PHB Referral

Personal Health Budgets (PHB) are offered to adults receiving support from East London Foundation Trust (ELFT) to help someone work towards a personalised mental health recovery goal.

If you like to discuss your PHB referral before submitting please contact the ELFT PHB team at elft.phb@nhs.net or 07436027771. Please see relevant checklist information and guidance notes on https://www.corearts.co.uk/phb-brokerage-service/

Any issues submitting your referral, or follow up of the application please contact PHB@corearts.co.uk directly.

We are particularly seeking (but not limited to) referrals from underserved or maginalised groups and encourage referrals from persons of African - Carribbean Heritage.

To receive a PHB, the person must be*:

an adult (18+)
receiving mental health support from East London Foundation Trust with a DIALOG+ plan and be subject to s.117 aftercare (MHA 2007)
a resident of City and Hackney
have recourse to public funds, unless receiving S117 aftercare (see NHSE right to have guidance, section 4.4)

If your referring on behalf on an inpatient or planning to submit a discharge PHB application please use the specific application form https://form.jotform.com/250284472378362

The PHB recovery goal must be time-bound to 3 month period, during this time as review and case closure will need to be undertaken alongside the PHB holder.

To make a referral to the service:

Please complete the referral form with the person referred for a PHB [please note the referral form includes a "quality of life" (ReQol/10) or DIALOG+ questionnaire that will need to be completed by the person].

Please upload and submit a DIALOG+ plan and PHB support plan that has been completed with the person and offer them a copy https://www.corearts.co.uk/wp-content/uploads/My_PHB_plan.pdf

(downloadable form https://www.corearts.co.uk/phb-brokerage-service/)

Please discuss the referral with the approving manager so they are aware we will be in contact seeking authorisation. Approval is required for any applications made over £250. The PHB Oversight Panel will need to approve any funds over £500.

If you are using direct payments for this PHB (PFS account allocation), the PHB holder will need to sign a DPA prior to the set up, we will be in touch to request this form to be completed to progress the application. https://www.corearts.co.uk/wp-content/uploads/PHB_Direct_Payment_Agreement.pdf

Please tick this box to confirm that the person you are referring meets the eligibility criteria**

Yes, I understand - tick to continue

Please check the box if you understand that by submitting this personal information you are consenting to Core Arts holding and using it in accordance with our privacy policy.*

Yes, I understand and have sought consent from the prospective PHB holder

If you need help or have questions about any aspects of the Personal Health Budget process please contact us at PHB@corearts.co.uk.

Full Name*

First NameLast Name

Telephone number*

Please enter a valid phone number.

Email address*

example@example.com

Borough*

Team*

Role*

Is another professional involved with this PHB?

Please note an allocated worker is required for the duration of the PHB timeline (3 months - a review and case closure is needed for every PHB approved funds)

Name

First NameLast Name

Role

Team

Email address

example@example.com

Name*

First NameLast Name

NHS number*

Please imput number in this format 111-111-1111

Date of birth*

Date

Email address*

example@example.com

Telephone number*

Please enter a valid phone number.

Address*

Postcode*

Borough

When was the last admission for this PHB holder?

Is this client a frequent attender of NHS services?

YesNo

Which services?

A&EDuty ServicesCrisis LineOther

If 'other' please state

Gender*

Ethnicity*

Sexual orientation*

Is the service user on s117 aftercare?*

Please note: PHB offer is currently open to those subject to s.117 aftercare

Accommodation status *

Employment status*

Have you been in the armed forces?*

The starting point and purpose to any PHB request is the recovery goal.

In your answer below please ensure the following;

What is the mental health recovery goal?
How does the item/ activity requested support that goal?
Why is this important to the person? E.g. Why have they selected this as their chosen support?
Use first person quotes or outline the personalised nature of the plan and what impact the PHB holder is hoping to achieve.

Please be as personalised and detailed as possible to demonstrate the individuals goals and voice in regards to the PHB. Please also include how value for money has been considered in the application, explaining why the item/ service has been chosen and how that decision was made.

Summarise the mental health recovery goal and how the PHB will support that goal:*

Please provide full description (item description section):*

If there are more than 3 items related to the PHB you are applying for, please use this section to specify the additional items. Please note the PHB timeline must be a 3 month period.

Please select the main area this request relates to:*

Please select any other additional areas that are support by this request (optional):

Further additions (optional):

Please upload your plan (DIALOG+, PHB plan, ILP)

Please select an outcome measure*

DIALOG+ monitoring

1 – Totally dissatisfied

2 – Very dissatisfied

3 – Fairly dissatisfied

4 – In the middle

5 – Fairly satisfied

6 – Very satisfied

7 – Totally satisfied

How satisfied are you with your mental health?*

How satisfied are you with your physical health?*

How satisfied are you with your job situation?*

How satisfied are you with your accommodation?*

How satisfied are you with your leisure activities?*

How satisfied are you with your relationship with your partner/family?*

How satisfied are you with your friendships?*

How satisfied are you with your personal safety?*

How satisfied are you with your medication?*

How satisfied are you with the practical help you receive?*

How satisfied are you with your meetings with mental health professionals?*

ReQoL/10 monitoring

Answer the following question in relation to last week.

