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Burning Issues by dEGCSJ

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									Personal Health Budgets - Burning Issues
The questions below were raised by people who attended the personal health budget
learning events which were held across the country during February and March this
year. Some were clearly addressed to us, some more generally sought ideas from
other people and organisations. We have tried to offer our input on as many of the
questions as we can, although this does not mean that we have all the answers. It is
therefore a living document, not a policy statement. Some of the issues will be for the
pilots to investigate, with our help. We will update and expand this list of issues as the
pilot programme develops so if you have any comments on any of these issues, or
want to see more issues added to the list, please write to us at
personalhealthbudgets@dh.gsi.gov.uk.


  FINANCE AND BUDGET SETTING ....................................................................................... 3
    1. Who decides who gets what ? ...................................................................................... 3
    2. Which costs will be charged to the package, e.g. governance, planning, support? .... 3
    3. How should pilot sites go about setting a personal health budget? ............................ 3
    4. How should pilot sites work out the price for services and resource allocation
        systems? ....................................................................................................................... 3
    5. Where is the money coming from to support the care professional input? ................. 4
    6. At what point does a surplus in a personal health budget become an overspend
        for the organisations involved in the pilot? ................................................................... 4
    7. Is the vision that pilot sites will have an integrated process across Health &
        Social Care, so that, for example, there is one bank account for direct payment
        users to avoid a confusing multitude of funding streams? ........................................... 4
    8. How do you silence the critics who feel this is just another cost cutting exercise? ..... 4
    9. How should sites work with Independent Living Fund? ............................................... 4
  ENGAGEMENT AND SUPPORT ............................................................................................ 5
    10. What is the best stage of the process to involve people who use services in a
        new pilot? ...................................................................................................................... 5
    11. How do you ensure all people /groups are included in developing Self Directed
        Support / Personal health budgets E.g. BME older people, etc? ................................ 5
    12. What support should pilot sites offer to support the family dynamics so that
        personal health budgets can work comfortably? .......................................................... 5
    13. Will pilot sites have to make sure advocacy is available for people with personal
        health budgets? ............................................................................................................ 5
    14. Will there be quality standards for advocates? ............................................................ 5
    15. How should pilot sites go about establishing monitoring and safeguarding
        systems for large numbers of individuals with personal health budgets? ................... 7
    16. How do pilot sites ensure that people who don’t want a personal health budget
        still get good quality services? ...................................................................................... 7
  PROVIDERS ............................................................................................................................ 7
    17. How do people choose a provider? .............................................................................. 7
    18. If sections of the NHS are subcontracted out to other companies will we still be
        able to ensure access to personal health budgets or personalised services? ............ 7


Personal Health Budgets – Burning Issues – July 2009 – gateway reference 12066
    19. What will be the impact of personal health budgets on the local voluntary sector? .... 7
    20. Can personal health budgets be used for intermediate care at home?....................... 8
    21. Will PCTs be able to simply give someone with complex needs the equivalent of
        their care costs in a direct payment?............................................................................ 8
    22. How do you work with local strategic partnerships to avoid duplication of process
        and support? ................................................................................................................. 8
    23. Why not use top-ups with personal health budgets? ................................................... 8
    24. If Primary Medical Services are excluded how will primary care commissioning
        be included? .................................................................................................................. 8
    25. How do you inform/train around the social model of disability and foster the
        culture shift? .................................................................................................................. 9




