Making robust decisions - example section

Below is a list of example based on making robust decisions.

Example: a decision is possible but difficult due to lack of information

In his application for Adult Disability Payment Imran describes having poorly controlled asthma. Imran provides a description of how his breathlessness affects him:

• He is out of breath when cooking, getting in and out of his bath and when bending to put his sock and shoes on. Imran clearly states that this is the case almost every day and for him not to have these symptoms is a clear exception.
   
• He can only walk a short distance before needing to rest. Imran does not provide much detail on how far he can walk and how consistent this level of need is.

He lists one inhaler, a reliever, under medication. He provides a prescription list, listing his inhaler, as confirmation from a professional. Imran also provides his GP’s contact details.

The case manager thinks there may be an inconsistency between the needs Imran has described in his application form and his medication.

As this may mean asking the GP additional questions, the case manager requests a case discussion with a health and social care practitioner to confirm that this inconsistency needs exploring further with the GP, rather than with Imran in a follow-up phone call.

The practitioner explains that Imran’s difficulties with cooking, bathing, and dressing, as well as his mobility needs, are a strong indication of Imran having severe, poorly controlled asthma. They confirm that his needs don’t seem to be in line with his medication.

The practitioner agrees with the case manager that it is unlikely that someone whose daily living and mobility is affected by asthma in the way Imran has described would only take a reliever inhaler. The practitioner explains that they would expect the client to additionally be taking one or more preventative inhalers. They also explain that clients with more severe asthma might also mention in their application that they often experience chest infections, especially during winter, lasting for approximately 1-2 weeks at a time. During a chest infection, they would be likely to take steroids and antibiotics. However, the fact that a client with more severe asthma does not mention chest infections in their application would not be an inconsistency.

The practitioner also tells the case manager that someone with severe asthma would usually have a specialist nurse practitioner or asthma nurse overseeing their care. They advise the case manager to ask the GP about Imran’s medication and care, rather than speak to Imram himself in the first instance.

The practitioner also suggests that the GP is asked to confirm whether Imran has reported respiratory conditions or is currently undergoing tests for any conditions which can cause shortness of breath. This is to ensure that there is no other medical reason why he may become out of breath when walking.

After being contacted by the case manager for additional supporting information, Imran’s GP provides minimal information in response. She confirms that Imran has asthma and that he is prescribed a reliever inhaler. She further states that he has not been prescribed any other medication for asthma for the previous 3 years, that his care is overseen by her without any input from a specialist, and that he has not seen her in relation to any other medical conditions. Her report does not cover Imran’s daily living or mobility needs and does not say whether he has other conditions that may impact on his mobility. The supporting information also doesn’t mention when she has last seen Imran.

The information from the GP confirms that there is an inconsistency between the description Imran has provided of his asthma and the care he receives for it. Taking a trust based approach, the case manager goes on to explore the reason for this inconsistency, rather than just concluding that Imran’s account of his needs is untruthful. As they struggle to get hold of the GP practice, they call Imran to ask when he has last seen his GP for a check-up regarding his asthma. They also want to ask a few follow-up questions on Imran’s mobility needs to understand the impact his asthma has on him.

During the phone call, Imran states that the last GP appointment regarding his asthma was about 3 years ago. The case manager establishes that this might explain the discrepancy between Imran’s account of his mobility needs and his prescription and his GP’s account.

The case manager goes on to ask a few clarifying questions on Imran’s mobility. However, when Imran starts providing more details on how restricted his mobility is due to breathlessness, the case manager realises that the simple follow-up questions they feel they can ask on the call are not enough to capture Imran’s needs. They bring the conversation to a close and decide that inviting Imran to a consultation will be necessary to fully understand how his symptoms impact on Imran’s functional ability and how variable this impact is.

During the consultation, the practitioner asks Imran more details about his mobility needs. This includes information about:

• the distance he can walk
• how frequently his mobility is impacted
• how long he needs to rest for
• how often he needs to use his inhaler
• if he has asthma attacks which require him to go to accident and emergency

As Imran has provided enough detail on his daily living needs already, the consultation focuses on his mobility needs only.