4 – None of the time

3 – Only occasionally

2 – Sometimes

1 – Often

0 – Most of the time

I found it difficult to get started with everyday tasks*

Answer the following question in relation to last week.

0 – None of the time

1 – Only occasionally

2 – Sometimes

3 – Most of the time

4 – Most or all of the time

I felt able to trust others*

Answer the following question in relation to last week.

4 – None of the time

3 – Only occasionally

2 – Sometimes

1 – Often

0 – Most of the time

I felt unable to cope*

Answer the following two questions in relation to last week.

0 – None of the time

1 – Only occasionally

2 – Sometimes

3 – Most of the time

4 – Most or all of the time

I could do the things I wanted to do*

I felt happy*

Answer the following question in relation to last week.

4 – None of the time

3 – Only occasionally

2 – Sometimes

1 – Often

0 – Most of the time

I thought my life was not worth living*

Answer the following two questions in relation to last week.

0 – None of the time

1 – Only occasionally

2 – Sometimes

3 – Most of the time

4 – Most or all of the time

I enjoyed what I did*

I felt hopeful about my future*

Answer the following question in relation to last week.

4 – None of the time

3 – Only occasionally

2 – Sometimes

1 – Often

0 – Most of the time

I felt lonely*

Answer the following question in relation to last week.

0 – None of the time

1 – Only occasionally

2 – Sometimes

3 – Most of the time

4 – Most or all of the time

I felt confident in myself*

Please state the date you will plan to review the PHB *

This should be in line with other scheduled reviews and no longer than 3months from the budget live date

Name of item/activity/service*

Website link*

Price (unit cost per session or product)*

Frequency*

Duration (number of weeks/sessions/one- off)*

Total budget amount (quantity x unit cost)*

Payment option *please note all PHB accounts are set-up as online accounts. If you require a physical card, please specify your reasons below for approval*

Please state your reasons for a physical card, this will be reviewed and approved by the brokerage service manager. *

Please note: referrers are able to support all purchases using the online accounts on PHB holder behalf. A very clear rationale for a physical card will be required and is subject to approval.

The virtual account requires a linked phone number to access the portal and for the OTP authorisation. Please Provide the mobile number PFS will set the account to

Please note if you leave this blank an email address only will be linked to the account as per below

The virtual account requires a email address to access and for the OTP (back up) authorisation. Please Provide the email address PFS will set the account to*

Please note if you leave this blank a phone number only will be linked to the account.

*Next steps

Any budget is under £250 does not require further approval, please download and go through this DPA agreement with the prospective PHB holder, please ONLY sign the DPA if the Core Arts Brokerage team have approved the PHB application.

If approved and signed/ agreed with PHB Holder - please send a completed copy to phb@corearts.co.uk for us to review and please provide a printed copy to the PHB Holder for thier records.

Another item:

YesNo

Name of item/activity/service

Website link

Price (unit cost per session or product)

Frequency

Duration (number of weeks/sessions/one- off)

Total budget amount (quantity x unit cost)

Another item:

YesNo

Name of item/activity/service

Website link

Price (unit cost per session or product)

Frequency

Duration (number of weeks/sessions/one- off)

Total budget amount (quantity x unit cost)

If there are more than 3 items related to the PHB you are applying for, please use the item description section above to specify the additional items. Please note, all items need to be linked to one clear Recovery goal.

Whole total budget amount request*

Please ensure this is the whole amount requested, including an delivery costs

What is the continued recovery goal beyond the PHB?*

Please explain how the plan can continued beyond the funded timeframe and what has been agreed with the PHB holder to maintain or continue beyond this time

Are there any risks associated with the PHB? How will these be mitigated?*

Please consider all risk widely and then specific to the individual and how the risks have been considered and planned managment

Additional information

How will purchase be made*

By referring for PHB the ELFT clinician agreed to have oversight of the account, and support the PHB holder to make purchases within one week of reciept of funds.

Requests over £250 need approval from a team lead/manager

Is the request over £250?*

If you have written approval from the approving manager please forward this to PHB@corearts.co.uk Please provide the approving managers:

Name*

First NameLast Name

Email address*

example@example.com

Telephone number*

Please enter a valid phone number.

Requests over £500 will be send to the PHB Oversight Panel for approval. This governance panel meets bi-weekly;

Is this request over £500*

*Next steps

If this budget is under £250 it does not require manager's approval, please fill and sign this DPA agreement and send it back to phb@corearts.co.uk for us to review the application and accept the referral.

Feedback helps us to learn what is working well and what can be improved.

Are you happy to be contacted by a member of the ELFT PHB team to share more about your PHB experience?*

PHB referral

Eligibility criteria

Referrer details

PHB holder

PHB Holder demographics

The Personalised Mental Health Recovery Goal

PHB request

Using the PHB safely

Approval