Personal Health Budgets – Burning Issues – July 2009 – gateway reference 12066
FINANCE AND BUDGET SETTING
                                                                                                    Formatted: Indent: Left: 0", Hanging: 0.25"
1.           Who decides who gets what ?
As we said in First Steps, we do not intend to specify, at a national level, details about who      Formatted: Normal
can get what and what can be bought. Local organisations will need their own decision
making processes, working within the principles and parameters that we have set. We believe
that personal health budgets, whether notional or real, may benefit anyone who would like
more control of their healthcare, and we are encouraging pilot sites to think broadly about this.
Our guiding principle is that personal health budgets can be spent on any goods or services
that are agreed in a care plan as likely to meet the patient’s agreed health outcomes, and
which it is appropriate for the state to fund.
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2.          Which costs will be charged to the package, e.g. governance, planning,
    support?
Different ways of organising the budgets may be appropriate: PCTs are likely to continue to
commission many aspects centrally, and this may well extend to e.g. care coordination,
advocacy and support. We are not specifying what is appropriate. On an individual level,
different elements of a person’s care and support plan may lend themselves to being
managed differently as part of one care package, eg an individual may be offered a budget
specifically for patient transport, or personal care as part of an NHS continuing healthcare
package and so on.
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3.          How should pilot sites go about setting a personal health budget?                       Formatted: Numbered Qs, None, Indent:
Setting the budget at the right level will be one of the major challenges to be addressed during    Left: 0", Hanging: 0.25", Space Before: 0 pt,
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the pilot programme. In many cases, the starting point will be the actual cost to the NHS of        keep with next
providing care. An individual’s budget could then be refined over time as they develop their
own care plan in partnership with the professionals involved in their care.

A small contingency component – in recognition of the fact that, as with care commissioned
conventionally, things do not always go according to plan over a given period – is usually
included in social care budgets, and it may be appropriate to follow this approach. A key
message from those who have developed individual budgets in social care is not to be
obsessed with the money, rather to focus on the person/outcome and accept that you will not
always get this right first time.
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4.          How should pilot sites work out the price for services and resource                     Formatted: Numbered Qs, None, Indent:
    allocation systems?                                                                             Left: 0", Hanging: 0.25", Space Before: 0 pt,
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The understanding and reliability of cost information varies from service to service and from       keep with next
PCT to PCT, and will present a significant challenge in many areas when considering the
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pricing of services. It is recommended that PCTs talk to their Local Authority partners, who
may have expertise in the area of understanding the costs of the services they provide having
gone through these exercises within the context of personal budget arrangements for social
care. There is also ongoing work within Payment by Results around developing national
currencies and prices (where appropriate) for mental health and community services. Pilot
sites could consider the findings from these projects when pricing services to be offered to
individuals.

While in the long term we will need systems that can accurately allocate resources, we do not
expect pilot sites to have working resource allocation systems in the early part of the pilot. We
expect them to be able to tell people up-front how much money there is to plan with as a core
part of the PHB process, but where there is only a sensible proxy available at the outset, this
is also fine. As the pilot progresses, we will work with those pilots who would like to be
involved in developing more sophisticated systems to explore this issue further.


Personal Health Budgets – Burning Issues – July 2009 – gateway reference 12066
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5.          Where is the money coming from to support the care professional input?                    Formatted: Numbered Qs, None, Indent:
As we said in First Steps, the Department of Health has a modest amount of money to                   Left: 0", Hanging: 0.25", Space Before: 0 pt,
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contribute towards the cost of piloting but we cannot cover service provision costs (e.g. any         keep with next
additional cost because of double running). Funding from the Department of Health will be for
the additional evaluation costs associated with being a pilot site. Any additional investment
necessary, e.g. in workforce capacity and capability, will therefore come from the
organisations themselves.

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6.          At what point does a surplus in a personal health budget become an                        Formatted: Numbered Qs, None, Indent:
    overspend for the organisations involved in the pilot?                                            Left: 0", Hanging: 0.25", Space Before: 0 pt,
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The progress of the patient should be monitored regularly so that any shortfall in the agreed         keep with next
budget, or a need for a change in services or provider, can then be spotted promptly and
corrected, or a different care plan agreed. If there is significant underspend, leading to a
surplus, this may need to lead to a change in the budget or a revision of the care plan, and
some money may be reclaimed. Note this issue will be most relevant for direct payments,
which requires legislation and will be underpinned by regulations developed with public
consultation. Subject to Parliament, we hope to publish draft regulations by the end of the
year.

