What makes integrated personal budgets for people with mental health problems work well?

Many of the things that make integrated budgets work are the same as those that make personal budgets or personal health budgets work, because so much of the infrastructure and the approach are shared – for example, information, advice and support, risk and so on.

Integrated budgets can be delivered without organisational integration but can be facilitated by it, as in the case of pooled budgets, shared IT and joint teams. But one does not have to wait for the other.

If the personal budget systems of the NHS and local authorities can be developed together, it could offer a powerful new way of integrating health and social care at the individual’s level, rather than across a whole population. By coordinating the service user experience, rather than using joint commissioning or pooled budgets as a starting point, integrated personal budgets could help to focus local efforts on what matters most.

[22]

Integrated personal budgets are new, so the evidence about what works is still emerging. The evidence we have accumulated comes from a number of related sources:

• evaluation of the personal health budget pilots [23]
• experience of individual budgets in social care
• evidence about integrated care
• evidence from emerging practice, including our practice examples
• experiences of users, their families and carers.

Based on these sources of knowledge, the following issues arise as central to the successful delivery of integrated personal budgets in mental health.

Flexibility, choice and control

• Success for the individual budget-holder is related to the flexibility and choice they have as to how they spend their budget. An integrated budget should mean that the budget-holder’s health and social care needs are addressed together in one place; the success of this relies on them having the choice and control to spend their budget on a wide range of support and services.
• The integrated budget provides the opportunity for staff to focus on an individual’s needs regardless of where these may be met, rather than retaining a service-led approach.
• This can mean a change in culture within a health trust or mental health team, to accept and acknowledge the role of a wide range of different services, support and non-traditional ways of promoting people’s health and wellbeing. Retaining a rigidly medical model approach will limit the options available to people.
• This in turn means a willingness to spend money on services or products that are not seen as fitting into either the ‘health care’ or ‘social care’ categories.

Information, support and advice

• For integrated budgets to work well, users, their families and carers need to have good, clear, accessible information readily available to them about what an integrated personal budget is and how to access it.
• Information and advice about integrated budgets can usefully be provided by local service user groups, user-led organisations, peer support or peer brokerage organisations, and other community and voluntary sector organisations (see Practice example 3: Project SWAP).
• This means that health and social care staff need to work closely with these local groups and organisations to ensure that such organisations have the necessary information with which to advise people.
• The commissioner may contract with one or more of these organisations to develop an individual’s personal support plan or to provide brokerage support to people, in which case there should be good communication networks between organisations in place to make this work.
• People need to be supported in how best to use their integrated budget. Many people, particularly those who have complex or long-term care needs, may be unfamiliar with the idea of being able to choose what to spend their budget on.
• In some local areas (for example in Northamptonshire – see Practice example 7: The Northamptonshire personal health budget pilot), peer networks have been developed to support people with personal health budgets and their families and to promote the use of these budgets locally.
• Support may be offered by a personal budgets support service, by an independent agency commissioned to provide brokerage or by a care coordinator spending time with the individual. In Practice example 3: Project SWAP, a service user-run organisation and community interest company provide peer brokerage to people with personal budgets.

'One-stop shop' for assessments

• A joint assessment of a person’s needs and a single personal support plan that covers their health and social care needs are one of the main reasons why integrated budgets make sense to people and to services. If this can be accomplished at a local level, the integrated budget will work well (see Practice example 1: Lambeth and Practice example 2: West Sussex).
• This works best if the process is supported by a single care coordinator with the authority to use resources from both agencies.
• The process of applying for a budget needs to be flexible, transparent and timely.

