However, some commonly identified barriersto progress are in fact myths resulting frommisunderstandings or misconceptions. Inmany cases, the perceived barrier either isnonexistent or can be overcome through theright approach and effective partnershipworking at local level.

This guide is intended for local use by thosedelivering personal health budgets andpersonal budgets in social care, as a conciseguide to current learning about integratingpersonal budgets, and as a prompt for localpolicy and practice development. It toucheson issues relating to the wider challenge ofintegrating health and social care systems andservices only as necessary context for itsprimary focus – integrating personal budgets.

The guide sets out the most common real andperceived barriers to personal budgetintegration as a series of myths. For eachmyth, a response explains the issue wherenecessary, refutes the myth wherepossible/appropriate, and presents a practicalway forward. The myths were identifiedthrough consultation with pilot sites,2 the peernetwork3 and the Department of Health. Theresponses reflect current policy and practice,and draw on the collective knowledge andexperience of pilot sites that have beenengaged and consulted throughout theproduction of this guide. Where possible, weinclude direct examples of how sites haveaddressed some of the issues and concernsthrown up by each myth. In all cases weinclude references for other publications andresources that people may find helpful.

1 Introduction

The guide is divided into four sections:

n Finance and legal – Section 75, pooledbudgets, VAT and accounting.

n Culture change – risk aversion, clinicalengagement and the medical versus social models.

n Workforce – assessment, care and supportplanning, sign-off processes and jointteams.

n Information and data – strategicplanning, data protection, IT and performance.

Resources

References refer to resources at the endof each section. Where no reference isgiven the resources listed in this guide accompany its online version at:www.personalhealthbudgets.dh.gov.uk/toolkit

1 See also Department of Health. Integratingpersonal budgets – early learning. 2012www.personalhealthbudgets.dh.gov.uk

2 Personal Health Budgets Website. About the pilot programme. 2009www.personalhealthbudgets.dh.gov.uk

3 The national peer network is made up ofpeople who have a personal health budgetand family members. Some members havefounded the peoplehub personal healthbudgets network www.peoplehub.org.uk

Integrating personal budgets – myths and misconceptions

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LEGAL

Myth

We can’t give the local authority money to pay on our behalf becausethat means they are providing NHSservices, which is illegal

Response

It is not unlawful for local authorities to commission healthcare services so long as an appropriate joint fundingagreement is in place.

NHS bodies and local authorities need towork in partnership to get better value fromthe resources available and to improve healthand wellbeing outcomes across the system.There is a statutory duty of co-operationbetween NHS bodies and local authorities inSection 82 of the NHS Act 2006 (the 2006Act),4 which states that when exercising theirrespective functions, NHS bodies and localauthorities must co-operate to secure andadvance the health and welfare of the peopleof England and Wales. This can includearrangements allowing for delegation ofcertain NHS and local authority health-relatedfunctions and/or an agreement for pooling

resources, delivered under a statutoryagreement under Section 75 of the 2006 Act,or through payments made to a localauthority under Section 256 of the 2006 Act.The Audit Commission has recognised thatjoint funding arrangements are often poorlyunderstood and implemented in practice,5,6

and that the perceived complexity ofrequirements for pooled funds deters peoplefrom setting them up despite the benefitsthey can bring.

Background

n The statutory duty of partnership betweenNHS bodies and local authorities wasestablished under the Health Act 1999 and the Health and Social Care (CommunityHealth and Standards) Act 2003. Thoseprovisions are replaced by sections 75 and 256 of the 2006 Act. The 2006 Actoutlines measures to further enable HealthAct flexibilities, including making it easier to delegate functions and create jointfunding arrangements in pursuit ofpartnership objectives.

n The 2006 Act makes provision for thefunctions (statutory powers or duties) of one partner to be delivered day to day by another partner, subject to agreed terms of delegation.

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2 Finance and legal

Integrating personal budgets – myths and misconceptions

Section 75

n Section 75 of the 2006 Act enables thedelegation of functions and/or pooled fundsto be spent on agreed objectives or specificservices where each partner contributes.One party can take the lead role incommissioning, whereby partners agree todelegate commissioning of a service to alead organisation that acts on behalf of the other party. For example, a primary caretrust may manage a health budget and alocal authority budget to achieve a jointlyagreed set of aims, with the two budgetsaligned under a single commissioningfunction. This may be a sensible optiondepending on the size and make up of the service to be commissioned.

n Section 75 also enables integration ofprovision, where resources and staff arecombined to deliver a service frommanagerial level to the front line, with oneparty acting as the host. This allows theNHS to fund a local authority to carry outsome or all of the duties associated withthe delivery of personal health budgets.

n A pooled fund is a single, common fund setup to meet an agreed list of partnershipobjectives. It contains contributions towardsexpenditure on combined NHS and localauthority functions to enable the sharedresponsibility of meeting specific localneeds. Partners decide on a host body thatwill manage the pool through agreeddelegation arrangements.7

n Audit Commission research found thatpooled funds are most commonly in use forpeople whose needs cross the health andsocial care divide, most notably for learningdisabilities, mental health and communityequipment services. Formal jointexpenditure accounts for a relatively smallamount of total health and social carespend (3.4 percent in 2007/08). However,this varies considerably by location, so inthe case of many NHS care trusts (egTorbay and North East Lincolnshire) all NHS and social care funds are pooled under Section 75.

n Partners pooling funds must ensure that a signed agreement is in place along witharrangements to manage operation of the fund. The agreement should identifythe host partner, functions, agreed aimsand outcomes, levels of contributions, and relevant financial accountability andaudit procedures.

n Partners can complete a single agreementcovering multiple separate pooled fundswhere the details of each pool are set outwithin separate appendices.

Section 256

n Section 256 of the 2006 Act enablesprimary care trusts to make payments(service revenue or capital) to localauthorities to support specific services. This is a grant for additional local authorityspending, not a transfer of health functions

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to the local authority. The provision can beused to create joint budgets for integratedservices so long as the NHS ensures thearrangement represents a more efficient useof resources than if an equivalent amountwas used directly for NHS services.

n Section 256 payments do not constitute adelegation of responsibilities to providehealthcare. Primary care trusts that usethem are required independently to accountfor the delivery of any functions relating tohealth needs.

Resources

4 Sections 75 and 256 of the NHS Act 2006www.legislation.gov.uk

5 Audit Commission. Clarifying jointfinancing arrangements: a briefing paperfor health bodies and local authorities.2008 www.auditcommission.gov.uk

6 Audit Commission. Means to an end:joint financing across health and socialcare. 2009 www.auditcommission.gov.uk

7 CIPFA. Pooled budgets: a practical guidefor local authorities and the NationalHealth Service (second edition).Chartered Institute of Public Financing and Accountancy. 2009 www.cipfa.org

POOLED BUDGETS

Myth

Pooled budgets are the only way toprovide integrated personal budgets

Response

A pooled budget is not a prerequisite todelivering integrated personal budgets.

