A: Yes, joint funded packages are possible. There needs to be a process for the NHS to calculate its contribution

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1 Questions Asked by Attendee Q: Can budgets be shared with LA if patient has considerable social care needs? A: Yes, joint funded packages are possible. There needs to be a process for the NHS to calculate its contribution Q: Is it the norm for the local authority to manage the financial element? e.g. invoices payments etc? A: A lot of PCTs have used existing LA infrastructure to reduce costs and to get up and running more quickly Q: Cheryl George Notts/Bassetlaw PCT's Q: Can it be spent on residential nursing care? A: Yes. I have included the text from the official DH document. A high proportion of people receiving NHS Continuing Healthcare are living in residential or nursing homes. Current social care policy does not allow direct payments for residential care, but people may still be able to have a personal health budget, and possibly direct payments for other aspects of their care. The personal health budgets team will be working closely with social care colleagues as the issue of direct payments for residential care is considered as part of the Social Care White Paper. Q: If this is a combined package of health and social care elements, how does this affect the calculation of client contribution towards social care element? A: This would not change. The same charges would be applied to the social care funded element as it would if there was no health contribution. Q: Should additional funds be made available to patients to train their staff adequately or will this always come from within the allocated PHB In the pilot programme, training was largely funded by PCTs. In some cases, certain types of training were mandatory e.g. moving and handling for CHC or food safety. Over time, this is likely to vary locally. Q: What is the most effective way to challenge a PHB which does not fully take account of social care needs? Are there any strong recommendations forthcoming around the levels of advocacy that may need to be commissioned in order that patients and their carers are supported to ensure PHB are allocated to meet both Health and Social Care Needs.

2 The guidance that is being developed by DH alongside the evaluation and the toolkit that has been published make it very clear that a PHB for CHC should cover health and social care needs. But there will have to be action taken locally to ensure that this is implemented well in each area. Working with other PHB holders through peoplehub ( may help. Q: I have no sound, what do I need to do? A: Hi do you want to try to login again. Are you listening on a headset? Q: Yes and I can't seem to make changes, I will have to pick up with technical people, my end I think. A: Ok, sorry you can't hear. we'll send you the link to the video Q: volume controls seem to be ok A: Have you clicked on your audio settings link on the audio pane in your control pane? Q: I have a headset but no sound at al A: Have you checked your volume? Q: Have the pilots any examples of how health services have been decommissioned to free up the money to be used for purchase of services by individuals. This was not necessary during the pilot because some sites had additional funding and the numbers were low so double running was possible. Decommissioning will be a big priority going forward. The Audit Commission has published a helpful document with strategies for how to transition about of block contracts and manage other financial risks. Q: Is it likely that an amount of the budget will be allocated for the support services specifically with managing budget, payroll etc that you have talked about or is the service user expected to pay for this support outside of the budget? A: As part of the pilot programme, this was largely funded by PCTs. But we know from social care that practice on this varies, with some Las paying for support services centrally and others requiring individuals to pay for some from their budgets. Q: Many thanks - very helpful

3 Q: In terms of Mental Health - is a Mental Health Foundation Trust the commissioner, or still the Commissioning Group? A: CCGs will continue to commission mental health services. Substance misuse services will be commissioned by Directors of Public Health based in LAs who will report to Public Health England Q: How will funds be released from existing services to fund the PHB's? A: There are a range of strategies that can be used. The first step is to figure out a price for the service. Commissioners can then transition from purchasing everything on a block basis to purchasing a proportion on a block basis and a proportion as PHBs. The balance can shift over time to enable providers to adjust and to ensure the market isn t entirely destabilized. Q: For children with Personal Budgets, where do universal services fit in. For example if a child / young person wanted more therapy than provided by the NHS A: A lot of people have used their PHBs for therapy in some cases because they have not qualified for it but found it to be beneficial. It would be possible to use it for additional therapy e.g. if the only thing on offer from the NHS is time-limited and not adequate. Q: Are there any examples of criteria that have been used in the approval process? A: This document includes criteria for sign off The bigger problem has been that clear criteria have not been set and communicated to individuals which then makes the approval process opaque and subjective. Q: Who will monitor? Is there a role for funding of case management approaches and models to address this? As an independent case manager I am very aware of the varying standards of delivery and the constant concerns for vulnerable adults. This is often from issues within the family who will be the main drivers behind the move towards a PHB for their vulnerable relatives. I guess this links to the liability issue too. There has to be a care coordinator named to work with the individual to manage the plan so there is some oversight built in. Q: engaged tone permanently

