Can I make a robust decision with the information available?
We ask all PADP applicants to provide confirmation from a professional. However, a number of PADP applications will be submitted without confirmation from a professional. In those cases, it will not always be necessary for you to either:
- request confirmation from a professional from the individual
- gather confirmation from a professional on behalf of the individual
In many cases you will be able to establish good cause and make a robust entitlement determination without confirmation from a professional. You can read more about the meaning of good cause in the context of PADP in this chapter’s section on Good Cause.
This is because confirmation from a professional is less likely to be available to people applying for PADP, for example, because they have had their condition for a long time without any input from professionals. Good cause can therefore be established in a greater number of scenarios, allowing you to make a determination without requesting confirmation from a professional in every case.
This is possible if:
- you’re able to broadly establish a holistic picture of the client’s circumstances based on the information you have AND
- there are no significant inconsistencies
However, some applications will require a confirmation from a professional. You should request a confirmation from a professional where the following are met:
- the individual applies without a confirmation from a professional OR the confirmation from a professional is not relevant
- there are significant inconsistencies that prevent you from being able to get a broad sense of the person’s circumstances and making a robust decision
A significant inconsistency refers to care needs that would not reasonably be expected or explained for an individual:
- with that condition
- of that age
- receiving the treatment detailed in the application form, for example the medication, physio or other therapies
The above points can also interact, and you should consider this when determining if something is expected or not. For example, an individual may:
- list care needs that are typically not associated with a condition but, due to their age, their needs could be reasonably expected
- list care needs that are sometimes associated with a condition, but the level of medication they take suggests their needs would be expected to be significantly less
- under report their needs, but the level of medication they take suggests their needs are higher.
Significant inconsistencies can relate to needs that are both more or less than are expected.
There does not need to be a set number of inconsistencies and they do not need to be a certain ‘size’ to be significant.
When determining if an application contains significant inconsistencies, you should consider the following:
- whether you are familiar with the condition and the care needs associated with that condition
- consulting medical guidance to help you gain a better understanding of what the expected symptoms and care needs are likely to be for that condition
- the age of the individual and whether this will impact how they experience the condition
- whether, on the balance of probabilities, it is more likely than not that the individual has the care needs reported
- the relationship between symptoms reported and the care needs indicated. This includes determining whether the symptoms reported can reasonably be expected to result in the care needs indicated.
You are not expected to require the input of a practitioner in every case where you think there is a significant inconsistency. This guidance is to support you to determine whether a confirmation from a professional is required without additional input.
However, in cases where you are unsure if what you have identified is a significant inconsistency, you should request a case discussion with a practitioner. This will help you determine if a confirmation from a professional is required. For example, you may be unfamiliar with the condition, or an individual may apply with multiple conditions, and you are unsure how they interact.
To establish whether confirmation from a professional is needed to make a robust determination, you should use the decision tree below and read the signposted guidance sections.
When requesting a confirmation from a professional, you should make efforts to also gather information that would help you resolve the inconsistency. For example, when sending out a supporting information request, you should ask questions relating to the significant inconsistency in addition to requestion a confirmation to broadly confirm their disability, condition, or needs.
Example: An individual applies with no confirmation from a professional and the case manager establishes good cause
Harriet is aged 73 and has Stage 3 Heart Failure. On her application, she explains that she
- frequently experiences breathlessness, particularly after carrying out an activity such as moving around her home
- experiences extreme fatigue and can find moving around her home exhausting
- is often lightheaded
- has swollen ankles and legs.
Her application also indicates the following care needs:
- Assistance getting in and out of bed as she finds it difficult to get comfortable
- Must sleep with pillow propped as she becomes breathless when lying flat
- Spends most nights sleeping on a recliner chair which adds to her fatigue
- Requires help getting in and out of the bath (she does not have a separate shower) due to increased effort and how this impacts breathlessness
- Requires help washing and drying her bottom half due to worsening of breathlessness if doing this activity without support
- Spends most of the day sitting down and only gets up to use the toilet, which results in breathlessness and her needing rest afterwards due to the exertion
Harriet explains that she lives with her husband who provides most of the support when she gets experiences breathlessness or gets dizzy during the day and night.
She also lists the medications she takes for condition. These are:
- Ramipril 10mg
- Furosemide 40mg
However, Harriet has not provided a confirmation from a professional with her application. The case manager moves on to establishing good cause by first reviewing the application for any significant inconsistencies that would prevent them from making a robust decision.
The case manager consults medical guidance to get a better understanding of the expected symptoms and needs associated with heart failure. By accessing the guidance, the case manager is able to establish that individuals with heart failure will experience breathlessness and extreme fatigue and will be prescribed medication similar to those listed by Harriet. The case manager concludes that what Harriet has indicated on her application form is broadly consistent with what would be expected for Stage 3 Heart Failure.
The case manager establishes good cause for why Harriet does not have a confirmation from a professional and moves on to establishing her care needs and entitlement.
Using the information Harriet has supplied in her application, and what they have learnt from medical guidance, the case manager establishes that:
- Harriet has a long-term health condition that although treated with medications, cannot be cured
- As her condition is Stage 3, her symptoms of breathlessness and fatigue are unlikely to improve
- Her breathlessness and fatigue make it difficult for her to be comfortable completing tasks that involve even minor activity, and that activity is likely to worsen her symptoms
- These symptoms consistently impact her daytime care needs with washing and dressing and mobilising around the home
- These symptoms also mean she has nighttime care needs relating to preparing for bed and quality of rest as she struggles to get comfortable as a result of breathlessness.
- Her husband checks on her frequently during the night to assist her to the toilet due to her light-headedness and previous falls.
