Integrating personal budgets - considerations for better joint commissioning

The government's 2022 Integration White Paper, Joining up care for people, places and populations, outlines a vision for improved and interconnected health and care services across all age groups. This vision is supported by integrated planning and commissioning, demonstrating a renewed commitment to personal budgets, specifically Personal Health Budgets (PHBs), and Integrated Personal Budgets (IPBs).

IPBs play a pivotal role in personalising health, social care, and education support for individuals, reflecting a practical shift outlined in the NHS Long Term Plan. This unified approach seeks to address individuals' needs, enhance their outcomes and experiences, and mitigate health inequalities by fostering service integration at both individual and community levels.

Individuals benefiting from jointly funded services across health, social care, and education can derive substantial advantages from accessing integrated personal budgets. These budgets offer increased flexibility, choice, and alleviate the administrative burden associated with managing different funding streams as distinct personal budgets.

Moreover, integrated personal budgets offer benefits to commissioning systems, including a reduced reliance on administrative staff as individuals take on a more active role in managing their care arrangements, leading to decreased duplication for service commissioners.

Local authorities and the NHS already have duties related to integration, as outlined in the SEND code of practice: 0 to 25 years and the Care Act 2014. Additionally, the Health and Care Act 2022's legislative foundation supports collaboration and partnership to integrate services through formalised integrated care systems.

As a result, the following groups presently have a legal right to a PHB:

• Children and young people with Education, Health, and Care plans
• Adults and Children eligible for NHS Continuing Healthcare
• Individuals eligible for aftercare services under s117 of the Mental Health Act
• Individuals eligible for NHS wheelchairs

Although the terms “joint-funded budgets” and “integrated personal budgets” are sometimes used interchangeably, they often represent different levels of integration. It is, therefore, crucial to differentiate between joint-funded and integrated personal budgets, which may not meet the six key features of PHBs (e.g contributions from health and social care for a jointly commissioned Mental Health Community service).

Presently, there isn't a legal entitlement to an integrated personal budget as there is for PHBs and personal budgets. However, commissioning systems should explore the potential of local joint-funded arrangements evolving into joint-funded budgets or, ideally, integrated personal budgets, with the latter offering the highest level of integration for the optimal experience for individuals and families.?

Ideally, there should be an evolution of the approach over time starting with:

Joint-funded arrangements:

• Commissioning care and support jointly by health, social care, and/or education
• No provision for joint notional budgets, direct payments, or third-party budgets/Individual Service Funds for individuals and families

Moving to joint-funded budget which:

• Meet the six key features of Personal Health Budgets
• Provide separate but coordinated assessments by Local Authority and NHS
• Deliver a single personalised care and support plan encompassing health, social care, and/or education outcomes
• Separate direct payments into different or a single bank account or distinct payments made to a single third-party budget provider/Individual Service Fund
• Distinct review and audit processes

Arriving eventually at integrated personal budgets which:

• Fulfil the six key features of Personal Health Budgets
• Offer a fully coordinated assessment by Local Authority and NHS alongside a single personalised care and support plan, including health, social care, and/or education outcomes
• Provide a single payment deposited into a lone bank account or managed by a solitary third-party budget provider/ISF alongside a fully unified Personalised Care & Support Plan/budget review and financial audit process

The extent of benefits individuals and families can reap from an integrated personal budget can hinge on the clarity and accessibility of the process for receiving and utilising funds. Meaningful choice in how the allocated budget is spent to meet assessed outcomes is also crucial.

There is also a growing acknowledgment that a fundamental shift of attention is required, towards better understanding needs at local community level and using this to build more effective neighbourhood-based models of care and support. This shift is not merely a theoretical concept; rather, it aligns with evidence and good practice that advocate for the critical role of neighbourhoods, as framework for organising mutual, peer led, and professional support.

Amplifying the role of neighbourhoods is therefore integral for addressing wider societal needs but can also lay the groundwork for building a wider range of locally based support options that can be funded by citizens using their integrated personal budgets.

To ensure that these benefits materialise, commissioning systems should ideally consider:

• Prioritising local integrated personal budget development
• Co-designing the model with individuals who have first-hand lived experience and those drawing upon care and support services, including unpaid carers
• Emphasising provider market development
• Ensuring there is provision of good information for citizens to support in choosing the right provision for them to micro commission.
• Depart from conventional, risk-averse and time and task-based commissioning models and work on an outcome’s basis
• Provide parity of access to brokerage support (either through independent support brokers or through in-house teams) to assist with finding the right care & support and negotiate on their behalf
• Enhance workforce capacity, knowledge, and capability to deliver personalised care and support plans alongside individuals and families
• Incorporate the quality standards outlined in the PHB Quality Framework into the local offer.