While a pooled fund agreed under Section 75can make things easier, it is not strictlynecessary and there is much that can beachieved without one. Services can be jointlyfunded through an aligned budget to meetagreed outcomes where funding streamsremain separately managed. This requiresneither a Section 75 agreement nor apayment made under Section 256. Undersuch arrangements, there is no delegation offunctions and no host partner, and thereforeeach party’s statutory duties remain their own.However, such options are often considereduseful given the perceived complexity andtechnical requirements of entering into formalpooled fund arrangements.8

For NHS care trusts, the legal basis for jointworking is a Section 75 arrangement of primarycare trust and local authority funding. The exactbasis of joint funding arrangements is unlikelyto be the most important thing affectingpeople’s experience of personal budgets.

Access to a seamless process and anintegrated personalised experience has moreto do with coherent communication and goodpartnership working than with the formal orinformal agreements that may be in place. Forexample, work done by pilot sites2 suggeststhat a shared approach to agreeing anestimated budget or to care and supportplanning has a positive impact on people’sexperience regardless of the separate back-office processes that make them possible.

It will be important for health agencies tobuild their local systems and processes so as to deliver the best possible experience for personal budget holders, rather thanforcing people to fit with what is easiest forlocal services and their existing respectivefunding arrangements. This may ultimately

involve formal budget pooling, but theabsence of such arrangements should not preclude efforts to integrate people’sexperience. Integration is not an end in itself, but a means of improving services and outcomes, so if there are simpler ways of achieving the same goals these should not be overlooked.9

Resources

8 Audit Commission. Financial managementof personal budgets: challenges andopportunities for councils. 2011www.audit-commission.gov.uk

9 NHS Confederation. Where next for health and social care integration?Discussion Paper. 2012 www.nhsconfed.org

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Example: Both NHS Oxfordshire and NHS Kent and Medway use pooled budgets. This isworking well and makes the financial process of delivering joint budgets easier and lessbureaucratic. They have found that this allows time and energy to be dedicated to care andsupport planning, arranging services and outcome-focused reviews rather than managingday-to-day discussions about who pays for what. Similarly, NHS Nottingham City is currentlyworking towards a Section 75 agreement with Nottingham City Council.

VAT

Myth

Different rules regarding VAT get in the way of integrating personalhealth budgets

Response

While it is clearly important to be awareof VAT rules and liabilities, these shouldnot prevent personal budgets integration.

Issues regarding integration, personal budgetsand VAT generally fall into two categories:those relating to the different VAT regimesthat apply to NHS bodies as opposed to localauthorities; and those relating to the differentVAT regimes that potentially apply toindividual personal budget holders as opposedto the funding bodies.

The NHS and local authorities

n NHS bodies and local authorities are subjectto different VAT regimes. NHS bodies cannotreclaim VAT as they are deemed to becompensated through their funding, whereaslocal authorities can reclaim VAT on goodsand services purchased because care servicesare not VAT rated. This has implications forintegrated personal budgets in terms ofunderstanding tax liability and where thislies, and ensuring the cost effectiveness ofarrangements for budget holders.

n Where a pooled fund is in place under aSection 75 agreement, the host party’s VATregime applies. This would apply to pooledfunds entered into to facilitate the delivery ofintegrated personal budgets. This means thatwhen a local authority delegates functions tothe NHS, it cannot recover VAT, whereas localauthorities can recoup VAT incurred whenundertaking the functions of an NHS body.

n When an NHS host acts as an agent for thelocal authority purchasing services on behalfof the partnership, VAT can be reclaimed solong as the invoice or financial report to thelocal authority clearly shows the proportionof VAT relating to expenditure to meet localauthority objectives. In all such instances,partner agencies should clarify how VAT willbe accounted for as part of the agreementand should be careful not to design partnershiparrangements so as to avoid tax.

Personal budget holders

n When budgets are transferred to people as direct payments to procure goods andservices previously purchased or provided by the NHS or the local authority, this canhave implications for the recovery of VATand for the personal budget holder.

n Concern has been raised that tax rulesdisadvantage direct payment holdersbecause local authorities can reclaim VATon care services, whereas budget holderscannot. This can reduce their purchasingpower by 20 percent as compared with the local authority, and may act as adisincentive to taking up direct payments.

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n HMRC has stated that this should nothappen in most cases as the majority ofgoods and services purchased throughdirect payments would be categorised aswelfare services and therefore exempt fromVAT.10 This can include personal care,support to live independently, and help withdomestic tasks.11 Education and vocationaltraining may also be exempt.11 Personalassistants do not incur VAT as they areemployees.

n VAT would still apply to those who taketheir personal budget as a direct paymentfor use on services that are not exemptfrom VAT, such as some day centres.Experience from social care shows that inthese situations, the person can choose tocontinue to have that part of their packagepurchased directly by the council, who canthen reclaim the VAT.

Resources

10 HMRC. Notice 701/2 Welfare. 2011www.hmrc.gov.uk

11 HMRC. Notice 701/30 Education and vocational training. 2011www.hmrc.gov.uk

ACCOUNTING

Myth

It’s not worth it – different accounting and financial governancerequirements for statutory partnersmake budget pooling just too difficult

Response

There are some different accounting andfinancial governance requirements for theNHS and local government relevant topooled budgets, but the numerousinstances of these operating across healthand social care show that they can beovercome through good planning,communication and partnership working.

The Audit Commission reported mixed viewsabout the complexities and benefits ofimplementing Section 75 legislation, highlightingthe technical and accounting challenges.5,6

A good experience of integrated personalbudgets does not necessarily depend on apooled budget being in place. Where a pooledbudget is the chosen local approach, it is importantto understand the implications of differentaccounting regimes, as well as the challengesthat personal budgets and personalisationbring to existing accounting practice.

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Difference and convergence

n Relevant financial reporting guidance forthe UK public sector is set out in the ‘NHSmanual for accounts’,12 the ‘NHSFoundation Trust annual reporting manual’13

and the ‘Code of practice for local authorityaccounting’ in the UK.14 Each sets out theprinciples and practices of accountingrequired to prepare a statement of accountto give a true and fair view of the relevantorganisation’s financial position andtransactions.

n The code for local government is producedby the Chartered Institute of Public Financeand Accountancy (CIPFA) and the LocalAuthority (Scotland) Accounts AdvisoryCommittee. The ‘NHS manual for accounts’is published by the Department of Health.

n There are differences in VAT regimes;charging; financial planning and budget-setting timetables; financial reportingarrangements; and accountability andgovernance arrangements. Many of theseare driven by national requirements.

n Differences arise because the legislativeframework for local government has notpreviously allowed for the adoption ofgenerally accepted accounting practice in anumber of areas (eg fixed asset accounting).

n Fortunately, these differences are beingeroded in a number of ways:

- from April 2010, both the NHS and localauthorities came under the international

financial reporting standards

- in May 2012, a memorandum ofunderstanding prepared by the FinancialReporting Advisory Board, which includesHM Treasury, CIPFA, the Department ofHealth and Monitor, set out thearrangements for developing financialreporting guidance for the UK publicsector; a working group is consideringproposals for greater consistency acrossthe sector and any amendments neededto relevant guidance

- the NHS Commissioning Board hasrecently confirmed the use of a commonintegrated finance and accountancysystem for use by the Board and clinicalcommissioning groups, the use of whichwill be a condition of authorisation.

n Clearly, many differences remain, and partneragencies should seek to clarify how thesewill affect the partnership in each instance.