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7.         Is the vision that pilot sites will have an integrated process across Health &             Formatted: Numbered Qs, None, Indent:
    Social Care, so that, for example, there is one bank account for direct payment                   Left: 0", Hanging: 0.25", Space Before: 0 pt,
    users to avoid a confusing multitude of funding streams?                                          After: 0 pt, No bullets or numbering, Don't
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We have heard very clearly the importance of integration between and health and social care
and were pleased that some of the provisional pilot proposals have already started to think
about how they will make the system as seamless as possible for the individual. Where
someone has personal budgets for both health and social care, these would ideally appear as
a single budget to the individual. However, since health services are free at the point of use,
and social care is a means-tested co-payment system, funds originating from different sources
– even when part of a pooled budget under a section 75 agreement - will have to be tracked
and monitored according to different legal frameworks. This will mainly be relevant for direct
payments for health care, when they become available.

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8.           How do you silence the critics who feel this is just another cost cutting                Formatted: Numbered Qs, None, Indent:
     exercise?                                                                                        Left: 0", Hanging: 0.25", Space Before: 0 pt,
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The aim of personal health budgets is not to cut costs. At this stage, we and our partners think      keep with next
it is important to address tensions upfront rather than try to silence any critics! There will be a
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lot to learn during the course of the pilot programme about their effect on services and their
cost effectiveness. Although we envisage that people having more control could lead to more
cost effective services, e.g. through decreased wastage and decreased reliance on crisis
services, we also anticipate additional administrative costs associated with personal health
budgets, particularly at the beginning. This is an area that will be looked at by the evaluation
team.

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9.          How should sites work with Independent Living Fund?                                       Formatted: Numbered Qs, None, Indent:
Independent living funds (ILF) provide money for personal care and domestic assistance to             Left: 0", Hanging: 0.25", Space Before: 0 pt,
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enable disabled people to live in the community rather than in residential care. The evaluation       keep with next
of the Individual Budgets Pilots highlighted that there were legislative barriers to alignment of


Personal Health Budgets – Burning Issues – July 2009 – gateway reference 12066
the Independent Living Funds and restrictions on how the funds could be spent. We hope pilot
sites will think carefully about how they deliver personal health budgets so that the people
receiving them get the most seamless service possible. The Department for Work and
Pensions (DWP) - which is responsible for ILF – has also launched a major consultation on
how the Independent Living Funds could be included in the “right to control” trailblazers. The
consultation runs until 30 September 2009 and you can take part at this website:
http://www.odi.gov.uk/working/right-to-control.php


ENGAGEMENT AND SUPPORT
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10.          What is the best stage of the process to involve people who use services in a
    new pilot?
We believe that input from people who will be using personal health budgets is crucial at every
stage and they should have the opportunity to influence the design and development of the
projects. We have asked would-be pilot sites to demonstrate their commitment to engaging
and working with people who use services and others in the local community. How best to do
this will be left to the locality to decide but we intend to share good practice as it develops.

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11.         How do you ensure all people /groups are included in developing Self                   Formatted: Numbered Qs, None, Indent:
    Directed Support / Personal health budgets E.g. BME older people, etc?                         Left: 0", Hanging: 0.25", Space Before: 0 pt,
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Personal health budgets, including direct payments for health care, have great potential to        keep with next
allow those least well served by the NHS to influence the way their care is delivered. This will
depend on effective support being available, designed to meet the particular needs of those
individuals. Our First Steps document, and our application form for Expressions of Interest (for
becoming a personal health budget pilot site), make it very clear that we are expecting pilot
sites to use personal health budgets to tackle inequalities. They should therefore be
considering how best to tackle inequalities through including unrepresented and under-
represented people in their pilots.
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12.        What support should pilot sites offer to support the family dynamics so that            Formatted: Numbered Qs, None, Indent:
    personal health budgets can work comfortably?                                                  Left: 0", Hanging: 0.25", Space Before: 0 pt,
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Having proper support, tailored to the needs of the individual, is vital for the success of        keep with next
personal health budgets. The care plan that underpins a personal health budget should take
account of the needs of family and carers as well as the individual receiving the budget. The
involvement of families and carers in the design of the project may well help pilot sites
understand how to design supportive and inclusive systems.

