Individual Health Budgets Pilot Begins

Author: Sam Sly

Beyond Limits is an Organisation that has been developed to implement a 3 year project commissioned by NHS Plymouth as part of its response to the QUIPP (Quality, Improvement, Productivity and Prevention) agenda. This is the first of a series of papers to share learning from the project, to help evaluate a more personalised approach to commissioning and measure the impact of tailor-made services on the lives of people who often face institutionalised living because their behaviour has challenged existing services. This paper provides an introduction to the project.

Project Planning and Design

The project is designed to make use of Personal Health Budgets (PHBs) for people with learning disabilities and mental health needs with the outcome of truly individualised tailor-made services and the development of flexible ways to promote long term stability for people and to prevent re-admission to institutions, including Specialist Hospitals, often far from the person’s home and community.

As Plymouth is not a pilot site for IHB’s, instead Individual Service Funds (ISF) will be used and paid directly to a new, purpose built, service provider - Beyond Limits. This new organisation will be 'grown out of' an existing organisation Partners for Inclusion, which itself was grown out of Inclusion Glasgow in 1999. For Partners for Inclusion this project is also an opportunity to grow a similar organisation to their own, replicating the original process that they followed growing out of Inclusion Glasgow in the mid 1990’s.

ISFs form an essential part of the delivery of tailor-made services. They were developed by Inclusion Glasgow in 1996 and are an essential part of the model of Personalised Support used by Partners for Inclusion and which was recently outline in the book of that name written by Julia Fitzpatrick.

Planning for the Beyond Limits started in the summer of 2010 and the organisation, a domiciliary care agency, started to function in July 2011. This year's delay was caused by the time it took the Care Quality Commission to register a new service. This suggests that the current regulator is not supporting the development of new and more flexible services.

The timing of this project coincided with the recent terrible, but unsurprising, revelations about the treatment of people with learning disabilities and labels of challenging behaviour at Winterbourne View and other Castlebeck establishments, which have followed on from the frighteningly similar investigation findings in Cornwall NHS Partnership Trust in 2006 and Sutton and Merton Primary Care Trust in 2007. 

Commissioning processes and provider services are under scrutiny once again. It is encouraging that NHS Plymouth is proactive about making positive changes. 

This is also a time of austerity. It will be interesting to see whether this leads to positive creativity (having less money can sometimes help stimulate more imaginative services) and or negative defensiveness (pre-occupation with budget reductions and knee-jerk reactions to saving money can sometimes destroy creativity).

National Commissioning Recommendations

Jim Mansell’s revised report ‘services for people with learning disabilities and mental health needs’ (2007) made several recommendations to commissioners on how to plan strategically for people who have the label of challenging behaviour, to develop preventative strategies to avoid crises and to make the most effective use of available funding. These recommendations underpin the framework for the project. 

The aims being:

1. To invest in local services so that they can better understand and respond to challenging behaviour and to provide specialist services locally to support good mainstream practice as well as directly serve a small number of people with the most challenging needs.
2. To give priority to improving services for people with learning disabilities whose behaviours present challenges to services and demonstrate value for money through improvements in outcomes identified in Valuing People – rights, inclusion, independence and choice. 
3. And at a service system level demonstrating value for money through a low number of placement breakdowns and out of area placements and replacement of low value high cost services with better alternatives. 
4. Avoiding increasing the burden on family carers by reducing levels of service.

The service models Mansell recommends that influence the project are:

1. Individualised, local solutions providing good quality of life not those too large to provide individualised support, too far from their homes, and not providing good quality of life in the home or as part of the local community.
2. Direct payments and individual budgets should always be considered and be more widely available.
3. Innovative day ‘services’ including supported access to further education and supported employment.
4. Closer co-ordination between the commissioners paying for services, the managers providing services and the professional specialist advising on the support people need to ensure advice is both practicable and acted on. 
5. Commissioners should allocate a budget to be used to fund a much wider variety of interventions as an alternative to placement in a special unit.

The service development Mansell recommends that influence the project are:

1. Develop partnerships – work with provider organisations who are committed to developing good services to support people whose behaviours present a challenge to agree commissioning and funding arrangements that will achieve value for money while sustaining investment and development of local services.
2. Create service development resource – identify people who know about challenging behaviour and services, to work with people to implement person-centred plans. 
3. Identify people as a first priority – focus on these people where problems are serious enough that intervention could make an important difference but where the context is supportive enough to allow the greatest impact. 
4. Develop services – support the person-centred planning process for these people and deploy resources to implement the plans developed.
5. Provide back-up – notice when problems begin to emerge (before crisis) and intervene to provide moral and material support to sustain arrangements through difficult times.

Beyond Limits' Project Goals and Impact Priorities

The Mansell recommendations also underpin the project goals and impact priorities.

The goals of the project are:

1. Each person supported will have a Service Design for their support (carried out with the person and those that know them best) which will be put together before the person is supported and include the detail required to develop a tailor-made service.
2. Each person supported will have a Working Policy developed for them which will detail how the person will be supported to live the life they want to lead.
3. Each person will have a budget (ISF) to plan and pay for what they need to have a good life, the degree to which they control this money will be dependent on their wishes and needs, but they will be involved and informed of financial decisions.
4. Each person will have a home that they feel safe in, in control and is a base for their life. 
5. Each person will chose the team that will support them. They will be in control of their support and people will not be over supported. Other forms of support such as natural support and assistive technology will be part of a person’s support plan. 
6. Each person will be supported to identify what they want to do and what they are able to offer in their communities. We will support them to work on promoting their individual gifts, skills and talents so that they become valued and respected citizens.
7.  As an Organisation Beyond Limits will share with other organisations, providers and families all their learning and developments and will set up a good practice sharing forum in Plymouth with like-minded organisations. Beyond Limits also aims to get external review of its development so that other organisations can develop the model should they wish to.

Impact priorities for the project are:

1. Change the commissioning focus for individuals who may challenge services towards individualised support at home.
2. Change the culture of planning and provision of support for individuals that are seen as challenging or risky.
3. Change commissioning processes to deliver long term stability for individuals and prevent re-admission to institutional services such as specialist hospital
4. Ensure a range of support is delivered, that is right for the person
5. Improve value for money in commissioning
6. Ensure control over support arrangements is with the individual
7. Develop a culture where over-support is reduced and the accepted culture is one of positive risk taking and supporting life choices of individuals. This will be achieved through the implementation of a detailed service design and working policies.
8. Delivery of year on year savings. 
9. End the use of hospital solutions and out of area placement for individuals that are seen as challenging and risky.

Next steps

Beyond Limits have started developing service designs with individuals currently living in out of area specialist hospitals working alongside NHS Plymouth and will be developing a provider forum in the coming months.
As the project progresses we will be writing papers on areas of interest and evaluate the process so that other interested Organisations can learn as we learn and develop. We don’t underestimate the journey we and the Commissioners are going to have to travel!

Sam is Director of Beyond Limits and can be contacted via email or telephone: 07900 424 144

The publisher is The Centre for Welfare Reform.

Individual Health Budgets Pilot Begins © Sam Sly 2011.

All Rights Reserved. No part of this paper may be reproduced in any form without permission from the publisher except for the quotation of brief passages in reviews.