Accounting for pooled budgets

n For accounting purposes, a pooled budget isdescribed as a joint agreement that is not anentity, the reporting requirements for whichare currently set out in the UK financialreporting standards.

n The host party is responsible for theaccounts and arranging the audit of thepooled fund. A memorandum accountprepared by the host can be used to ensure accountability and transparency by

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explaining the purpose of the partnershipand each party’s contribution and grossincome and expenditure, although this isnow discretionary.

n Partners must also agree on the process forreporting and managing surpluses anddeficits and any subsequent responsibilities.The pooled fund cannot be used to carryforward surpluses or deficits over the yearend, and each party must account for itsown share of the assets, liabilities and cashflows arising from the pool.

n The technical and accounting requirementsfor pooled funds are set out in FinancialReporting Standard 9. This stipulates thatpartners to pooled funds must report theirshare of assets and liabilities in theirrespective financial statements at the end ofthe year. This may cause problems becauseof differences between NHS and localgovernment accounting schedules (NHSbodies’ annual accounts are audited earlierin the year) and the availability of financialinformation at the right time.

Resources

12 Department of Health. NHS manual for accounts 2011–12 www.dh.gov.uk

13 Monitor. NHS Foundation Trust annual reporting manual 2011–12www.monitor-nhsft.gov.uk

14 CIPFA. Code of practice for localauthority accounting 2011–12. TheChartered Institute of Public Financing and Accountancy www.cipfa.org

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Integrating personal budgets – myths and misconceptions

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DIFFERENT FUNDING STREAMS

Myth

You cannot have a joint personalbudget for health and social carebecause there are different rules onhow the money can be used

Response

While different regimes govern the use ofhealth and social care funding, consistentprinciples should be applied within localpolicies for personal budget expenditurethat support people to make decisionsthat are right for them.

A personal budget can be used to pay forcare, items and/or services set out and agreedin a care and support plan, which meet anassessed health or social care need. Regardlessof whether the budget comes from health,social care or a combination of the two,subject to any relevant legislation, it is good

practice for funding authorities to supportpeople to make decisions about their carethat make sense to them, with as fewrestrictions as possible. The social careexperience indicates that greater value formoney and potential savings can result frompeople’s creative choices of products andservices that may be cheaper than formalservice alternatives. An example might be thecost of personal assistance to attend asporting or cultural event as opposed to thecost of a traditional day service placement.

There are a few things a personal healthbudget cannot be spent on, for example, tobuy emergency care.15 Equally, a personalhealth budget cannot be used to buy GPservices such as a medical consultation.However services recommended by GPs canbe included (eg physiotherapy).

Resources

15 Department of Health. Understandingpersonal health budgets. 2012www.dh.gov.uk

MEANS TESTED VERSUS FREEAT THE POINT OF DELIVERY

Myth

You cannot have a joint personal budgetfor health and social care because social care is means tested and the NHS is free at the point of delivery

Response

It is possible to integrate personalbudgets across health and social care inline with their respective eligibility andfunding models, including recognition ofthe fact that social care is means testedand provision of NHS services is free atthe point of delivery.

This does not mean that doing so in practiceis straightforward. This fundamentaldifference between health and social caremeans the different components of thebudget need to be dealt with separately sothat fairer charging can be applied to thesocial care element. This means being clearand upfront with people early in the processso that everyone involved understands howtheir estimated budget is calculated, whatproportion of an integrated personal budgetwill be subject to means testing, and howmuch they will be expected to contribute.

Different systems

n When the NHS was founded in 1948, theprinciple that it would be free at the pointof delivery, and based on clinical need, notability to pay, was a central component of asystem designed to ensure that good healthcarewas available to everyone, regardless ofwealth or standing.16 These principles haveguided the development of the NHS overmore than 60 years and remain at its core.Personal health budgets do not change this.

n Section 1 (3) of the 1948 Act provides thatservices must be provided free of chargeexcept in so far as the making and recovery ofcharges are expressly provided for by or underany other enactment. This prevents NHSbodies recovering charges for NHS services,unless specifically provided for in legislationsuch as the regulations that enableprescription charges (Section 172 of the 2006Act) or charges for dental and optical care.

n Unlike healthcare, social care services aresubject to means testing and charging. Underthe current system, people pay all their carecosts unless they have assets of less than£23,250 or are in receipt of NHS ContinuingHealthcare, in which case all the person’sassessed needs are provided free of charge bythe NHS.

n The regimes under which means testingoccurs differ between residential andnonresidential services. Statutory national rulesgovern means testing for residential care;17

local discretion is applied to means testing andcharging for nonresidential services, within DHfairer charging guidelines.18

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The future

n There is general recognition that the currentresources for care and support will not beadequate within the existing system infuture as a result of demographic change,earlier diagnosis and people living longerwith long term conditions.

n Options for the future funding of care andsupport are currently under considerationby the government and the outcome couldhave a considerable impact on currentmeans testing regimes.19,20

Resources

16 Department of Health. The NHS Constitution: theNHS belongs to us all. 2012 www.nhs.uk

17 Department of Health. Charging forresidential accommodation guide(CRAG). 2011 2012 www.dh.gov.uk

18 Department of Health. Fairer chargingpolicies for homecare and other non-residential social services. 2003 2012www.dh.gov.uk

19 Department of Health. Fairercontributions guidance 2010:calculating an individual's contribution to their personal budget. 2010 www.dh.gov.uk

20 Dilnot, A. et al. Fairer care funding: the report of the Commission onFunding of Care and Support. 2011www.dilnotcommission.dh.gov.uk

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Example: Many of the complexities of dealing with different funding streams and chargingpolicies can be overcome by good partnership arrangements and ensuring that clearprocedures are in place.

n A number of pilot sites have delivered integrated personal budgets, including Kent, whichfound that joint health and social care assessment helped with early identification ofcases where joint funding is likely.

n During the pilot, panel decisions have proved helpful to agree the funding split for eachperson and therefore the chargeable component. In Nottingham, this has meantidentifying a percentage split at the outset. In Oxfordshire, it has meant identifying unitsof costed health time and totting them up as a proportion of the overall budget. The splitof health and social care funding should then be detailed in the care and support plan –including any contribution from people themselves.

n When opting for a direct payment, a personal budget holder should ideally receive onepayment into their direct payment bank account to pay for their health and social careneeds (adjusted to reflect any contribution). This activity can be delegated to a lead partyunder a Section 75 pooled fund.

RISK AVERSION

Myth

Approaches to risk between health and social care are very different and it isn’t possible to bring them together

Response

It is important that health and social carestaff work together to understand whatrisks are relevant to each person to ensurethe co-ordination of good safeguardingpractice and promote a risk-enablingapproach wherever possible. This couldimprove people’s safety as a single holisticappraisal will mean fewer gaps betweenhealth and social care services.

A variety of potential risks need to be takeninto account when supporting people withhealth and social care needs, includingfinancial, clinical and personal risks. A sharedunderstanding of risks and a co-ordinatedplan for managing them is an essential part ofgood safeguarding practice and should not beconsidered a barrier to integrated personalhealth budgets. Rather, there needs to be ashared responsibility for working jointly andconsistently with people with health andsocial care needs to identify risks and managethem in ways that make sense to them.