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13.         Will pilot sites have to make sure advocacy is available for people with               Formatted: Numbered Qs, None, Indent:
    personal health budgets?                                                                       Left: 0", Hanging: 0.25", Space Before: 0 pt,
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Having proper support in place is vital for the success of the policy, and support could be        keep with next
delivered in many different ways. We would expect the PCT to work in partnership with local
authorities and third sector organisations to ensure that people being offered personal health
budgets, including direct payments for health care, receive appropriate guidance and support.
Independent or peer advocates may have a role in supporting people through the process.
Some of the evidence from other healthcare systems suggests that peer or expert patient
involvement as advocates is effective.

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14.        Will there be quality standards for advocates?                                          Formatted: Numbered Qs, None, Indent:
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There are no plans for a national set of quality standards for advocates of people with            After: 0 pt, No bullets or numbering, Don't
personal health budgets. However, if you are interested in finding out more about quality          keep with next



Personal Health Budgets – Burning Issues – July 2009 – gateway reference 12066
standards for advocates “Action for Advocacy” has developed a Quality Performance Mark
(QPM) which is a quality assessment system for all forms of advocacy. This is not a
Department of Health endorsement.




Personal Health Budgets – Burning Issues – July 2009 – gateway reference 12066
GOVERNANCE AND SAFEGUARDING
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15.         How should pilot sites go about establishing monitoring and safeguarding             Left: 0", Hanging: 0.25", Space Before: 0 pt,
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    systems for large numbers of individuals with personal health budgets?                       keep with next
The PCT will be responsible for overseeing and monitoring all personal health budgets to         Formatted: Font color: Auto
ensure that the individual is safe, making progress towards agreed health and wellbeing
outcomes and receiving high quality services – as they would do for traditionally
commissioned services. We are not specifying how they should do this at this stage, although
there will have to be particular safeguards for direct payments, underpinned by regulations
which will be subject to public consultation. We, together with the implementation support
team, will be supporting pilots to help them address the issues of safeguarding and scaling up
as learning develops.

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16.         How do pilot sites ensure that people who don’t want a personal health
    budget still get good quality services?
One of the key principles of this pilot programme (as set out in First Steps) is that having a
personal health budget does not entitle someone to more or more expensive services, or to
preferential access to NHS services. We need to work with pilot sites to make sure that
happens and understand how best to retain this equity. The evaluation team will be
specifically looking at this area.

PROVIDERS
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17.        How do people choose a provider?
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We would expect the PCT to work in partnership with local authorities and third sector           Left: 0", Hanging: 0.25", Space Before: 0 pt,
organisations to ensure that people being offered personal health budgets, including direct      After: 0 pt, No bullets or numbering, Don't
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payments for health care, receive appropriate guidance and support to help them choose
appropriate services. Independent or peer advocates may play an important role in supporting
people through the process. Pilot sites will also have a role in developing and managing the
market so that people have a genuine choice of provider.
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18.         If sections of the NHS are subcontracted out to other companies will we still        Left: 0", Hanging: 0.25", Space Before: 0 pt,
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    be able to ensure access to personal health budgets or personalised services?                keep with next
Some individuals may already be receiving NHS services via private or third sector providers.    Formatted: Font color: Auto
However, there should still be someone in the NHS who has oversight of their care who
should be able to address the issue of whether a personal health budget or other mechanism
of gaining more control could be appropriate.
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19.        What will be the impact of personal health budgets on the local voluntary             Formatted: Numbered Qs, None, Indent:
    sector?                                                                                      Left: 0", Hanging: 0.25", Space Before: 0 pt,
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As voluntary sector organisations may well be providers of services as well as advocacy,         keep with next
support and information, this will be a key area for us to understand as part of the pilot. We
believe that voluntary sector providers may be particularly well placed to understand and
respond to the needs of people using personal health budgets. Some of the provisional pilots
have already started working with local voluntary sector partners and we will also be liaising
with national bodies to see what support they can offer to local organisations.