The case manager makes a decision that Harriet is entitled to the higher rate of PADP as she has care needs during both the day and night that require significant support of another to manage.
Example: An individual applies without a confirmation from a professional and the case manager requires support from a practitioner to establish good cause
Tommy is 69 and applies for PADP with obesity. He applies without a confirmation from professional but provides the following details on his application form:
- That he has a BMI of 54
- His symptoms include breathiness after activity or at rest, feeling tired the majority of the time (made worse when moving around the home), joint pain, sleep apnoea, and incontinence
- His daughter lives with him to provide support
- That he is prescribed Orlistat 120mg to take 3 time a day
Tommy explains that he has the following care needs:
- Requires assistance getting in and out of bed due to increased breathlessness and joint pain
- Has a CPAP machine to aid with breathing through the night. That he has to be assisted back into the mask when it disconnects, which happens 2-3 times per night
- He sleeps with pillows propped as he is breathless when lying flat
- Requires assistance getting washed and dressed. He has a shower over the bath that he needs help getting in and out of due to joint pain and breathlessness. Due to these symptoms, he also cannot dry or dress his bottom half without help.
- Relies on furniture to walk around the home due to his breathlessness and joint pain.
As Tommy has applied without a confirmation from a professional, the case manager needs to decide whether they can establish good cause.
Although the case manager is familiar with obesity as a condition, they are unfamiliar with what care needs would reasonably be expected of someone with a BMI of 54. They consult medical guidance, but this provides them with a variety of symptoms associated with obesity and they feel uncertain whether the level of BMI impacts what symptoms and needs and individual has. The case manager is unsure whether what Tommy reports are his needs are what would expected be expected of someone with a BMI of 54. As the case manager is unable to say whether the application is more likely than not to be consistent with someone of Tommy’s circumstances, they request a case discussion from a practitioner.
This also means that they have not yet applied good cause to Tommy’s application.
In the response to the case discussion, the practitioner provides the following information:
- The Body Mass Index (BMI) serves as a measure to determine whether someone falls within a healthy weight range. A BMI of 40 or higher indicates severe obesity.
- Common symptoms associated with severe obesity include breathlessness, increased sweating, snoring, difficulty with physical activities tiredness, and joint and back pain.
- In the case of the client, their BMI of 54 aligns with the severely obese range.
- Additionally, they report experiencing challenges with dressing, washing, and mobilising around the home due to joint pain and breathlessness, which is consistent with the indicated condition.
With the outcome of the case discussion, the case manager is now satisfied that the needs Tommy detailed in his application form are consistent with those of someone with his condition and of his age. The case manager establishes good cause and moves on to establishing Tommy’s needs and entitlement.
They establish that Tommy has the following needs:
- Requires help morning and night to get in and out of bed
- Needs frequent monitoring during the night due to treatment for his condition
- Has aids to help him move around his home
- Needs help getting washed and dressed
The case manager determines that Tommy is entitled to the higher rate of PADP as he has care needs that satisfy both the daytime and night-time condition.
Example: An individual applies without a confirmation from a professional and determines that there are significant inconsistencies that require a confirmation
Marcel is 75 and has long covid. He does not provide a confirmation form a professional with his application, but he does explain in his application that he is experiencing the following symptoms:
- Breathlessness after activity, like moving around the home, and during rest
- Fatigue for a lot of the time and finding moving around the home tiring
- Joint pain in their knees
- Dizziness
- Brain fog
- Collapses and loses consciousness 4-5 times per week with no explanation
As a result of these symptoms, Marcel reports the following care needs on his application:
- Requires assistance getting in and out of bed, as he finds it difficult due to breathlessness and joint pain
- Sleeps with pillows propped to alleviate breathlessness
- Needs help to get in and out of bath (has shower over bath)
- Requires help drying and dressing his bottom half as bending causes breathlessness and light-headedness
- Relies on furniture to walk around the home due to difficult walking with breathlessness and joint pain
- Need supervision at all times due to sudden loss of consciousness and dizziness.
He explains he lives with his wife who provides support where needed.
The case manager is aware of the symptoms associated with long covid but knows that this is a new condition and that the needs can vary from person to person, as well as the period of time for which they are impacted. Whilst the case manager determines that most of what Marcel reports in regard to his needs are consistent with what would be expected of someone with long covid, requiring supervision due to loss of consciousness is not typically associated with long covid and is a significant inconsistency.
The case manager does not establish good cause and decides to collect a confirmation from a professional that can also resolve the identified inconsistencies in Marcel’s application.
As Marcel did not provide contact details for a professional the case manager contacts Marcel for the supporting information. Marcel agrees to submit an outpatients letter from a hospital visit with his consultant from last month.
The letter provides a summary of the visit, in which it confirms that:
- Marcel is receiving treatment and further testing in relation long covid (further blood test, checking blood pressure and heart rate, chest x-ray, ECG)
- They are also carrying out further cardiac and neurological investigations in relation to his loss of consciousness to rule out any physical cause
- The letter concludes that they have had initial discussions with Marcel about preparing him for the possibility that loss of consciousness is a rare side effect of long covid, potentially with no cure.
- Marcel has been referred to the long covid service for support while awaiting further investigations.
Using the information provided by Marcel, the case manager is able to confirm his diagnosis of long covid and resolve the inconsistency relating to Marcel’s loss of consciousness. The case manager moves to establishing his needs and entitlement.
The case manager determines that Marcel is entitled to the higher rate of PADP as he has both daytime and nighttime care needs. These are in relation to needing helping getting washed and dressed, preparing for bed, and needing constant supervision in case of loss of consciousness and dizziness.