Making robust decisions – example section

Esther is 79 years old and lives alone. She has always been in good health and active for her age but over the last two years she has experienced a decline in her independence.

Esther’s daughter supports her with her care needs around her work schedule. Esther’s neighbours check in on her on a regular basis and help her with small chores around the house. Her neighbour suggests that she should apply for PADP.

In her application form, Esther explains that she contracted Covid about 2 years ago and has not managed to fully regain her fitness and strength since. Esther can become breathless very easily from minimal activity and needs attention from another person in relation to her bodily functions.

Esther needs help to bathe and dress herself. This is because doing so can leave her breathless. When this happens, it can take between 5 to 10 minutes to recover. Esther would be unable to bathe or dress herself without this attention because she would have to take multiple breaks to recover from her breathlessness. Esther similarly requires support getting to and from the toilet and requires attention with managing cleanliness. She also used to change incontinence pads independently, but she now requires support with this task.

Due to Esther’s exhaustion and lack of strength, she is unable to eat independently. She isn’t able to grip cutlery effectively and struggles with getting food to her mouth. Esther requires someone else to help her with taking nutrition, and also needs prompting to encourage her as she often becomes upset and frustrated when trying to eat.

Esther also reports that she has had a number falls over the past two years. Most of these have occurred at home. Once she slipped in the bath and hurt her right wrist when trying to stop her fall. Whilst she did not break the wrist, it has felt painful and stiff ever since. Esther has had handrails installed in her bathroom to prevent further falls, which she now uses for additional stability when her daughter assists with washing and bathing. The case manager considers this to be a reasonable aid to reduce the need for supervision with falls, but not practicable in relation to Esther’s need for attention when washing and bathing due to her breathlessness and exhaustion.

Esther doesn’t report any night-time needs.

Esther does not take any medication and has not been to see her GP since her covid infection. She does not provide confirmation from a professional and the statement of support section has been left blank.

The case manager reviews Esther’s application. 

From the information provided, they establish that Esther has symptoms of Long Covid and in combination with frailty, as commonly associated with someone of Esther’s age, requires assistance with a number of bodily functions, such as:

• moving around indoors
• eating, drinking and taking nutrition
• washing, bathing and personal hygiene
• continence and use of toilet

There are no significant inconsistencies in Esther’s application. The case manager therefore establishes good cause and proceeds to making a determination without requiring confirmation from a professional.

They establish that Esther has satisfied the daytime condition and is entitled to the lower rate of PADP as she requires frequent attention with her bodily functions throughout the day. As Esther is more likely than not to experience increased symptoms as she ages, her care needs are highly unlikely in decrease. However, it is reasonably likely that she will develop night-time needs as well in the future. Therefore, the case manager thinks that an indefinite award is not appropriate for Esther. They set a review period of 5 years.

Sandy (aged 68) applies for Pension Age Disability Payment due to a mental health condition. They do not provide any supporting information with their application, including their statement of support having been left blank. Sandy doesn’t name a particular condition but states they have mental health problems, that regularly cause them to struggle with motivation and low energy. The application form doesn’t provide a lot of detail on Sandy’s needs, other than Sandy explaining that they regularly don’t manage to prepare food or get dressed and end up missing meals and wear the same clothes for days and nights on end. They also provide the name of their medications on their application form, which includes Duloxetine, an anti depressant but do not mention the dosage they’ve been prescribed.

The case manager establishes that being prescribed this medication for depression is consistent with Sandy’s account of their mental health. They therefore apply good cause and go directly on to establishing the Sandy’s level of needs.

Sandy describes having difficulty with taking care of themselves and experiencing fluctuations in how they are impacted by their condition. However, the application, including the information on Sandy’s medication, is lacking in details about how significant this impact is, and whether these needs are limited to the day, or also occur throughout the night. The case manager needs further information before they can make a determination on Sandy’s entitlement. The case manager decides to contact Sandy with follow-up questions.