Imran advises he is only able to walk for around 5 minutes before he feels he has to rest. Imran feels that his walking pace has slowed noticeably recently, and he also slows down if there is an incline as he can start to feel more breathless. Where he used to feel able to walk to the corner-shop, about 200 metres, without aids, it now takes him about 5 minutes to get halfway, at which point he has to stop and rest. Only when he has rested for at least 5 minutes does he feel able to walk for another 5 minutes. He needs to use his inhaler more than half of the time during these rests. Generally he feels his mobility is consistent, unless he has a chest infection which causes him to be more breathless. Imran confirmed he only has 2 or 3 chest infections a year and they last around 2 weeks. Generally after walking for around 10 minutes he develops a tightness in his chest and has to use his inhaler. He would then rest for around 10 minutes after using the inhaler to let the tightness in his chest ease and to catch his breath. He feels he can then continue walking again, but would likely rest every 1 - 2 minutes at this point as the tightness in his chest only continues to worsen. He does not feel his inhaler helps with this and his chest can feel so heavy that he has to stop walking and if he was away from home, he would call a taxi or family member to collect him. Because of this, Imran cannot walk to the corner shop anymore and either asks a family member to give him a lift to the shops or to manage the shopping for him. Imran advised that he feels this tightness in chest start occurring over the last 6 months.

He attended hospital two weeks ago due to this tightness and heavy feeling on his chest. The hospital staff advised he speak to his GP about his symptoms and a medication review as the presenting symptoms suggested a potential strain on his heart and they also made a referral to the cardiology department, but he is still awaiting an appointment. He tried to make a GP appointment, but every time he calls the reception staff advise there is no availability, so he gave up and figured he would just wait on the hospital appointment first. When asked Imran advised this heavy sensation and tightness in his chest started to develop over the last year and comes on the more he exerts himself.

After receiving the consultation report, the case manager now has enough information to score Imran’s needs and establish his entitlement based on:

• Imran’s application form
• Supporting information (prescription list and GP letter)
• The case discussion
• The follow-up phone call with Imran
• Imran’s consultation report.

They award Imran 0 points for the planning and following a journey activity within the Mobility Component. His condition does not appear to have impacted his ability to plan journeys or follow directions. They award Imran 8 points for the moving around activity of the mobility component. Though Imran indicates that he is able to walk 100 meters (half the distance to the corner shop) without aids, this alone takes him 5 minutes therefore he cannot walk 100 metres at a normal pace. He then needs to rest for a long time before he can attempt this once more, at which point he cannot repeat this without use of an inhaler and a significantly longer rest. Thus he cannot achieve this in a reasonable period of time, and he cannot repeat this effort. For 8 points, Imran is entitled for the standard rate of the Mobility component of Adult Disability Payment.

The case manager sets a review period of 2 years. This is because Imran is waiting to be seen by a hospital consultant and is still intending to speak to his GP, which is likely to trigger a change in his medication and care. Once this has been updated to match to his current level of symptoms, and Imran has had time to adjust, his needs are likely to decrease slightly and stabilise.

Example: a case manager uses decision-making tools to establish the facts of a case

In her application form for ADP, Orla provided a good level of detail to allow the case manager to understand her conditions (Autism and Dyspraxia) and level of needs.

Orla:

• needs social support to engage with people face to face;
• relies on her parents to help her manage complex budgeting decisions;
• needs prompting to select appropriate clothing to reflect changing weather;
• uses ear protectors at university and in other noisy environments.​

Orla also supplied the contact details of her GP, who the case manager reaches out to for confirmation from a professional.

The supporting information the case manager receives from the GP confirms Orla’s Autism diagnosis. Furthermore, the GP says they don't think Orla’s symptoms are as severe. They recommend consulting Orla’s autism assessment report that Orla’s psychiatrist completed in the past. The GP does not provide information on any adjustments or equipment used by Orla.

As the case manager has confirmation from a professional, confirming one of Orla’s conditions, they are able to move on to making a determination on her entitlement.

The application form is detailed, so they have all the information needed to understand Orla’s level of need. However, when reviewing the application form together with the confirmation from a professional, they notice a few inconsistencies. Firstly, the GP doesn’t mention Orla’s use of ear protectors. As confirmation from a professional does not have to confirm all details mentioned by the applicant, the case manager decides that, based on the information available, it’s more likely than not that Orla uses ear protectors and her GP is either not aware or did not think providing this level of detail was necessary. They decide that, therefore, this is not an inconsistency that needs further exploring.

Secondly, the case manager notices that the GP raised doubt regarding the severity of Orla's Autism. As this is in conflict with Orla’s account, the case manager explores this further. The case manager wants to understand if this inconsistency is a genuine concern, or if these are merely differing perspectives that are reasonable when making a subjective judgment. They therefore consult medical guidance. The guidance does not provide the information they had hoped for. They therefore go on to request a case discussion with a health and social care practitioner, asking for information on how Orla’s needs and symptoms might differ between contexts and asking for advice as to whether or not to request a consultation.

