Examples from emerging practice for integrating personal budgets for people with mental health problems
Practice example 1: Lambeth
In Lambeth, integrated personal budgets started in July 2012 when the clinical commissioning group put some money into the existing social care pot. This pooled budget is hosted by Lambeth Council and agreed by the clinical commissioning group. Lambeth had about 50 integrated budgets in action as of February 2014. When a budget is approved, a decision is taken about the percentage to be divided between health and social care (often 50:50).
Once the budget is set, a worker from the voluntary sector Community Options team will usually work with the individual as a broker to produce a support plan. Community Options is independent of both health and social care services; workers have a good knowledge of community resources and are more able to think ‘outside the box’. Examples of things that people have spent their budgets on include: seasonal affective disorder (SAD) lights, gym membership, SKY TV, removal fees and a gravestone.
All mental health team staff receive training in support planning (one day) and recovery support planning (one day), and the personalisation coordinator often goes into teams as part of their development.
The service has reviewed its procedures with the aid of an external consultant in order to cut down on bureaucracy. Currently, non-integrated budgets are signed off at team level and the plan is for this to be done with integrated budgets.
- A pooled budget makes it possible to provide integrated personal budgets.
- The system works because key people want it to work and are very flexible.
- Risk remains an issue for some staff; there are concerns that if things go wrong they will be blamed.
- The capacity of care coordinators is a concern due to the increased bureaucracy involved.
Practice example 2: West Sussex
West Sussex has well-established structures to support integrated budgets, having implemented personal budgets and self-directed support early on. It has had integrated mental health teams for over 10 years for adults of working age. The local authority hosts a joint commissioning unit.
Currently (2014), West Sussex has approximately 150 integrated personal budgets in place for people with substantial or critical needs.
Care coordinators – community psychiatric nurses, social workers and occupational therapists – have been working generically for a long time and are used to working across professional boundaries. They do the assessment and budget allocation, and voluntary sector providers usually then work with the individual to come up with a support plan within the personal budget. In general, West Sussex staff now use a much broader range of voluntary sector providers. Because of a pooled budget, care coordinators do not need to specify which needs are health-related and which are social care-related.
Bureaucracy and paperwork have been too cumbersome and a new system was launched in June 2014.
There has been a coming together of NHS and social care perspectives over the years, but more work is needed to forge a culture that is truly integrated between the two organisations.
For more information, see:
CAPITAL Project Trust – a service-user-led organisation, founded in 1997, with knowledge of personal budgets in practice
Practice example 3: Project SWAP
Project SWAP is a community interest company, owned and run by mental health service users. It trains users to become peer brokers.
Mark Kilbey, Director of Canterbury and District Mental Health Forum, set up Project SWAP. His strong commitment to users taking the lead is expressed in the following ‘three Ds’:
- designed by users
- developed by users
- delivered by users.
Innovative ‘knowledge transfer’ funding led to the involvement of Canterbury Christ Church University and Rayya Ghul (Senior Lecturer) supported the development of the training team. The university also provided advice on becoming a clinical commissioning group and obtaining funds, such as a developing user-led organisations grant. Accreditation for the training is currently being sought with the Open College Network.
Kent County Council gave Project SWAP a grant in 2012 to train 14 peer brokers to support personal budgets. Currently (2014), one of the Kent clinical commissioning groups has provided funding to train a further group of 12 peer brokers.
Peer brokers work with someone for a maximum of five hours to help them understand the terminology, develop a support plan, gain the support required and review the plan. Peer brokers also do research into resources and options for support in their locality, including free or minimal cost activities and services.
At the heart of peer brokerage is that it is provided both by and for people who have a shared experience of mental distress: ‘At Project SWAP, we feel this provides the peer brokers we train with a unique insight into the challenges and discrimination that we all face at times as people who have faced mental ill-health.’
Practice example 4: Together for Mental Wellbeing’s leadership and peer support training programmes
Together for Mental Wellbeing is a mental health charity that has a dedicated Service User Involvement Directorate (SUID). The Directorate:
- develops service user involvement and leadership within Together for Mental Wellbeing
- creates links between other individuals and groups beyond Together for Mental Wellbeing to influence local, regional and national decisions about mental health care
- publishes guides, runs workshops and makes connections with universities and other organisations
- takes on tenders and contracts for projects relating to mental health user involvement, such as financial literacy programmes and skills training
- develops peer-to-peer initiatives.
