Shorter review periods (2 to 5 years)

John is 73 years old. He lives alone and he enjoys regular physical exercise, such as long hikes and cycling. He has no prior conditions. However, 6 months ago he was involved in a cycling accident. He sustained a spiral fracture of his left leg, which has affected his movement and his ability to care for himself. Due to the severity of the injury he underwent surgery and an external fixator was used to support the bone to aid healing. The metal work had to be removed due to infection and John has been advised he has to non-weight bear for the next 3 months, until the infection is cleared. At this stage, he is due at the hospital again for a review of his progress.

John requires help transferring from bed to a chair, due to his non-weight bearing status. He requires assistance with bathing as he has to prevent the leg from coming into contact with water due to the ongoing infection. He also requires assistance with dressing his bottom half, as the dressing on his leg is bulky and he is unable to bend his left leg.

He has his dressing changed weekly at present, and the District Nurses attend his home for this.

He is on Intra-venous antibiotics and has a line in place for these to be administered due to the severity of the infection. His family have been taught how to administer these as he is unable to manage this independently, due to the positioning of the line. He requires these 4 times daily. John has started physiotherapy and manages his pain with the use of strong pain medication. Although he requires assistance getting into bed, John states in his application that he does not have any night-time needs.

The case manager establishes that John satisfies the daytime condition and is entitled to the lower rate of PADP. They are aware that, for people of John’s age, a full recovery is not always possible and will heavily depend on other relevant factors impacting on John. They determine that due to

• John’s overall physical fitness
• The improvements that he’s already achieved by continually carrying out his physiotherapy exercises
• the expected improvement with spiral fractures (18-24 months) generally,

it is likely that John will experience significant improvements in his overall condition. The case manager therefore sets a 2-year review period.

Ted (79 years old) has been struggling with severe depression for the last 5 years. Despite his condition, he was able to manage with the support of his wife, who took care of all the household responsibilities and managed his healthcare needs. His wife passed 4 months ago, leaving Ted to cope on his own. His family realised the severity of the situation after his wife passed, and have tried to seek professional input to address his depression. He has refused to engage with any services and refuses medications. His family have now convinced Ted to apply for PADP.

The application explains that Ted’s symptoms include persistent sadness, loss of interest in activities, feeling hopeless and worthless and often tearful, poor sleeping and poor concentration. Ted frequently expresses that he would be better not here, indicating a risk to self. The family has become reluctant to leave him unsupervised.

He requires prompting with eating as he has no interest and often skips meals with no appetite. This has led to weight loss.

In their statement of support, Ted’s family says that Ted also experiences insomnia and paces around at night. The family have created a rota to stay and supervise Ted throughout the night, especially regarding his thoughts of no longer wanting to be here. There have been instances of Ted attempting to lock himself in rooms unsupervised during the night due to these thoughts. He has lost all motivation and never leaves the home.

Ted also refuses medication or to engage with services that may offer support, as he sees no point. His family keep medication away from him to reduce risk. His family also express their hope that, with their increased support, Ted will make small improvements in the medium-term future, including re-engaging with services and treatment.

The case manager consults medical guidance to better understand Ted’s condition and prognosis. They establish that, as Ted is refusing medications and specialist input and has recently lost his wife as his main care giver, it is likely that at present, the condition is unlikely to improve if Ted continues to refuse engaging. However, they establish that it is more likely than not that, over time, Ted will slowly become more open to receiving professional support and take medication.

The case manager awards Ted the higher rate of PADP and sets a 5-year review period. This is because Ted requires continual supervision throughout the day and for another person to be awake for a prolonged period of time to watch over him to avoid substantial danger during the night. Should Ted’s needs improve sooner, he is required to report a change of circumstances.

Jack (68) was involved in a serious car accident 7 months ago that resulted in substantial skeletal injuries including multiple fractures to his legs, pelvis and ribs. #]

His carer suggested Jack should apply for Pension Age Disability Payment. His application describes that Jack requires assistance with washing, as he is unable to bend to wash the bottom half of his body. He also requires assistance with dressing as he is unable to bend to dress due to his shattered pelvis. He has had a raised toilet seat and handrails installed in his bathroom, but still requires physical assistance to get on and off the toilet, due to all injuries and his level of pain.

Jack has difficulties moving around the home due to his level of injuries, and requires assistance when moving from room to room. He also requires assistance getting in and out of bed due to level of pain and restricted movement. During the night, he requires assistance 2-3 times per night turning in bed to aid with pain and reduce bed sores. This takes around 30 minutes each time for his carer to support with. His medication is kept in a pill box and he can manage this independently.

The discharge and referral letters Jack sent with his application tell the case manager that Jack was reviewed by an Orthopaedics specialist and required immediate traction to stabilise his fractures and prevent further damage. He was placed in traction for around 8 weeks to allow for proper alignment of his bones. Following the traction period, Jack underwent surgery to repair his fractured bones and is scheduled for a further 4 surgeries over the next 18 months.

The case manager is unsure what these surgeries are and what Jack’s recovery afterwards will be like. They consult medical guidance but are still unsure. They request a case discussion. The Health and Social Care practitioner tells them that the surgeries include procedures such as internal and external fixation to realign and stabilise the bones. Bone grafts may be necessary. Each surgery and recovery is estimated to be around 6 months, to ensure success, and no rejection of bone grafts. This means that it will be around 2 years for the surgeries to be competed. Following this, Jack will require an intensive rehabilitation programme aimed at restoring strength and function. Physiotherapy will be lengthy and play a crucial role in his recovery. Jack’s recovery is expected to be long and challenging. The case manager decides to give Jack a higher rate PADP award and sets a review period of 4.5 years.

Gertrud is 69 years old with a diagnosis of sciatica and has a number of care needs.

She experiences pain from the sciatic nerve from her bottom to her toes in her left leg. The area is painful and Gertrud feels a burning sensation. Often, around 2-3 times per day, she loses feeling in her foot when the area becomes numb. This causes her leg to give way, resulting in multiple falls per week (around 2-3 times). She requires assistance in the shower, as standing for long periods causes the weakness and numbness increasing her risk of falls.

Sitting makes the pain worse and she will often lie on the couch as opposed to sit. She needs support when bending as any additional stress on her lower back increases the pain, which shoots down her leg. If this is aggravated she experiences muscle spasms in her lower back, which can debilitate her for 2-3 hours, and this occurs 3-4 times per week. This means that Gertrud also needs support with dressing and undressing, as the movements required to do this independently trigger muscle spasms.

She has to sleep with support from her pillows to keep her spine aligned, to reduce the pressure on the sciatic nerve. She sleeps with a cushion between her knees, which normally helps alleviate the symptoms. Moving around she can stumble, and she relies heavily on the furniture for support when moving around the home. She has had surgery but it was not completely successful. Gertrud attends the pain clinic every month and continues to be under review by the specialist consultant every six months.

Gertrud has been advised of further surgery she will need to have and has been placed on the surgery waiting list. The consultant specialist is hoping she can have the surgery in 1-2 years as this is the current waiting time. After the surgery Gertrud will need time to rehabilitate for 6-9 months. She will need to have intensive physiotherapy for a further 6-9 months where there should be improvement in her condition.

The case manager makes a determination that Gertrud is entitled to the lower rate of PADP, as she satisfies the day time condition through requiring prolonged or repeated attention in connection with her bodily functions. She does not satisfy the night-time condition, as the aids she uses support her during the night. The case manager determines that a review in 4 years would be appropriate after taking into account:

• the waiting time for surgery
• the recovery period
• the treatment post-surgery.