Adding personal health budgets to your mental health nursing skill set

Personal health budgets allow patients to use NHS funding to purchase mental healthcare outside traditionally commissioned services

• Personal health budgets (PHBs) will be an integral part of health services and could become mandatory
• There are three types of PHB to consider when formulating patient care plans
• PHBs empower mental health service users to self-manage care and regain control of their lives

Personal health budgets (PHBs) can personalise healthcare by giving patients more control over their healthcare funding and enabling them to use their knowledge and skills to develop care plans based on ‘what matters to them’ (NHS England 2018).

In the context of mental health care, PHBs are also a mechanism for promoting recovery-focused services that work beyond diagnosis and symptomology to formulate personalised care and support based on patients’ desired outcomes for their health and well-being (NHS England 2019a).

PHBs are an alternative way of using NHS funding in which a sum of money is agreed between a patient, their support network and local NHS services to purchase care outside the remit of traditionally commissioned services (NHS 2017).

The Department of Health and Social Care (DHSC) (2018) consulted on extending the legal right to PHBs and with overwhelming support has committed to reviewing this right for those eligible under Section 117 of the Mental Health Act 1983 (DHSC 2019).

Referred to as Section 117 aftercare, this enables some people who have been in hospital under the Mental Health Act to access free help and support when they leave. Meanwhile, the NHS Long Term Plan recommends PHBs as an intervention for mental health patients as part of the drive to ensure that everyone is offered choice and control over their care, and they form an intrinsic part of the NHS Comprehensive Personalised Care Model (CPCM) (NHS England 2019b).

Aims of the personalised care model

The personalised care model aims to deliver healthcare that empowers people of all ages to manage their long-term physical and mental health conditions. The push to standardise PHBs is important to nurses as they are inherently involved in a process that requires a named care coordinator to assess a patient’s health needs, determine their motivations for making their care choice and formulate a care and support plan collaboratively (NHS England 2014).

All four UK countries have published mental health strategies that include the right to recovery-focused care.

Shifting the purchase of support from mental health practitioners to patients can empower people to self-manage their care, make choices and regain control over their lives. Accessing services outside of statutory systems enables people to redefine their life goals and aspirations, and rediscover their sense of agency, of being in control of the actions taken to support them with their mental health. This helps them to form connections with their local communities.

The individualised nature of PHBs also means they can encompass wider issues, such as social care and employment, and help meet people’s cultural and spiritual needs to prevent deterioration in their mental health (DHSC 2018).

• RELATED: Personal health budgets and the role of nursing

Using PHBs in mental healthcare is supported by user-led groups and the voluntary and social enterprise sectors. For example, National Voices (2018)  and the National Association for Voluntary and Community Action (2018) believe PHBs are pivotal in transforming healthcare by creating more choice and control for service users, while Voluntary Voices (2018) suggests they are revolutionary support mechanisms with infinite potential to improve the lives of those with complex, long-term health conditions.

PHBs can capture the central qualities of mental health recovery so, if nurses develop their knowledge and skills in relation to PHBs, these can become an integral part of their recovery skill set, enabling them to support patients in line with UK policy and guidance.

Nurses can implement personal health budgets effectively

Nurses already have valuable skills that can help them implement PHBs effectively, while the PHB process can create opportunities for them to improve patient care.

PHBs give nurses the opportunity to support patients to access options beyond the mental health system and that are not synonymous with or inextricably linked to their mental health conditions. This flexibility means patients can use their personal strengths to de-medicalise their care by choosing activities linked to life outside of their mental health condition (Alakeson and Coyle 2011, Coyle 2011, White 2011).

PHBs can be useful when working with patients who have disengaged or who have found that commissioned services are ineffective for their recovery (Coyle 2011, Alakeson et al 2016).

Patients with PHBs are unrestricted by authoritative guidance or evidence-based treatments and can make choices that differ from clinicians’ suggestions. By blending patients’ lived experience with practitioners’ professional expertise, nurses can help people access support mechanisms that promote engagement with mental health recovery (Tew et al 2015).

Sensible risk management can reduce potential dangers

Nurses may be concerned that PHBs are risky for some patients and that funding will be spent unwisely, that budget holders are in danger of financial exploitation or that a proposed care package might be ineffective or harmful (NHS Confederation 2011, Alakeson et al 2016).

Risk-averse and defensive front-line management can obstruct the dynamic use of PHBs when they seek to protect organisations and individuals from financial harm (Carr 2011), while reluctance to engage with positive risk-taking can inhibit care progression (Higgins et al 2015).

Implementing sensible and proportionate risk management can mitigate or reduce potential dangers (Chambers 2017), support nurses to engage with positive risk-taking and help create trusting and therapeutic relationships within which nurses and patients share risk decisions and responsibilities (DH 2010).

Move towards a coaching style of care planning

Mental health service users can become disempowered if nurses do not relinquish control, as their autonomy and capacity to make appropriate healthcare decisions are reduced (Griffith and Tengnah 2013). To promote constructive use of PHBs, Tew et al (2015) and Alakeson et al (2016) have called for professionals to move towards a coaching style of care planning that uses partnership working, creativity and mutual understanding of patients’ goals to achieve their desired outcomes and identify and manage risks safely.