The SUID believes that users need training and development opportunities in order to be able to take the lead in their support plans. It has developed two substantial training programmes for users: ‘Voices together: service user involvement and leadership’ and a peer support training programme. Both programmes are accredited at Level 4 by Middlesex University.
For more information, see:
Service User Involvement Directorate at Together for Mental Wellbeing
Practice example 5: Recovery colleges
Recovery colleges have gradually increased in number since the first one, the South West London Recovery College which opened in 2009. Currently (2014), there are over 20 in England.
They are usually run by NHS trusts in close collaboration with users and their families. They bring together, in a spirit of cooperation, two types of expertise: professional expertise and lived experience. An aim is to break down the barriers between users and providers.
The colleges provide a range of courses, which are open to users, their families and mental health workers/staff, in a stigma-free environment. The aim is to promote an educational model in supporting people to become experts in self-care, as part and parcel of their recovery journey.
Although there may not be courses specifically on personal budgets, most recovery colleges run courses on wellness planning, setting goals, managing money and many other important elements that will contribute to managing personal budgets.
Through learning together, it is more likely that users, their families and mental health professionals will have the expertise needed to make personal budgets work well for all involved.
Practice example 6: South Kent Coast Clinical Commissioning Group (SKC CCG)
South Kent Coast Clinical Commissioning Group (SKC CCG), in partnership with Kent County Council, is one of nine ‘Going Further, Faster’ sites established at the end of 2013. The nine sites are part of a programme to mainstream personal health budgets, introducing them beyond NHS Continuing Healthcare and with a focus on integrated health and social care budgets.
SKC CCG has established 23 integrated personal budgets. All participants have an existing social care personal budget. The integrated budget is established in partnership with the person’s general practitioner, who agrees the health need suggested by the assessor. A broker then establishes the health element of the integrated budget. They work closely with the person using services to ensure that they purchase services or goods that clearly link with their agreed outcomes.
Recipients can use their budgets in a flexible way through a direct payment, managed budget or pre-paid card. They do not have to purchase services or support approved by the National Institute for Health and Care Excellence (NICE). Health and social care professionals find that this flexibility enables them to assist people for whom established services have not been able to help in the past, for example those with ‘medically unexplained symptoms’.
The next stage of the pilot will involve rolling out the budgets to those who do not currently have a social care personal budget, through the establishment of joint assessment processes and a more strengths-based brokerage process.
The pilot has faced a number of issues, which illustrate the way that attempting to integrate around the individual can challenge the structures above them. These include:
- IT systems – the pilot has had to create a manual recording mechanism
- information governance – there is a need for clearer consent
- double funding of established services – there is some nervousness from mental health providers.
For more information, see:
South Kent Coast Clinical Commissioning Group
Practice example 7: The Northamptonshire personal health budget pilot
The personal health budget pilot in Northamptonshire, led by Nene Practice-based Commissioning Group (now Nene Clinical Commissioning Group), offered personal health budgets to 16 people attached to a community mental health team.
The size of the personal health budget offered to each person was based on the services it was thought they required for the year rather than using a needs-based formula. Commissioners worked with Northamptonshire Healthcare NHS Foundation Trust to identify the costs of clinical services for the purposes of calculating budgets.
Northamptonshire set up a local peer network as part of its approach to implementing personal health budgets. The peer network supports budget-holders and helps to ensure that the perspective of budget-holders is central to implementation and the evaluation of how well the programme is going locally.
The experience of Northamptonshire suggests that people want to manage their health as part of broader goals for their lives, for example returning to work, managing their finances, being an active part of the family and having a social life. The kinds of things those in the pilot chose to spend their budget on in order to achieve these goals included: IT equipment, complementary therapies, education, respite, exercise and a range of other items (for example vehicle repair and clothing).
The pilot found a small decrease in costs due to reduced use of (mainly) inpatient, general practitioner and Accident & Emergency services. Participants in the pilot talked of:
- experiencing a sense of hope, responsibility and renewed confidence
- the ability to choose alternative services to support their recovery in a different way from traditional clinical services
- the opportunity to choose which professional to work with, among other things.
For more information, see:
Nene Clinical Commissioning Group (Gill Ruecroft, Personal Health Budget Lead)
See also the forthcoming report by Vidhya Alakeson ‘Personal health budgets for mental health: The experience in Northamptonshire’.