Department of Health guidance emphasisesthe need for a joined-up approach:

Developing multi agency policies can helpensure that there is a positive and joined-upapproach to risk across the wholecommunity.21

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3 Culture change

Example: Many personal health budget pilot areas have taken steps to enhance andimprove joint management of risks. North East Lincolnshire Care Trust has developed shareddocumentation for health and social care staff to use in assessing risk, and has established ajoint panel to review care and support plans where specific risks are identified.

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In 2011, the Social Care Institute forExcellence together with NHS London, theMetropolitan Police and the Association ofDirectors of Adult Social Services published apan-London, multi-agency policy forprotecting adults at risk,22 which highlightsthe need for a collective approach that needs to be seen as everyone’s business. The foreword states:

In London, as elsewhere, the main statutoryagencies, local councils, the police and NHS organisations – need to work togetherboth to promote safer communities toprevent harm and abuse and to deal wellwith suspected or actual cases…It is our firm belief that adults at risk are bestprotected when procedures between statutory agencies are consistent…

Resources

21 Department of Health. Practical approachesto safeguarding and personalisation. 2010www.thinklocalactpersonal.org.uk

22 Social Care Institute for Excellence.Protecting adults at risk: Londonmultiagency policy and procedures tosafeguard adults from abuse. 2011www.scie.org.uk

CLINICAL EVIDENCE

Myth

NHS money can’t be used for treatments and services not endorsed by NICE, and integratedpersonal health budgets make this more difficult

Response

There is no prohibition on using personalhealth budgets for treatments andservices not endorsed by the NationalInstitute for Health and Clinical Excellence(NICE),23 although these should be agreedwith a clinician. Where health and socialcare staff are working togethereffectively, integrated personal healthbudgets should not make this processmore difficult.

Personal health budgets can be used fortreatments that have not been reviewed byNICE. Indeed not all services currentlycommissioned by the NHS have beenconsidered by NICE. People will need to havethe right information to enable them to makeinformed decisions about what to use theirbudgets for. Where NICE has reviewed atreatment and concluded it is not costeffective, but someone wants to use theirpersonal health budget to buy the treatment,the request would need to go throughexisting local exception processes.

In circumstances where the planned use of abudget is not approved, the healthorganisation should clearly communicate thereasons for refusal, for instance if a chosenprovider is not a member of relevantregulatory bodies.

Where people have personal budgets to meethealth and social care needs the sameprinciples should apply. In such instances, careand support planners have an important roleto ensure they provide correct advice andguidance, help to manage people’sexpectations about what is possible, anddirect people to more specialist advice whereneeded. Care and support planners shouldknow who to involve in the planning processand should take care to engage with the leadclinician – particularly around complementarytherapies and where there is little experienceof people using alternative treatments orprovisions. Where people are usingnontraditional services and treatments,

it is particularly important that reviews areused to check outcomes are being met andfunds are being used appropriately. Manypilot areas that have built up experience ofpeople using budgets in nontraditional waysemphasise the importance of sharing people’sstories with clinicians and frontline staff, asthis helps to build confidence in permittingpeople to use their budgets in ways thatmight seem unusual but ultimately couldimprove people’s health and wellbeingoutcomes. The Department of Health iscurrently working with NICE to look at thisarea in more detail and expects to make more information available to support theNHS with these issues.

Resources

23 NICE guidance www.nice.org.uk

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EQUALITIES

Myth

Personal budgets for health and social care will work only for peoplewho understand the system and havethe time and skills to navigate it to get what they want

Response

It is imperative that those tasked withimplementing personal budgets acrosshealth and social care do so in a way thatensures equal access and opportunity foreveryone who might benefit, regardlessof background, age or condition.Learning from personal budgets in socialcare suggests this is possible with theright approach.24

The requirements on public bodies in England,Scotland and Wales in relation to equalitiesand human rights that are applicable to theimplementation of personal budgets are setout in the Equality Act 2010.25 The Actincludes a new public sector equality duty,Section 149, which came into force in April2011.26,27 The public bodies to which the duty applies including health bodies and localauthorities, are set out in Schedule 19 of theAct. Part of the general duty sets out thatpublic authorities must, in the exercise of theirfunctions, advance equality of opportunity by:

n removing or minimising disadvantages

n taking steps to meet the needs of peoplewhere these are different from the needs ofother people

n encourage people to participate where theirparticipation is disproportionately low.

In particular, the duty states that meetingdifferent needs includes (among other things)taking steps to take account of needs of olderpeople and people with a disability. The dutyalso relates to equalities in terms of age,gender, race, religion and sexuality. To have dueregard to the aims of the equality duty, publicbodies need to understand the potentialimpact of their decisions and identify mitigatingsteps to reduce or remove any potentiallyadverse impacts for different groups of people.Personal budgets for social care are intended tobe universally available to everyone who iseligible who could benefit from them.

Personal health budgets have been testedthrough the pilot programme2 for a broadrange of healthcare needs and long termconditions. However, many people struggle tounderstand and navigate the health and socialcare system, and without the rightinformation, advice and advocacy, accessingand making good use of personal health andcare budgets can be difficult.

The largest ever survey of people usingpersonal budgets, conducted in 2011 (thePOET survey),28,29 found that most peopleexperienced significant benefits over andabove those attributable to traditional

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Integrating personal budgets – myths and misconceptions

services. It found that the benefits offeredwere fairly universal, stating that in terms ofequalities monitoring there are no differencesin outcomes according to gender, ethnicity orreligion. In particular, the survey noted thatolder people received the same benefits asothers from personal budgets and directpayments, so long as the right informationand support was available. This is reflected inthe experience of the Oxfordshire personalhealth budgets pilot, where older peoplereceiving NHS Continuing Healthcare havebeen supported to recruit personal assistantsusing direct payments.

There is also evidence that personal budgetscan work well for people with a mental healthdifficulty. The individual budgets pilot evaluationreport of 200830 compared the experiences ofpeople using individual budgets with thoseusing traditional services, and found that

mental health service users in the individualbudgets group reported significantly higher quality of life than those in thecomparison group.

Research by the Social Care Institute forExcellence31 shares a wealth of learning fromthe experience of older people and those withmental health problems about personalbudgets and direct payments. This illustratesthat although older people and mental healthservice users are likely to benefit greatly frompersonal budgets, there can be attitudinal andcultural obstacles to people from both groupsbeing offered different ways to managepersonal budgets, in particular direct

payments. In response to such findings, recentguidance from Think Local Act Personal32

recommends that to make personal budgetsand direct payments more universal, actionneeds to be taken in the following main areas:

n reducing unnecessary process andrestrictions and increasing flexibility

n improving equality of access

n providing good information and adviceabout personal budgets and how they can be used

n improving delivery of both direct paymentsand managed personal budgets

n developing and engaging the provider market.