On the phone, Sandy seems hesitant to talk about their needs and whether or not these also include night-time needs. They tell the case manager that they are mostly fine and only struggle sometimes when they are not in a good place.

The case manager concludes that the phone call has not provided the answers they need to establish Sandy’s level of need. Furthermore, the information that Sandy did provide was inconsistent with the level of needs suggested by their application form and medication. The case manager is aware that individuals can struggle to talk about their conditions and needs. They also take into consideration that Sandy might currently be experiencing a period of depression and might therefore not be able to engage with them about their application. Therefore, they conclude that it is more likely than not that there is a reasonable explanation for this inconsistency. However, they still require more detail to make a determination. They decide that additional supporting information would be the best decision-making tool to fill the gaps in Sandy’s application.

The case manager asks whether Sandy might have someone from their wider support network who could provide additional supporting information. Sandy confirms that their brother keeps an eye on them and that they see him every day. Sandy is happy to give their brother's contact details so he can provide additional supporting information.

The case manager sends a supporting information request to Sandy’s brother. In his response, the brother explains that Sandy generally struggles a lot with depression and a mood disorder. Their mood can be very changeable and when feeling positive they tend to stop taking their medication and refuse support but these times are infrequent and short lived. He generally sees Sandy every day and visits in the morning and evening to provide reminders and encouragement with routine tasks such as attending to personal hygiene, taking medication and encouragement to eat. Sandy’s brother regularly spends more than an hour each time he visits supporting Sandy with their needs, as he is aware that Sandy will not carry out such tasks without his support. Sandy also experiences insomnia at times but manages this independently and does not have any related care needs. When the brother is not able to provide support to Sandy, he explains that they tend to ‘let things slide’ and need additional support to get back into a routine again. This cycle has been going on for a long time.

With this additional supporting information the case manager is able to draw conclusions about Sandy’s level of need. Although Sandy said that they are mostly fine and only struggle sometimes, the support provided by their brother suggests they experience the difficulties they describe more frequently. Their changeable mood and tendency to stop taking their medication or engage with the support available to them, suggests they may lack some insight into their condition. Their brother, who sees them regularly, is well placed to provide additional information.

The case manager now has the information they require to make a robust decision on Sandy’s entitlement. They award Sandy the lower rate of Pension Age Disability Payment as they have satisfied the daytime condition through requiring frequent attention throughout the day in relation to their bodily functions.

In his application for Pension Age Disability Payment, Imran describes having poorly controlled asthma which causes him to become very out of breath. He explains that he uses an inhaler, a reliever, as medication to control his symptoms.

Imran provides a description of how his breathlessness affects him. He requires assistance with washing and dressing himself, as he experiences shortness of breath wheezing due to the mild exertion. Due to his shortness of breath, Imran becomes dizzy when washing and requires support to wash his hair and to get in and out of the bath. This has led to injuries in the past. Imran requires someone to watch him closely because of this. Due to his symptoms, Imran now has toileting accidents as he is unable to get to the toilet in time. This means his wife has to support him when he needs to move around the house and with his hygiene by supporting him with additional washing and bathing.

He also becomes breathless when moving around the house and has to pace himself or rest frequently. Imran also explains that he struggles with eating and drinking, as his condition can cause Imran to be unable to use cutlery at mealtimes due to the exhaustion from being out of breath. Imran generally needs support using cutlery at each mealtime.

His symptoms are frequently worse at night and early in the morning, when he often struggles to breathe, coughs a lot and also experiences tightness in his chest area. This can make it impossible for him to sleep through the night. Imran can also feel dizzy and drowsy in these moments.

Imran’s wife has to ensure that he is propped up in bed, as he cannot breathe reasonably well when lying flat. If Imran slides down the bed, he can become more breathless. His wife also has to administer Imran’s inhaler as he often becomes panicked at night. She then has to help Imran settle back to sleep due to how unsettled he can become. Imran sets out in his application form that this happens most nights of the week and takes at least half an hour for his wife to help him from the onset of symptoms.

