Children and young people’s continuing care is excluded from the default expectation.  However, this group have a right to have a personal health budget and ICBs are expected to work alongside parents / guardians, local authorities and schools on the implementation of integrated education, health and care plans, and the offer of personal budgets to improve the lives of children and young people with special educational needs.

The default expectation does not apply to Fast Track NHS Continuing Healthcare. However, this group also has the right to have a personal health budget and ICBs are encouraged to explore use of personal health budgets in this area as part of their planning. There will be circumstances when a personal health budget will improve a person’s wellbeing and enable them to achieve the outcomes they wish in the final stages of life.

Sheltered housing, supported living and shared accommodation arrangements fall within the scope of home care, therefore personal health budgets are expected to be the default approach for providing care and support. If the accommodation includes an element of care, then it may be difficult to include this element into a personal health budget. This will need to be agreed on a case by case basis.

ICBs have a legal duty to inform people about their right to have a personal health budget once they become eligible for NHS Continuing Healthcare. Setting up a personal health budget takes time, even when the person choses a notional budget. It is not practical to expect that all new NHS Continuing Healthcare home care packages will be delivered as personal health budgets from the date of eligibility.  However, ICBs should have commissioning arrangements in place to ensure care is delivered as soon as possible from the date of eligibility with the aim for the individual’s care package to be created with an approved provider and an admission / commencement date agreed within 3-4 days. The ICB should work to a reasonable timeframe thereafter to ensure that all home care packages are subsequently transitioned to a personal health budget. This could mean that the care continues to be delivered by the approved provider for notional budgets or other arrangements are made as defined in the individual’s personalised care and support plan.

There is no maximum time limit on how long it takes to implement a personal health budget. Some budgets will take longer to put in place than others, particularly if there is a need to recruit and employ personal assistants. However, to ensure maximum opportunity to benefit from increased choice, flexibility and control, it is beneficial for people and families for home care packages to be transitioned to a personal health budget as soon as possible following the eligibility decision.

An ICB is identified as having achieved the default expectation if a minimum of 85% of home care packages are personal health budgets at any given time. This accounts for personal health budgets in the process of being set up for people who are newly eligible for NHS Continuing Healthcare, or existing arrangements in the process of transition to a personal health budget.

A good personal health budgets process should give people more choice, control and flexibility over how their care is delivered. It is not sufficient for an ICB to simply inform people of their budget amount in a letter and subsequently identify that arrangement as a notional budget. Providing an indication of how much money a person has available for their care and support is only one step in the personal health budgets process. The person must also have the option of direct payment, a notional budget or a third party budget, where it is appropriate, and they must be supported to develop a personalised care and support plan.

Regardless of the budget management option chosen by the person, there are six key features which must be in place in order for the arrangement to be identified as a personal health budget.

The person with a personal health budget should:

1. Be central in developing their personalised care and support plan and agree who is involved
2. Be able to agree the health and wellbeing outcomes they want to achieve, together with relevant health, education and social care professionals
3. Get an upfront indication of how much money they have available for healthcare and support
4. Have enough money in the budget to meet the health and wellbeing needs and outcomes agreed in the personalised care and support plan
5. Have the option to manage the money as a direct payment, a notional budget, a third party budget or a mix of these approaches
6. Be able to use the money to meet their outcomes in ways and at times that make sense to them, as agreed in their personalised care and support plan.

It is important to incorporate the steps above into the local case management process to ensure personal health budgets, including notional budgets, are meaningful for people and support them to achieve good outcomes.

In circumstances where a person refuses a personal health budget it is important to understand why this is the case and how information about personal health budgets and the different options for managing the money has been provided. Evidence shows that people want improved choice and a personalised approach to care and support, but not everyone will want control of the money. It is possible that a person may be refusing a direct payment but not a notional budget.

The requirement is for ICBs to deliver personal health budgets as default for home care packages, not to deliver direct payments as default. The option of a direct payment however must be available to everyone who could benefit from receiving care in this way.

The process for commissioning a traditional package of care as set out in the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (2018) is very similar to the process for arranging a notional budget. Both pathways require

• a discussion with the individual and their representatives, on care and support options;
• developing a personalised care plan (for personal health budgets this is referred to as a personalised care and support plan);
• meeting assessed health and associated care and support needs and agreed outcomes;
• care and support commissioned by the ICB to meet the assessed needs;
• regular monitoring and reviews.

The additional step for a notional budget is the provision of upfront information about the amount of money available for care and support (indicative budget).