Resources

24 Department of Health. Personal budgets forolder people – making it happen. 2010www.thinklocalactpersonal.org.uk

25 Equality Act 2010 www.legislation.gov.uk

26 Equality and Human Rights Commission. The essential guide to the publicsector equality duty. 2012www.equalityhumanrights.com

27 Equality and Human Rights Commission.Meeting the equality duty in policyand decision making. 2012www.equalityhumanrights.com

28 In Control and Centre for DisabilityResearch, Lancaster University. POET –the Personal Budgets Outcomes and Evaluation Tool. 2011www.incontrol.org.uk

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29 Hatton, C. and Waters, J. The nationalpersonal budget survey. Think Local ActPersonal. 2011 www.incontrol.org.uk

30 Social Policy Research Unit, University ofYork. Evaluation of the individualbudgets pilot programme. 2008www.dh.gov.uk

31 Social Care Institute for Excellence.Keeping personal budgets personal:learning from the experiences of olderpeople, people with mental healthproblems and their carers. 2011www.scie.org.uk

32 Routledge, M. and Lewis, J. Personalbudgets: taking stock, moving forward.Think Local Act Personal. 2012www.thinklocalactpersonal.org.uk

MEDICAL MODEL

Myth

There is an unbridgeable gap between the medical and social models of care which makes integration impossible

Response

In the social model of disability, disability isdefined as the disadvantage experiencedby a person as a result of a broad range ofexternal barriers. These can range frominaccessible public spaces and transport tosegregation in education, all of whichmake inclusion more difficult for peoplewith impairments and/or ill health. Themedical model of disability sees disabilityas a functional deficit – either physical orpsychological, which resides in the personand requires them to adapt as best as theycan to their environment. Adopting andembedding an understanding of the socialmodel of disability continues to be anintegral part of the modernisationagenda within the NHS.33

The social model of disability is an importantthread running through many other aspects ofgovernment policy on health and social care,and is central to personal health budgets.34

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People with health needs should alwaysremain at the centre of decision making abouthow resources can best be used to maintainand improve their health and wellbeing.Personal health budgets allow a more flexibleapproach, where health professionals cansupport people to use resources in ways thatmake the most sense to them and give themthe best chance of maximising the benefitsfrom the treatments and services they receive.

There are many instances where people canmeet their health needs using approachesthat might not look anything like traditionalhealth services. Allowing people to try newthings that might better meet their health andwellbeing outcomes is vital to the success ofany local personal health budgets programme.Health and social care professionals should beengaged throughout the development ofpersonal health budgets to ensure theyunderstand the importance of enablingpeople to take more control over their healthand wellbeing and are confident in thesystems and checks in place to ensure peoplecan use personal health budgets safely.

Resources

33 PM Strategy Unit. Improving the lifechances of disabled people. 2005. p. 88www.cabinetoffice.gov.uk

34 Office for Disability Issues. The socialmodel of disability. 2010 odi.dwp.gov.uk

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CLINICAL ENGAGEMENT

Myth

Personal health budgets will fail because they are not supported by health clinicians

Response

Many of the values underpinningpersonal health budgets mirror theprofessional codes of ethics and standardsthat drove many to enter their chosenprofession within the health service, andthere are many examples of healthprofessionals who are supportive of them.

For example, the College of OccupationalTherapy code of standards35 makes explicitreference to the need for practitioners to enablepeople to optimise their independence, focuson outcomes and promote choice and controlfor people with support needs – principles thatare also central to personal health budgets.

Developing the infrastructure to deliver personalhealth budgets and integrated personal budgetsacross health and social care is central to

government policy. By April 2014, peopleeligible for NHS Continuing Healthcare will havethe right to ask for a personal health budget,including a direct payment for healthcare. TheNHS will also be able to offer personal healthbudgets more widely – for example to peoplewith long term health conditions or people withmental health problems who could benefit.

Laying the future foundations for this should bea strategic priority for all primary care trusts andclinical commissioning groups through theirtransition planning, even where there areconcerns among clinicians.

Evidence suggests that the issues that mostconcern frontline staff and clinicians who havenot yet worked with personal health budgets arenot shared by people who have had directexperience of working with them. A report bythe NHS Confederation in March 201136 foundthat the main concerns of staff who had yet towork with personal health budgets were thatbureaucracy would subsume the potentialbenefits, and that enabling people to haveadditional choice could serve to undermine goodclinical judgment. Early evidence from pilot sitessuggests that such concerns are not borne out inpractice and that the positive impact felt bypeople using personal health budgets serves to

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Example: At the South London and Maudsley (SLAM) NHS Foundation Trust, it becameclear that it is important to engage commissioners and clinicians early in the developmentof systems to deliver personal health budgets. The Trust has found that co-production andrelationship building is the key to success, and has appointed a dedicated champion to leadthe agenda and bring people together.

increase staff engagement and confidence inthem over time. Personal health budgets canenable health professionals to support andempower people to take more control over theirhealth and wellbeing without compromisinggood clinical judgment. There are many examplesof people using personal health budgets to greateffect, in some cases leading to significantimprovements to health and wellbeing. The jointworking needed to deliver integrated personalbudgets will enable health professionals tobenefit from the experience of social care staffwho have been through a similar progressthrough uncertainty to greater confidence inhow personal budgets can work for people.

All primary care trusts and clinicalcommissioning groups should ensure thatclinicians and commissioners, along withfrontline staff and people using health services,understand the benefits that personal healthbudgets can offer people and play an active rolein developing the systems for ensuring they aremade available safely to people.

Resources

35 College of Occupational Therapists.Professional standards for occupationaltherapy practice. 2011 www.cot.co.uk

36 NHS Confederation and National MentalHealth Development Unit. Facing up tothe challenge of personal healthbudgets. 2011 www.nhsconfed.org

CO-PRODUCTION

Myth

Meaningful engagement with people is easier in social care – people usinghealth services are often ill and do notwant to engage in this way

Response

Many pilot sites have found wayssuccessfully to engage people with healthneeds and their carers – while the languageof co-production is less common in healththan in social care, there are manyexamples of how this is working in practice.

From 2013, as part of the Health and SocialCare Bill proposals, all clinical commissioninggroups must be able to demonstrate they haveappropriate mechanisms in place to involvepeople with healthcare needs and their widercommunities before they can attainauthorisation. Commissioners need to getbetter at capturing the experiences of peopleusing health services and using thatinformation to drive the way the system worksto support them. Health and wellbeing boardsalso have responsibilities in this area.37

In November 2011 the NHS Confederation38

published a brief discussion paper about publicand patient engagement in the newcommissioning environment, which manypeople have found useful. In relation topersonal health budgets, developing ways tocapture, understand and harness information

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from people using budgets about what is andisn’t working for them will be vital to theirsuccess. That is not to say that people shouldbe forced to engage, but they should have arange of options to do so, and healthorganisations should make it clear that theyvalue the information people share about theirexperiences and are committed to using it toimprove services.

Resources

37 NHS Confederation et al. Operatingprinciples for health and wellbeingboards: laying the foundations forhealthier places. 2011www.nhsconfed.org

38 NHS Confederation. Patient and publicengagement in the new commissioningsystem. Discussion paper 11. 2011www.nhsconfed.org

39 Think Local Act Personal. Working togetherfor change: using person-centredinformation for commissioning. 2009www.thinklocalactpersonal.org.uk

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Example: Many of the personal health budget pilot sites have involved people with health needs in the governance of local pilots alongside clinicians and social and healthcaremanagers. In Teesside the NHS has used a best practice methodology for engaging people, using aggregated and person-centred information from people with health needsto influence strategic decision making. The process, called ‘Working together for change’,has been adopted with support from local authority partners who have worked with health colleagues to develop their expertise in using this methodology routinely to improve services.39

ASSESSMENT AND CARE AND SUPPORT PLANNING

Myth

Health and social care professionalsdon’t have the skills needed or thetraining available to provide anintegrated approach to assessment or care and support planning

Response

Developing the workforce to be able todeliver an integrated approach toassessment and care and support planningshould be a core part of any localworkforce development strategy.