The practitioner confirms that people with Autism can often ‘mask’ their behaviours in environments outside their home.

The case manager decides that a consultation is not needed, as they now

• Understand Orla’s conditions and how they affect her in different contexts,
• Understand that, on the balance of probabilities, the inconsistencies between the pieces of information are to be reasonably expected, and
• Have enough detail to score Orla for each activity.

They also decide that they do not need to reach out to Orla or her psychiatrist for her Autism assessment report. Using the balance of probabilities, they establish that, based on the:

• application form,
• GP’s letter, as well as
• medical guidance and case discussion,

Orla scores 2 points for Activity 6 of the Daily Living Component (Dressing and Undressing), as she needs prompting from her parents to select appropriate clothing when the weather changes. She then scores 4 points for Activity 9 (Engaging socially face-to-face) as she sees a community learning nurse on a weekly basis and struggles to understand peoples body language and expressions; Relying on her parents and trusted friends to help her manage social engagement. Finally she scores 2 points for activity 10 (making budgetary decisions) of the Daily Living Component as she cannot reliably change her budgeting decisions to reflect a change of circumstances.

As a result, Orla meets the eligibility criteria for a standard award of the daily living component of Adult Disability Payment.

Example: a case manager works with the individual to obtain the information needed to make a determination

James applies for ADP due to back pain which he has had since a bad cycling accident four years ago. Although the hairline fracture caused to one of his vertebrae healed as expected, the pain in his back has only slightly improved in the years since. The GP confirms James has mechanical back pain and is prescribed co-codamol as required for pain. The GP further states that James was offered a referral to the pain management service two years ago but declined.

In his application James describes difficulties with a number of daily living activities including: preparing food, taking nutrition, washing and bathing, dressing and undressing, engaging with others, and making budgeting decisions. He states that he needs prompting in relation to each of these activities. Additionally, James states that he cannot bend down to put on his socks and shoes, or wash his lower legs and feet, due to pain and stiffness in his back.

The case manager has confirmation from a professional and moves on to establishing James’ level of need and entitlement. However, they realise that there is not enough information in the application form for them to make a decision about entitlement. James has not explained why he needs prompting to undertake the various activities he's referred to, nor how frequently he needs that support. Without any further information it would be reasonable to conclude that it is more likely than not that James does not need prompting due to back pain for the majority of the time. However, the case manager establishes that it would be unreasonable to just dismiss this information. They therefore need to explore this potential inconsistency and decide to request a case discussion with a health and social care practitioner.

The practitioner explains that it is not uncommon for people who have continuing pain following a traumatic injury to also experience low mood, anxiety, or depression. This can make it more difficult for the individual to engage with the rehabilitation process which in turn can impact the extent to which they recover. Chronic pain can have a significant impact on a person’s mental health but they may not recognise themselves as having a mental health condition or discuss it with their doctor. In terms of the impact of low mood or depression, the practitioner tells the case manager that difficulties with motivation are common, and may make it difficult for an individual to complete various activities without prompting.

The case manager thinks that if James is experiencing low mood or depression, it would be reasonable for him to need prompting with some of the descriptors due to a lack of motivation.

They consider speaking to James to find out if that is the case. However, due to the open and potentially sensitive questions required to establish James's potential need for prompting, they decide that a consultation would be more appropriate, because James would be speaking to someone with a health and social care background. They request a consultation.

James attends the consultation over the phone, with his wife there for support. The practitioner asks James questions to find out more about how James is impacted by his low mood, and how his low mood is related to his back pain and his lack of progress in his healing process.

James describes feeling very down due to his back pain and the ongoing impact the pain has on his life. He tells the practitioner he feels as if he has lost the life he had before his accident.

James expresses low mood, as well as self-neglect, and has given no indication that their GP is aware. This suggests that no clear supportive strategies are in place. Therefore, the practitioner considers a safeguarding referral. To establish James’ risk of harm, they ask James if he is at risk of harm and/or suicide. James states that he is not. James also mentions that his wife provides emotional support. His wife confirms that James isn’t at risk of harm or suicide, which reassures the practitioner that a safe-guarding referral is not needed.

The practitioner asks James if he can say more about needing prompting, and he explains that he doesn’t feel like doing anything and can’t be bothered to look after himself unless someone hassles him to. James says he doesn’t like talking about it and suggests that his wife could tell the practitioner how she looks after him, as she would be able to better explain how things are.