Imran experiences acute asthma exacerbation regularly and describes that these attacks tend to come on suddenly. During these asthma attacks, his symptoms become worse and he struggles to breathe.

Imran does not provide confirmation from a professional with his application but provides his GP’s contact details, who he has regular check-ups with.

Based on existing knowledge of Imran’s condition, and medical guidance, the case manager identifies a significant inconsistency between the impact Imran has described on the one hand and the medication he takes and the fact that his condition is not being managed by a specialist on the other hand. With the information available, the case manager is unable to make a robust determination. Based on the balance of probabilities, the case manager concludes that it is more likely than not that Imran’s needs are not consistent with someone who does not receive specialist input.

They think that this inconsistency is significant, as

• there is conflicting information about the severity of Imran’s needs. Individuals with poorly controlled asthma will typically use more effective medication and will have been referred to a specialist. As Imran is seen regularly for his condition, it is more likely than not that his GP would have prescribed medication that is appropriate for his symptoms and would have referred him.

The case manager therefore decides that confirmation from a professional is required. They send a supporting information request to Imran’s GP.

The GP provides a short statement that confirms Imran’s condition and lists his prescriptions. The GP explains that

• Imran’s symptoms have only recently deteriorated
• He has recently been referred to a specialist but most likely is still waiting for his first appointment letter
• His medication is currently under review.

The confirmation did not include a detailed account on Imran’s care needs. This is fine, as the role of confirmation from a professional is to broadly confirm the individual’s disability, condition, or needs. As this piece of supporting information has resolved the inconsistency between severity of symptoms, medication, and clinical support, and Imran’s condition and needs are straightforward, the case manager now has enough information to go ahead and

• establish the facts of the case
• make a conclusion of law

They determine that Imran is entitled to the higher rate of PADP, as he satisfies both the daytime and the night-time condition. Imran requires frequent attention throughout the day with his bodily functions, and prolonged attention in connection with his bodily functions at night. His new award rate will start being paid once he has met the backwards test. They set a review date of 18 months because they expect Imran to see a significant improvement in his symptoms once his condition is better controlled.

James (aged 69) applies for PADP due to back pain which he has had since a bad cycling accident four years ago. He does not provide any confirmation from a professional or additional supporting information.

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. James also states that he has mechanical back pain and is prescribed co-codamol as required for pain. James was offered a referral to the pain management service two years ago but declined.

James describes that he needs assistance with a number of bodily functions during the day, including washing himself, dressing and undressing as well as managing his toilet needs and moving around indoors due to pain and stiffness in his back. He also states that his accident is having an impact on his mental health. James is often in pain and the impact the accident has had on his independence has left him with low self-esteem. James states he has felt depressed at times since his accident and that his partner needs to prompt him in relation to eating, drinking and communicating with others.

After case familiarisation, the case manager establishes there is an inconsistency in James’ application: Based on the information provided, it is unclear what causes James’ need for prompting and how significant the inconsistency is.

The case manager therefore goes on to establish whether or not this inconsistency is significant enough to prevent them from making a robust decision. They consult the Decision-Making Guidance chapters on supporting information and principles of decision-making. They determine that the inconsistency is not significant enough to prevent them from making a robust decision. This is because some of the needs James is describing clearly stem from his accident. Whilst not being a direct symptom of the accident, such as the pain in his back would be, it is reasonable to conclude that individuals experiencing sudden health and lifestyle changes may also experience mental health difficulties. The case manager determines that James’ need for prompting is more likely than not to be related to his accident. They establish good cause and move on to establishing James’ entitlement.

The case manager considers whether the existing inconsistencies in James’ application are relevant, i.e. whether they would prevent them from establishing James’ level of needs and therefore would have to be explored.

They establish that James requires assistance with several bodily functions during the day, caused by his accident. He therefore satisfies the daytime condition for PADP as he requires frequent attention throughout the day. His need for prompting would not impact on James’ entitlement. Therefore the case manager decides that this inconsistency is not relevant and does not need to be explored further.

They award James the lower rate of PADP and set a review period of three years.