Many pilot areas, including NHS Kent andMedway, have engaged people using budgetsin training frontline staff. They have foundthis an effective way of communicating theimportance of personal health budgets and

gaining buy in from staff to new ways of working.Such an approach can sit well alongside othertraining to help staff learn new skills.

Not all tasks involved in delivering personalhealth budgets will necessarily fall to frontlinestaff. In particular, developing a care andsupport plan is not a task that health andsocial care staff are required to do. Experiencehas shown that often community-basedorganisations are much better placed to helppeople develop a care and support plan. Thisis because good care and support planningrequires a set of skills and competencies thatare about working with people holistically tomeet their needs and aspirations, skills thatare not exclusive to health and social careprofessionals. Some professionals will alreadyhave these skills. However, there is muchevidence from social care that people oftenprefer to get the support they require fromindependent people and organisations ratherthan from health or social care professionals.As a result, a number of councils have begunto outsource care and support planning totheir local voluntary sector and to build

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4 Workforce

Example: As part of workforce development planning, NHS Kent and Medway held a half-day workshop that brought together health and social care staff to look at integratedbudgets. During the session, staff had the opportunity to work together to complete casestudies and complete a self assessment to look at training and development priorities. Using this information, a joint health and social care steering group was set up to deliverintegrated training sessions.

greater capacity for peer support. Dependingon health and social care need, furtherprofessional input and expertise will continueto be part of the care planning process.

Statutory duties require health and social carebodies to conduct relevant assessments ofneed and to set a clear framework fordelivering a care and support plan. Beyondthat, there should ideally be a range of careand support planning options available topeople. Once the care and support plan iscomplete, it is for health and social careprofessionals to ensure conditions have beenmet to enable plans to be signed off. Wherelocal decisions are made to involve health andsocial care staff in care and support planning,it will be important to complete a workforcedevelopment plan, looking at what skills theywill need to be able to do this well.

Staff can also use other ways to support theirown learning and development. In setting theiryearly action plans, staff should aim to identifyongoing development opportunities aroundhealth and social care integration. Regularsupervision is equally essential to provideongoing support to staff. Helping staff to beclear about their roles and responsibilities isalso central. In some cases, this may meanreviewing existing job descriptions.

Examples

n Joint care and support plan (Doncaster)

n Care and support planning guide(Nottingham City)

RESOURCE ALLOCATION

Myth

Joint personal budgets for health and social care need an integratedapproach to budget setting, which is way too complicated

Response

It would be ideal to have a singleapproach to budget setting, but this is by no means necessary to deliverintegrated personal budgets.

Experience so far suggests that an integratedbudget-setting system is very difficult toachieve and would require a significantamount of time and effort. So far this has not been felt to be a worthwhile endeavour.

Most pilot sites have been using parallelsystems for setting budgets, and workinghard to make them work as seamlessly aspossible. In Doncaster the primary care trustuses an indicative budget-setting tool for fully funded NHS Continuing Healthcare. For people with only social care needs, thelocal authority has its own resource allocationsystem, and where there is a jointresponsibility to meet needs, staff from bothorganisations work out how best to meettheir respective responsibilities and the mostappropriate split of funding in order toprovide as seamless a service as possible.

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When a patient becomes eligible for fullyfunded NHS Continuing Healthcare, althoughthe funding stream changes, the delivery ofcare is still progressed by the joint health andsocial care team.40 This ensures mainstreamsocial care is provided in addition to anyidentified health needs.

Experience more generally from the pilot sitesseems to confirm that the most importantfactor for any local system is the person’sexperience of how simple and seamless theoverall process is.

Resources

40 Department of Health. Setting budgetsfor NHS Continuing Healthcare. 2012www.personalhealthbudgets.dh.gov.uk

SIGN OFF

Myth

An individual worker can't sign off an integrated package. They will have a good understanding of only one aspect – health or social care

Response

Many pilot sites are already empoweringfrontline staff to sign off integratedbudgets for people whose needs are nothighly complex. With the right trainingand support, it is possible – andpreferable – for a single practitioner tosign off an integrated budget, with inputfrom colleagues where necessary.

Developing such an approach can be adifficult undertaking – people’s needs arediverse and some health needs are veryspecific and complex, especially where thereare multiple conditions. A clear understandingof where decisions can safely be made by asingle practitioner is an essential prerequisitefor making this possible.

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Staff need training in the care and supportplanning process to build confidence, andshould be supported to understand therequirements across both systems to enablean integrated approach to sign off. It isneither effective nor efficient to involve toomany people in the sign-off process. Someareas use joint panels as a means to ensurejoint sign off, although this can lead toincreased bureaucracy and delays. Panels areonly necessary and useful when consideringcomplex cases where there may be somesignificant issues that need to be understoodand accommodated before a decision can bemade. In most cases, sign off should be asimple decision taken at practitioner level –though in health there will always need to beclinical governance of the process in somecapacity, which can be defined locally.

Empowering staff to make such decisions inall but high-risk cases is likely to be a moreeffective and less resource-intensive solution.Frontline staff need to understand the wholeprocess, from assessment to budget settingthrough to care planning and outcomesmonitoring, so that they feel comfortable withmaking decisions. Where people are notconfident to do this, it should be possible totake a plan to a team meeting and talk itthrough. Clear exception processes are neededto ensure that where more input is needed, thiscan be clearly identified and additional expertisebrought in swiftly to assist decision making.

Example

n Support plan review template (Tees)

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Example: NHS Kent and Medway is moving forward with its integration programme, and has appointed a single manager for health and community services. This has helped to integrate the decision making process and makes it easier to devolve decision makingwhere appropriate.

PANELS

Myth

Joint personal budgets for health and social care will mean more timespent at panel meetings

Response

Panels are not a prerequisite for signingoff integrated personal budgets.Experience from the pilot programme andsocial care suggests they should be usedin limited circumstances rather than as acore part of the process.

It is important to have a robust process inplace to sign off of care and support plans,whether these are for health, social care orintegrated personal budgets. In health, thereis an additional requirement to ensure

adherence to clinical governance. Whilehealth and social care bodies commonly usepanels, they are rarely the most efficient oreffective way of supporting local decisionmaking around sign off.

In some cases, the costs and staff timeassociated with running and attending panelmeetings can far outweigh the value of thepersonal budgets under scrutiny. Panel decisionstake time, and the deference to professionalopinion, while justifiable in some circumstances,can undermine the personal choice and controlthat personal health budgets are intended touphold. Experience from social care shows thatpanel meetings and their outcomes are a sourceof considerable anxiety for personal budgetholders, who are usually excluded from theirdeliberations and find their judgments difficultto understand. Panels should be used onlywhen strictly necessary, and other moreproportionate methods of signing off personalbudgets should be explored.