Personal Health Budgets – Burning Issues – July 2009 – gateway reference 12066
DELIVERING SERVICES AND TRAINING
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20.         Can personal health budgets be used for intermediate care at home?                           Formatted: Numbered Qs, None, Indent:
Yes. A personal health budget could be used for Intermediate care in a variety of locations              Left: 0", Hanging: 0.25", Space Before: 0 pt,
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including at home. Intermediate Care is most commonly jointly commissioned by the NHS and                keep with next
social services. It usually lasts for up to first six weeks and is free during this period, even if it
is social services who have commissioned it). Our guiding principle is that personal health
budgets can be spent on any goods or services that are agreed in a care plan as likely to
meet the patient’s agreed health outcomes, and which it is appropriate for the state to fund.

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21. Will PCTs be able to simply give someone with complex needs the equivalent of
    their care costs in a direct payment?

The short answer is no – personal health budgets and direct payments are about much more
than simply handing over money, and this is particularly important for people with complex
needs. Most individuals will need to be supported carefully through this process. Assessing an
individual’s needs and agreeing a care plan will provide information that supports the
individual and the commissioner in agreeing how best to personalise the various aspects of
their care. It is therefore essential that all the necessary information is available and that all
the individual’s needs and circumstances – including the needs of the carers and/or family -
are taken into account. Whatever the form of personal health budget, the NHS retains its
responsibility for effective and proportionate governance.

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22.        How do you work with local strategic partnerships to avoid duplication of                     Formatted: Numbered Qs, None, Indent:
    process and support?                                                                                 Left: 0", Hanging: 0.25", Space Before: 0 pt,
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PCTs will want to agree with their partners in the local strategic partnership how they wish to          keep with next
deliver personal health budgets in a joined up way, whenever this is appropriate. It will also
make sense for them to work together on e.g. care planning, advocacy support, market
management and so on. We also expect PCTs to forge links with their local patient
organisations, third sector bodies to ensure that people are well informed about the range of
choices available to them. Staff engagement is clearly key, both in the design of a pilot and in
the implementation of personal health budgets, and commissioners will also have to be
engaging local providers to ensure real choices are available.

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23.         Why not use top-ups with personal health budgets?                                            Formatted: Numbered Qs, None, Indent:
As set out in Personal health budgets: first steps, personal health budgets must be compatible           Left: 0", Hanging: 0.25", Space Before: 0 pt,
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with the core principle that NHS care is based on clinical need not ability to pay – as set out in       keep with next
the NHS Constitution. The budget is there to meet the individual’s agreed needs in full, not to
part-fund them. So patients may not “top up” their personal health budgets from their own
resources, which would risk creating a two tier service.

If, for any reason, a patient wished to purchase additional care privately, this would have to
take place separately, with clear accountability, in line with the Government’s response to
Professor Mike Richards’ review of additional private drugs last year.

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24.        If Primary Medical Services are excluded how will primary care                                Formatted: Numbered Qs, Indent: Left: 0",
    commissioning be included?                                                                           Hanging: 0.25", No bullets or numbering
GPs, including practice based commissioners, can still offer personal health budgets – it is the
primary medical services themselves that we think need to be excluded - e.g. routine GP visits



Personal Health Budgets – Burning Issues – July 2009 – gateway reference 12066
and tests etc. This is because GPs provide comprehensive, registration-based services, and
we don’t wish to change that. Of course, if the pilot provides evidence that we ought to re-
examine this in future, we could do.

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25.         How do you inform/train around the social model of disability and foster the
    culture shift?
We hope that learning will emerge as part of this pilot but also building on the experience in
the Individual Budgets pilots. Suggestions made at the learning events included starting with
what makes sense to a particular locality, e.g. building on experience of personalised services
in any particular area.




Personal Health Budgets – Burning Issues – July 2009 – gateway reference 12066

								
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