Nurses can coach patients through the PHB process using their passion and commitment to deliver high-quality care, alongside their emotional intelligence and interpersonal skills. This can support the development of trusting patient-nurse relationships within which conflicts about use of funding can be resolved and which can produce egalitarian, collaborative care (Cope and Murray 2017).

Vital that nurses access training opportunities

A fundamental component of nursing is a commitment to lifelong learning (Royal College of Nursing 2019), while the Nursing and Midwifery Council (2019) requires frequent participation in learning and professional development activities as part of revalidation. PHBs are likely to become an integral part of mental healthcare, so it is vital that nurses access training and development opportunities to ensure effective implementation.

NHS England (2016) recommends using the Care and Support Planning Guide (National Voices 2014), to plan and integrate PHBs into patients’ care and support. The guide should enable nurses, through a cycle of preparing, discussing, documenting and reviewing, to work with patients to develop support that focuses on what matters to them, therefore creating relevant and personalised treatment and care plans.

Using this method of co-production, nurses can work creatively with patients, pulling together their clinical skills and adapting their knowledge, to find inventive, individualised solutions and support them to achieve better therapeutic outcomes. Creativity can also promote nurses’ sense of self-worth as they become ‘entrepreneurs of innovation’, increase their belief in their skills and become positive role models (Isfahani et al 2015).

PHBs will become an integral part of health services, and offering patients who access mental health services this option could even become mandatory. With potential legal changes for people eligible under Section 117 aftercare, and a target of 2.5 million people enrolled in the CPCM by 2024 (NHS England 2019b), nurses may have no choice but to instigate PHBs for their patients.

Examples of use of personal health budgets

• Football tickets, to help reduce social isolation
• Employing family members and friends to support day-to-day activities
• Writing courses
• Aromatherapy
• Exercise groups and gym membership, to improve mental and physical health
• Respite care
• Volunteering and training: contributing to local communities and developing career opportunities

Mental health recovery-focused support should be multifaceted to empower patients to rediscover what it is that makes them an individual (Mental Health Foundation 2019). The care plan approach aims to support patients holistically with a wide range of needs and life goals (Rethink Mental Illness 2017) and some may decide that PHBs are not a viable option (Mind 2013). It is vital that nurses use PHBs alongside other interventions and that decisions to use PHBs are based on informed choice.

Nurses will need to adapt their skills to work collaboratively to implement PBHs by being creative, applying positive risk-taking and handing control to their patients. The scope of PHBs means nurses can support patients to actualise their mental health recovery by enabling them to access care and treatment tailored to their preferences. PHBs should be considered when formulating patient care plans and nurses must educate themselves about this resource and integrate it into their recovery-focused skill set.

Vicki Chinn is a mental health nurse employed by Kent County Council as a hospital case manager at Medway Maritime Hospital, Medway NHS Foundation Trust

Find out more

• Alakeson and Coyle (2011) Personal health budgets and the role of nursing
• Alakeson et al (2016) Debating personal health budgets
• Carr (2011) Enabling risk and ensuring safety: self‐directed support and personal budgets
• Chambers (2017) Psychiatric and Mental Health Nursing
• Cope and Murray (2017) Leadership styles in nursing
• Coyle (2011) Impact of person-centred thinking and personal budgets in mental health services: reporting a UK pilot
• Department of Health (2008) Refocusing the Care Programme Approach
• Department of Health (2010) Nothing Ventured, Nothing Gained: Risk Guidance for People with Dementia
• Department of Health and Social Care (2018) A Consultation on Extending Legal Rights to Have for Personal Health Budgets and Integrated Personal Budgets
• Department of Health and Social Care (2019) Extending Legal Rights to Personal Health Budgets and Integrated Personal Budgets: Consultation Response
• Griffith and Tengnah (2013) Shared decision-making: nurses must respect autonomy over paternalism
• Higgins et al (2015) Best practice principles for risk assessment and safety planning for nurses working in mental health services
• Isfahani et al (2015) Nurses' creativity: advantage or disadvantage
• Mental Health Foundation (2019) Recovery
• Mind (2013) Personal Health Budgets in England - Making Them Work in Mental Health
• National Association for Voluntary and Community Action (2018) Personal Health Budgets and the VCSE Sector
• National Voices (2014) Care and Support Planning Guide
• National Voices (2018) Personal health budgets give people choice and control
• NHS (2017) What is a personal health budget?
• NHS Confederation (2011) Facing up to the challenge of personal health budgets: the view of frontline professionals
• NHS England (2014) Guidance on Direct Payments for Healthcare: Understanding the Regulations
• NHS England (2016) Personalised Care and Support Planning Handbook: The Journey to Person-centred Care
• NHS England (2018) What is personalised care?
• NHS England (2019a) Personal health budgets for mental health
• NHS England (2019b) Comprehensive Personalised Care Model
• Nursing and Midwifery Council (2019) Revalidation
• Rethink Mental Illness (2017) Care Programme Approach (CPA)
• Royal College of Nursing (2019) RCN joins health bodies and unions to launch principles for continuing professional development
• Tew et al (2015) ‘And the stuff that I'm able to achieve now is really amazing’: the potential of personal budgets as a mechanism for supporting recovery in mental health 
• Voluntary Voices (2018) IPC and Personal Health Budget Support and Development Programme: Learning and Next Steps
• White (2011) Do personal health budgets lead to better care choices?