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Example: NHS Norfolk has decided that panel meetings are not the most efficient method of sign off for integrated budgets in most instances. Instead, responsibility isdevolved to key workers. NHS Doncaster has produced guidance for staff that allows robust initial decision making, which helps to minimise process and reduce unnecessarybureaucracy. Experience has shown that personal health budgets often result in moreholistic packages of care and better outcomes. This has boosted confidence in delegateddecision making and reduced the use of panels.

One way of doing this is by giving a socialworker, health professional or other staffmember the authority to approve plans.Where a joint sign off is needed, this can bedone via email or by two people meeting faceto face, but the bulk of the work can still bedone individually rather than in a panelmeeting. Where a key worker has theauthority to sign off plans, clinical governancecan be done behind the scenes, rather thantaking the personal health budget holderthrough a drawn out decision making process. This has the dual benefit of givingpeople the choice and freedom to meet theirneeds and enabling the key worker to supportthem in doing so without recourse to toomuch process. This helps to change thedynamic from having the key worker acting asa barrier to care, to actively working to helpmeet someone’s care needs with the budgetprovided. A reduction in using panels shouldalso speed up the process of getting apersonal budget – an important considerationas research in social care shows that thedelays and difficulties people experience inaccessing personal budgets have had asignificantly negative impact on people’sexperience and outcomes.

JOINT WORKING

Myth

Joint teams are needed to provideintegrated personal budgets, which is complicated and time consuming

Response

While delivering integrated personalbudgets inevitably involves health andsocial care staff working together moreclosely, many areas have succeeded indoing so without creating joint teams.

Delivering integrated personal budgets canfeel like a complicated undertaking, and thereare many challenges to overcome in addressingfragmentation between health and social careservices. There are strong established traditionsof integrated working across differentorganisational boundaries to develop integratedpathways in areas such as long term conditionsand rehabilitation, where commissioners andproviders work together successfully to delivergood outcomes for people.

Joint teams are one approach people havetried, but they are not the only way – a lot canbe achieved through good communication,openness and the commitment and enthusiasmof staff, regardless of where they are sitting.While it can be time consuming initially toestablish the mechanisms and understandingthrough which joint working can happen, this

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should not be an ongoing requirement oncethe customer journey and associated processeshave been mapped and agreed.

In practical terms, health and social care staffcan be brought together through meetings andworkshops to discuss the best approach todeveloping and delivering integrated personalbudgets. Staff will need support to understandthe roles they will play and how they can bestwork together. They will also need and timeand support to familiarise themselves with eachother’s systems and processes. This can bedone through joint training, backed up by clearguidance and procedures.

Health and social care professionals oftenneed to contribute jointly to assessing aperson’s needs, and should continue to liaise

throughout the process until the personalbudget is set up and running well. Jointworking at the assessment and planningphases should result in people receiving morejoined-up, holistic support. Accountability andrisk should be shared across bothorganisations, and process and governanceapplied in a similar way. The goal is to providea seamless service, which can empowerpeople to take more control in managing theirhealth and wellbeing, regardless of whetherjoint teams are in place behind the scenes.

Example

n Joint self-assessment questionnaire(Doncaster)

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PLANNING AND REPORTING

Myth

The differences in strategic andfinancial planning cycles and prioritiesmake integration difficult

Response

Although there are many differences,health and social care organisations havesimilar cycles and processes for strategicand financial planning, and their prioritiesoften converge. These synergies willstrengthen as health and wellbeingboards take on their new roles andresponsibilities.

There are some specific differences relating tofinancial governance and accounting cyclesthat are outlined in the section on accounting(page 10). Health and social care services haveshared responsibility for delivering betterhealth and wellbeing outcomes for peoplewith care and support needs, and forimproving the quality and continuity ofservices. These shared responsibilities are true,irrespective of whether formal pooled fundingarrangements are in place.

Integration is driven by the recognition thathealth and social care outcomes areinterdependent. In the current financialenvironment, it is even more important thatpartnerships across health and social care helpto target resources better and preventduplication. From 2013, health and wellbeingboards37 will become a focal point for localdecision making, with the responsibility forfacilitating joint working between clinicalcommissioning groups, local authorities andother stakeholders. These new arrangementspresent new opportunities for system-wideleadership to improve health outcomes andhealth and care services, as well as links to the wider determinants of health, includinghousing, leisure, transport, education andemployment.41,42 Boards will have an explicitduty to promote integrated working, andtheir main purpose is to drive improvementsin health and wellbeing by promoting jointcommissioning and integrated delivery. The role of health and wellbeing boards incarrying out joint strategic needs assessmentswill enable a direct route into strategicplanning through joint health and wellbeingstrategies. The new boards can best be seenas a forum for shared leadership that placesequal responsibilities on councils and the NHSto work towards shared priorities, includingthe delivery of integrated personal budgets.

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5 Information and data

Resources

41 Local Government Association. New partnership, new opportunities: a resource to assist setting up andrunning health and wellbeing boards. 2011 www.idea.gov.uk

42 Department of Health. Joint strategicneeds assessment and joint health andwellbeing strategies explained. 2011www.dh.gov.uk

CONFIDENTIALITY

Myth

Sharing information between healthand social care is difficult and thisundermines integration

Response

It is not unduly difficult to shareinformation between health and socialcare organisations so long as agreementsand processes are in place to share datasafely and appropriately within thelegislative safeguards provided by theData Protection Act 1998.43

Sharing information effectively in health andsocial care is a critical building block towardsintegration. Without data sharing, people areforced to grapple with a system thatduplicates processes and misses opportunitiesto improve the co-ordination, delivery andexperience of care and support services. Thereare important legislative safeguards in place toensure people’s rights are protected, and localprocesses must be robust to ensureinformation is shared safely and compliantly.The Data Protection Act 1998 is the mainpiece of legislation governing the protectionof personal data in the UK, and anyorganisation holding personal informationmust comply with the 1998 Act.

The need to facilitate better informationsharing is at the centre of a number of recentdevelopments in policy and practice. In 2012,the DH published a new information strategy,44

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which sets out a ten-year framework androute map to lead a transformation in theway information is collected and used. Thestrategy sets out the ambition that informationbe used to drive integrated care across thehealth and social care sector, underpinned bysystems that ensure information is recordedonce at first contact, then shared securelybetween those providing care while keepingconfidential information safe and secure. Thestrategy also describes the important role ofculture change and IT, including electroniccare records. In parallel, a three-year commonassessment framework programme45 isdrawing to a close, where a number of siteshave been testing and refining systems tofacilitate better information sharing betweenhealth and social care IT systems.

Defined protocols can be used to improve thecommunication between organisations and tofacilitate a more seamless and integrated careand support experience. Explicit and informedconsent needs to be sought early on in theassessment process to ensure peopleunderstand why and how data might be

shared, and with whom. Where there arecapacity issues affecting people’s ability toconsent, relevant guidance derived from theMental Capacity Act 200546 (including thecode of practice) should be followed todetermine whether the person is able to makethe decision and that appropriate steps aretaken to protect their best interests.