Good joint working

• Joint working between health and social care staff is an essential foundation for integrated care and for the success of integrated budgets. The evidence suggests that good partnership working at the local level is more important than formal agreements at a higher level (see Practice example 2: West Sussex).
• Good communication between health and social care staff may mean co-locating those staff (having joint or integrated teams) or simply finding ways to ensure good communication between them.
• A shared approach towards agreeing an estimated budget, or towards care and support planning, has a positive impact on people’s experience regardless of arrangements in place behind the scenes.
• Integration of the medical, psychological and social models of care and support will help to ensure that all practitioners are able to help users to build on and apply their strengths and abilities.
• Joint training on assessment and support planning, involving users and their families where appropriate, will support an integrated approach to care and support.
• A reduction of bureaucracy is essential, as it can stifle the growth of personal budgets. One example of how to do this is to empower front-line practitioners to sign off integrated budgets, using joint panels for sign-off only sparingly. Another is given in Practice example 1: Lambeth, where a consultant was brought in to advise on how to reduce bureaucracy.

Systems integration

Some degree of systems integration helps to support integrated budgets. For example:

• some basic integration between health and social care IT systems
• systems for sharing information between health and social care
• efforts to move towards the use of integrated (shared) outcome measures
• integration of health and social care strategic and planning cycles.

Financial arrangements

Integrated personal budgets need to be backed up by financial processes that enable mental health practitioners and users to access the budgets in a simple and relatively uncomplicated way. [24] It is helpful to have:

• an appropriate joint funding agreement between health and social care - possibly using Section 75 arrangements (see box below)
• pooled budgets or at least a shared approach to agreeing a shared budget – Practice example 1: Lambeth shows how a pooled budget has helped the implementation of integrated budgets
• clarity over VAT (Value Added Tax) as it impacts on personal budgets
• good partnership working in relation to accounting and financial governance requirements
• consistent principles across health and social care for personal budget expenditure
• recognition of the fact that social care is means-tested and NHS services are free at the point of delivery as part of the process of integrated budgets
• payment of both sources of money into a single bank account for the budget-holder, making the amount available to the individual more transparent, easy to manage and accountable.

Positive risk management

• Health and social care staff need to work closely together to ensure that concerns about risk do not act as an unnecessary barrier to people accessing integrated budgets. There can be a more risk-averse culture among health care professionals, which can be alleviated by a joint approach to managing risk across health and social care staff.
• One way of doing this is for staff to work together to share risk as a team, reducing the burden on individual staff members.
• Another approach is to establish a ‘positive risk’, ‘risk enablement’ or ‘risk management’ panel. These panels can improve the management of risk and share the responsibility for managing people who present a risk to services between and across individual professionals, clinical teams and the management team. There are many examples of this in practice, for example at the Southern Health NHS Foundation Trust and in the London Borough of Hounslow.

Brokerage and support services

• Some form of brokerage or personal budget support service will help to ensure that people with mental health problems who want an integrated health budget will have the support they need to access and manage it. Voluntary sector brokerage and advice or advocacy services can play a crucial role in supporting people to navigate the process and make informed choices. Practice example 3: Project SWAP is an example of peer brokerage.
• Support planning can be experienced by users as more ‘human’ when delivered by a user-led organisation than by a local authority, with less bureaucracy involved. [26]
• Peer support from people who have used an integrated budget, often as part of brokerage or advice services, can help to ensure that these services reflect the needs and experiences of people with mental health problems. [27]
• A brokerage service is likely to be commissioned by the local authority or clinical commissioning group, but it is important that health and social care staff liaise closely with the brokerage or support service to ensure that people get the support they need. The service is often of great assistance to staff in understanding and navigating the process.

Co-production, involvement and empowerment

• Integrated services work best when they promote people’s involvement in their own care and, importantly, promote choice and control. Contracting with local service user groups and organisations to provide some aspect of the process – for example, peer support or peer-led brokerage – can strengthen this and ensure that the individual is supported to make the choices that matter to them.
• Commissioners should consider contracting user-led organisations/user trainers to provide training and development to ensure that users, and perhaps also their carers, are better equipped to take a leadership role in relation to personal budgets – for example, the Together Leadership and Peer Support training programmes, the Cool Tan Arts personalisation film-making and podcasting project, recovery colleges and personal assistance training courses run by people with disabilities.
• Investment in the ‘demand’ side of services will help to drive co-production into all areas of commissioning and delivery of key local services. This means providing people, families and communities with the information, skills and ‘images of possibility’ to ask for and support changes in public services.