4 A: Hi do you want to try re-logging in? Q: What about using PHB to purchase equipment? Would this have to go through OT services? A: No.Indiviudals have used their PHB to purchase equipment, although if the equipment can be bought through another route, then the PHB can be used for other things. It will stretch further Q: Thank you very much for this Q: What are clinical commissioning groups please? A: -These are the organizations that are replacing PCTs as of April 2013 and will be responsible for the majority of commissioning in the NHS, including PHBs. Q: Mateusz0901 Q: Do you anticipate that monitoring will be held within health or within Social Care - given that social care has experience of dealing with this and also that the funding is intended to cover both aspects of an individual's needs. A: Where individuals are fully funded by the NHS, monitoring will remain within the NHS. Individuals should have a formal review that is part of the standard review process for CHC as well as having opportunities to review how things are going informally as and when they need. Q: at the moment our health colleagues aren't able to make a Direct Payment and so our children who are eligible for 100% funded children who are using a dp as a child flounder at the point of moving to adult 100% CHC funding. Will all health CCGs be required to be able to make a direct payment. A: This will need legislation which the Department of Health is working on. But the intention is that the legislation to allow all CCGs to make direct payments will be in place in time for roll out in April 2014 Q: is there any training being given to clinicians at the moment? It has been a huge learning curve for social care staff so I anticipate it would be a huge culture change and learning curve for health A: There are roll out events happening in every region which clinicians can attend. There also needs to be training offered locally and on an ongoing basis as this is a major culture change and it won't happen overnight. Q: choice and control is only meaningful if there are choices to be made and suitable services are available to buy. E.g. training for P.As is very difficult to find.

5 A: Yes, training for PAs particularly for clinical care has been difficult to find and yes, an important part of making PHBs work well will be to develop the market so that there are real choices for people. Even when they are not directly purchasing services, there is an important role for commissioners to play in stimulating market development and supporting micro-enterprises and small providers to come into the market. Q: Working in a social care PB field it seems that the theory of PNBs is the same, but in practice the RAS does not cover all needs, budgets are set in stone before planning and based on the cheapest option, there are massive restrictions in use and there is more monitoring than ever before - how are you going to ensure that PHBs don't follow the social care PBs in these respects A: These are all challenges that we will need to work on as part of roll out. The scenarios you paint has not taken place in all areas. Some areas have implemented PHBs in a way that is true to purpose and the DH has drawn on these sites in developing its tool kit and other guidance. But these issues won't go away, in large part because we are pushing against a medical model of care and a tight budget environment. Q: Where someone has joint social and health needs, is it expected that the LA social services will pay for the social and the NHS pay for the clinical needs then - in the LA where I work social services funding is withdrawn and Continuing healthcare takes over the whole package meaning that there is no longer any contribution - is this not the case with the PB pilots? (CHC is often seen as an easy way for Social Services to save money and people with large packages are automatically assessed for CHC even if it is clear that they only have social needs). A: A PHB is only calculated after an individual has been assessed as eligible for CHC using the national framework and decision support tool. If someone coming from social care is found to be eligible for CHC, then they will have the right to ask for a PHB as of April Q: Is there a timeframe for the rollout from pilots to mainstream implementation of PHB? A: When the final evaluation report is published later this month, there is an expectation that the government will confirm the timetable for roll out. This means that everyone eligible for CHC has the right to ask for a PHB from April There is an expectation that roll out will be staggered for other long term conditions but that roll out will go beyond CHC. The final timetable will be announced with the evaluation.