Resources

43 Data Protection Act 1998www.legislation.gov.uk

44 Department of Health. The power ofinformation: putting us all in controlof the health and care information weneed. 2012 informationstrategy.dh.gov.uk

45 NHS Networks. Common assessmentframework lessons learnt – overview. 2012 www.networks.nhs.uk

46 Mental Capacity Act 2005www.legislation.gov.uk

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Example: A good example of a local process is Devon’s protocol for sharing person-identifiable information between health and social care organisations, available online at:www.devon.gov.uk/index/socialcare/policies-procedures-guidance/organisationalprocesses/info-sharing-protocol.htm A consortium of ten health and social care organisations acrossHampshire, Portsmouth and Southampton has produced a pan-Hampshire information-sharing protocol. This commits each organisation to share information, so that people usinghealth and social care services experience a more joined-up approach and are not asked forthe same information by each organisation separately.

IT SYSTEMS

Myth

It's pointless trying to offer jointpersonal budgets for health and social care because our IT systems don't speak to one another

Response

Integrating personal budgets is certainlymade more difficult when local IT systemsdo not talk to each other, but there areplenty of ways of making progresswithout waiting for the ideal IT solution.

IT plays a critical role in enabling health andsocial care systems to run smoothly, andfragmented information systems can result indelays, duplication and extra costs. Ensuringthat IT systems are well aligned is a centralpart of the government’s plans for integratinghealth and social care services and is centralto the recent information strategy publishedby the Department of Health.44

There are a host of different IT systems in usein health and social care, from internal casemanagement and client data systems, throughto outward-facing information systems andweb portals. Lining these up so thatinformation moves in a timely and secure wayaround the system and is available when andwhere it is needed is a massive challenge.

Systems often work in isolation and are notdesigned to interact with other systems; datatend to be entered multiple times; and inmany cases IT systems have their ownstandards that may not work with othersystems. A report from the AuditCommission47 notes that local authoritiesoften do not have the capability to use thedata they have and highlights resultinginefficiencies and impacts on service qualityand user experience.

There are also numerous examples whereorganisations are breaking new ground interms of IT and effective information use. Thecommon assessment framework for adultsdemonstrator programme45 has seen anumber of sites test new approaches toinformation sharing to ensure that commondata follows a person through the system.This includes a range of approaches, fromusing secure email to linking local health andsocial care IT systems via the NHS spine andthe development of shared customer portals.The learning from the programme is availableon the NHS Networks website.

While significant progress can take time,much can be done to work around issues inthe short term. Integration between systemson a particular issue (with specific workflowand data requirements) is not as difficult ascreating a new or merged system. With aclear vision of the information you want toshare, there are plenty of ways to worktogether to ensure data sharing happenssafely and effectively. There are a range of

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options, from simple solutions using existingtechnology (eg secure email) through tosecure portals to allow different organisationsto access each other’s information, to fullystandardised solutions such as the NHSinteroperability toolkit.48 Local information-sharing protocols are particularly helpful.

Resources

47 Audit Commission. Is there something I should know? Making the most ofyour information to improve services.2009 www.audit-commission.gov.uk

48 NHS Interoperability Toolkitwww.connectingforhealth.nhs.uk

PERFORMANCE

Myth

The quality and performance regimes in health and social care are different,which makes integration difficult

Response

Health and social care do have differentperformance regimes, but this does nothave to hinder integrated working giventhe shared responsibility to improvehealth and wellbeing and the recent shifttowards systems that measure outcomes.

There have been a number of importantdevelopments in recent times that should helpbring health and social care closer together,including the development by the Departmentof Health of outcomes frameworks for the NHS,public health and adult social care.49 Theseframeworks use outcome measures rather thaninputs and outputs to determine the outcomesfor people and communities of health andsocial care interventions. Together, the threeframeworks are designed to provide localpeople and organisations with evidence-basedmeasures to help judge the success of servicesacross the health and social care system.

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While the frameworks are different, they areintended to work together to enable healthand social care systems to be held to accountfor the outcomes delivered and to reflect thecollective effort needed to deliver improvedhealth and wellbeing. The NHS outcomesframework is a tool through which theDepartment of Health can hold the NHSCommissioning Board to account for theoutcomes delivered in the NHS. The adultsocial care outcomes framework comprises aset of outcome measures, which have beenagreed to be of value both nationally andlocally for demonstrating achievements inadult social care. Similarly, as part of the wide-ranging changes to the health service, thenew NHS Commissioning Board will beagreeing a commissioning outcomesframework. This is a lever between the Boardand clinical commissioning groups by whichhealth outcomes can be measured andpriorities set. The framework will be used tohold clinical commissioning groups to accountfor the health outcomes and quality of carethey achieve (including patient-reportedoutcome measures and patient experience),and will be operational from April 2013.

At a local level, good joint working and aperson-centred approach, which focuses onthe person’s needs rather than those of theorganisations involved, can go a long way toensuring good practice. Developments such asthe outcomes star in mental health haveproved useful, and tools such as POET28 and‘Working together for change’39 can helpcapture and use vital information about howwell services are working.

Resources

49 Department of Health. Transparency inoutcomes: a framework for quality inadult social care. 2011 www.dh.gov.uk

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OUTCOMES

Myth

Health outcomes are often very specific and can’t be integrated with other health outcomes or with social care

Response

An integrated approach to outcomes is animportant component of the shifttowards integration in health and socialcare. When a holistic approach is taken toa person’s outcomes, all their outcomesbecome linked.

The lack of a shared view of outcomes acrossthe system currently causes confusion and cancreate disincentives. For example, publichealth expenditure on a stop smoking servicecan accrue benefits to the NHS budget (eg ifit leads to a person not contracting lungcancer), despite the origin of the initialexpenditure. One of the main drivers forintegrated personal budgets lies in thepotential to remove this divide by putting theperson at the centre. By taking a holistic viewof people’s lives, we can avoid imposingcategories that are meaningless to people ontheir needs and aspirations.50

The NHS Future Forum report recommendspulling together a basket of indicators fromacross the three outcomes frameworks (seeabove) to be used by health and wellbeingboards.51 At the level of individual outcomes,

a number of pilot sites have developedintegrated approaches to personal care andsupport planning so that people don’t have tocreate separate plans for the health and socialcare components of their budget. Thisinvolves people identifying the outcomes thatare right for them with the support theyneed, regardless of whether they relate tohealth or social care. There will inevitably beoverlaps, and good personal care and supportplanning should help identify these. Workingfrom a single plan where people identify theirown outcomes will help bring different partsof the system closer together.

Several pilot sites have been workingalongside In Control to develop a process forunderstanding outcomes for personal healthbudget holders as an equivalent to thepersonal outcomes evaluation tool (POET)used in social care.28,29 It is striking that whenstarting from the person rather than theservice, the information needed to understandpeople’s outcomes is remarkably similar.

While some outcomes may require very specificmeasures that are not jointly owned, the morewe can do to foster a shared understanding ofoutcomes across the system, the more effectiveintegrated personal budgets will be.

Resources

50 Think Local Act Personal. Changing livestogether: using person-centred outcomesto measure results in social care. 2010www.thinklocalactpersonal.org.uk

51 NHS Future Forum. Integration. 2012www.dh.gov.uk

39

Integrating personal budgets – myths and misconceptions

Gateway Ref No. 18286

Personal health budgets team

Websites: www.personalhealthbudgets.dh.gov.uk/toolkitwww.nhs.uk/personalhealthbudgets

Email: personalhealthbudgets@dh.gsi.gov.uk

Department of Health customer service centre: 020 7210 4850