Earlier this year, the government published a consultation paper entitled 'Direct Payments For Health Care - A Consultation on Proposals for Regulations and Guidance' seeking views on the piloting of direct payments for health care. The deadline for responses to this consultation is 8 January 2010.

Direct payments would allow patients more control over their own health care, and are part of the wider pilot programme to explore personal health budgets announced in 'High Quality Care For All.' Following expressions of interest from more than half of the Primary Care Trusts (PCTs) in the country, some of the 70 provisional pilot sites for personal health budgets achieved full pilot status in early October 2009.

Direct payments differ from the personal health budget scheme, as the latter does not involve giving money directly to patients. However, patients who participate in the proposed direct payments scheme will receive money from their PCT, which they must use to arrange and pay for the care identified in an agreed care plan. This mirrors the current system of direct payments for social care.

Proposed direct payments scheme

The consultation paper describes the suggested content of the regulations and guidance needed to implement a direct payments pilot scheme. The former would be made under the recently enacted Health Act 2009.

(i) Pilot sites

It is intended that pilot sites:

  • will test the practicalities for a range of different patients, including children and those with chronic conditions, learning disabilities, or requiring mental health or end of life care;
  • could be run by PCTs which are not personal health budget pilot sites;
  • will be given ample room to develop best practice through innovation during the pilot, rather than having to follow detailed guidance. If the pilot scheme is successful, comparison of the different pilot models will help to identify the most beneficial practices, which will shape future policy and guidance.

(ii) Impact on patient care

Using direct payments, patients can decide to swap traditional NHS services for treatment by other agreed health care services (including equipment, respite care or employing a member of staff).

However, not all patients and treatments will be covered by the direct payments scheme. For example, the scheme will not cover treatment by GPs or emergency care. And only those patients who fulfil the personal criteria in the proposed regulations will be able to participate.

The suggested criteria include that, before patients can receive a direct payment, they must:

  • be capable of managing a direct payment (either themselves or using a nominee);
  • not be subject to certain criminal justice system requirements regarding alcohol or substance misuse (mirroring the restrictions in social care direct payments);
  • agree a care plan with their PCT;
  • use a dedicated bank account for all direct payments;
  • meet the PCT's criteria regarding medical condition and personal circumstances;
  • be able to meet their obligations as an employer where the patient wishes to employ a care worker.

The consultation paper also makes clear that direct payments are not a step towards privatisation of the NHS and patients will not be allowed to 'top up' direct payments from their own funds.

(iii) Impact on health care administration

The proposed regulations impose certain conditions on PCTs participating in the pilot scheme. For example, they must:

  • use their discretion to prepare and agree a care plan with the patient. Care plans are intended to specify the desired health outcomes, the services to be purchased and the available budget;
  • be able to monitor and audit the patient's participation in the scheme adequately. For example, all direct payments are intended to be time limited. If the relevant time limit is exceeded, the care plan must be reviewed;
  • investigate the need for the patient to have managerial support to arrange the services in the care plan;
  • ensure that there are appropriate safeguards in place (e.g. that providers have appropriate qualifications, indemnity cover and complaints procedures). The services purchased by the patient should satisfy the same regulatory requirements as if the services were procured through traditional channels;
  • ensure that the receipt of a direct payment is 'distinct and secure';
  • be able to provide advice, information and support throughout the patient's participation in the scheme.

Protective measures are also proposed to prevent direct payments being misused or going unused. The consultation paper details a variety of suggested circumstances where the participating PCT can reclaim the money as a civil debt, including death of the patient, fraud or changes in the care plan.

Consultation response

If the procedure for developing and passing the new regulations and required amendments to the National Health Service Act 2006 runs smoothly, selected pilot sites could be operational by the summer of 2010. Pilots would then run until 2012, unless extended.

The deadline for responses to the consultation is 8 January 2010. The consultation documents are available here.