James’ wife provides the following information:

Preparing food: James has never learned to cook, it’s beans on toast or nothing. He’ll do tea for him and the kids during the week while I’m at work but that’s just putting something frozen in the oven and managing not to burn the place down.

Taking nutrition: James hardly has any appetite and the weight has fallen off him. If I didn’t make him food and guilt him into eating it he would just live on toast and the occasional takeaway.

Washing and bathing: James won’t shower unless I am there to nag him, he doesn’t see the point. On a good week I might be able to get him to shower a couple of times but most weeks I’m lucky if I can get him in there once.

Dressing and undressing: James will sit in the same clothes for days on end. Even if he has a shower he’ll often just put the same dirty clothes back on.

Engaging with others: All of his friends were through the cycling. They’ve tried to keep in touch but there’s only so many times you can get no response, they’ve moved on over the years. I try and encourage James to get out and meet people but he says he’s got nothing to talk about. He probably speaks to the Amazon delivery guy more than anyone else. At least he gets a blether with the neighbours now and then when they come over to say hello.

Making budgeting decisions: If I’m not around, nothing gets opened. The mail would pile up behind the door if left it to James. He’ll pop out and buy milk and things from the shops when I nag him, and the direct debits come out of his account, but that’s the lot, the rest is up to me.

After receiving the consultation report, the case manager has enough information to score James’ needs and determine his entitlement.

Preparing food: 2 points

Though James has reported some difficulty when preparing/cooking food, he has not provided detail on whether this difficulty is due to back pain or stiffness. Instead, the information given focuses on the fact that James does not prepare or cook food for his own benefit. James’ wife’s contribution details that James will prepare meals for their children on week days, but that he never learned how to cook, and any meals he prepares will consist of frozen food.

The fact that James has not learned to cook is not relevant because there is no information establishing that James would be unable to learn to cook from a clinical perspective. So the case manager considers whether James’ lack of motivation to cook is sufficient to meet the requirements of descriptor D (Needs prompting to prepare or cook a simple meal). From the information provided, the case manager does not find that descriptor D is suitable in James’ case. James demonstrates motivation to prepare food for his children without prompting.

However, this activity relates to an individual’s ability to prepare food from fresh ingredients, and the information provided in his application only directly discusses James’ motivation regarding cooking. The case manager then considers the information provided in James’ application relating to Washing and Bathing and Dressing and Undressing, where the pain James experiences impacts his ability to complete each activity to an acceptable standard. Considering this information in the balance of probabilities, it would then be reasonable to conclude that James would not be able to safely and reliably stand at a counter when chopping and straining food and when standing at the hob unaided. A sitting aid could be beneficial in these circumstances.

On the balance of probabilities it is more likely than not that James requires aids to prepare and cook a simple meal from fresh ingredients. The case manager selects descriptor B, stating that James needs aids to complete this activity.

Taking nutrition: 0 points

The case manager knows from the information available that James has a lack of  motivation to eat and a restricted appetite due to low mood or depression. Although his wife describes what can be considered, prompting him to eat, she also says that without that support he would only eat toast or a take away. While James might not eat a healthy balanced diet if left to his own devices, it is reasonable to conclude that he would eat a sufficient amount to complete the activity to an acceptable standard without the need for prompting.

Washing and bathing: 2 points

The information suggests that James has difficulty completing this activity to an acceptable standard on the majority of days due to both back pain and his mental health. It is reasonable for James to use a long handled sponge to help wash his lower body when showering due to pain and stiffness in his back. As the descriptor relating to an aid or appliance is the first that is applicable to James, the case manager selects it.

Dressing and undressing: 2 points

The information suggests that James has difficulty completing this activity to an acceptable standard on the majority of days due to both back pain and his mental health. It is reasonable for James to use an aid to help him put on/take off his shoes and socks due to pain and stiffness in his back. As the descriptor relating to an aid or appliance is the first that is applicable to James, the case manager selects it.

Engaging with others: 2 points

James states that he needs prompting in order to engage socially. His wife has described that James has lost touch with most of his friends and does not proactively seek out other people to engage with. The conversations that James does have with neighbours are initiated by the neighbours, rather than by James. It is therefore reasonable to conclude that James has become socially isolated and needs prompting to engage with others.

Making budgeting decisions: 2

Whilst it is evident that James is able to make simple purchases, as well as make both simple and complex decisions, it became clear that James will not open his mail which is in keeping with low mood and depression. Therefore it is more likely than not that James needs prompting with complex budgeting decisions

Conclusion:

Using all of the information available the case manager has determined that James is entitled to the standard rate of the daily living component of ADP, as he has been awarded 10 points.