6 Q: Thanks you, very helpful! Q: Who is responsible for the initial training of procedures that are carried out for chc patients by carers or qualified staff employed by the budget holder and who is responsible for the regular updates? would this lie with the service user? Would the nhs be liable for any problems that may occur through lack of training as it is this body that is supplying the money to the service user? A: The training needs of any staff should be thoroughly documented in the care plan and ongoing training needs covered in the review process. Some PCTs have made certain elements of training mandatory. Where a third party holds the budget, they can provide support around training. PHBs involve sharing risk and responsibility between the NHS and the budget holders but thorough documentation of the discussion and training needs will protect the NHS if there is an incident. In reality, individuals find that hiring their own staff who know them well keeps them safer than using agency care. Q: Thank you for this Webinar, very interesting. Q: Will people have to pay for input from district nurses, community physios etc or will these services still be free for people with a PHB? What about people with equipment needs -will they have to fund equipment themselves e.g. continence products, walking aids, wheelchairs etc A: These services will continue to be free if an individual is eligible for them. Q: I'm afraid I missed the first 20 mins of the webinar due to technical problems, so apologies if you have answered this already, but I was wondering what Vidhya could tell us about the kinds of options for support with support planning had been explored in PHB pilots so far? A: Most pilot sites used independent support brokers, often working with brokers from the LA. Clinical staff were tried but were less good at the role. Some sites are looking to develop more peer support, both paid peer support, and informal support where someone who has completed a plan volunteers to plan with someone else. Q: is mark's Q partly about an individual employer being equivalent to a small business (albeit nonprofit-making), though not a limited company, more like a sole trader Not sure what this means

7 Q: Have any of the pilots included Children's Continuing Care? If not, are there any plans to do so? A: As of April 2014, parents of children with special educational needs or disabilities will be able to ask for a personal budget based on a single assessment across health, social care and education. Q: Has the pilot sites seen an increase in care package costs A: No, if anything in CHC there has been a decrease in care package costs as individuals have hired their own PAs rather than using agencies. Q: If the Whole package is CHC then I cannot see how the separation for means testing can work : surely this would be done in practice as separate entities? A: If the whole package is NHS CHC, then there is no means testing. The individual has the right to have their care fully funded by the NHS and this funding should cover both health and social care needs Q: do you need to set up a limited company for a PHB - some PCTs say this is the only model A: No. Once all CCGs are able to offer a direct payment, then there will be more options for people. CCGs will be able to specify the kind of third party that they will accept but the DH guidance is clear that this can be a range of different types of organization user trusts, independent living organizations, providers etc Q: who holds the contract with the provider A: It depends. If the individual has a direct payment, then they make the purchases directly. If a third party manages the money, they make the purchases and act as the employer of record. If it s a managed budget, then the contracting is done by the commissioner according to the choices the individual makes Q: how will quality be monitored e.g. safeguarding? A: Any risks and how they will be managed need to be documented in the care plan e.g. there needs to be a backup plan if staff are ill. In general, individuals report feeling that quality improves when they hire their own staff as the staff are better tailored to their own particular needs and know them much better. There is greater continuity of care than with agencies. When PHBs are used for care where there is a professional body then providers have to be registered with that professional body. Q: HCD employs PA's chosen by the individual using their PHB - allowing them the choice and control of PA but without the responsibility of being a legal employer. We can arrange training for the more complex tasks, however we struggle to get district nurses/trainers to sign off on going competency. Is there anything you can suggest to allow companies such as ours to support people in the community?

8 Nurses and PCT's are still suggesting many tasks should take place in a hospital environment - even when individuals being the employer themselves have traditionally been employing people to carry out these tasks at home.. A: This is a major problem in some areas. District nurses and other NHS staff will not play ball and do the sign off. My only suggestion would be to contact an area where it works well like Oxfordshire and see whether the team there can give you any tips to win your district nurses over.