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Condition
Considering an individual’s conditions and understanding how they are likely to impact the individual over time is one of the important factors to consider during this decision-making process.
It is important to remember that the typical features of a health condition might not apply to every individual. Some conditions will potentially involve a future change in the individual’s level of care needs, but for some individuals with this condition, this may not be the case. The presence or absence of these features may still be relevant to the award review date, as you should set the review date when needs are likely to change in a way that would impact entitlement. If the individual’s needs are highly unlikely to change in a way that would impact entitlement, you should consider giving an indefinite award.
If it is unclear what the natural progress of a health condition may be, and how the typical progression of a condition applies to the individual in question, you should - consider medical guidance A to Z list of common illnesses and conditions | NHS infor ; Health A to Z – NHS (www.nhs.uk); Scottish health information you can trust | NHS inform
request a case discussion with a practitioner.
Conditions can be categorised according to their likely progression over time. Considering this is important when making a decision on whether or not setting a review period might be appropriate. You should bear in mind that the severity of some conditions may change over time.
Individuals may have a number of conditions that fall into different categories. You will have to consider how the individual’s overall needs will develop over time. It is possible that an individual’s level of need is highly unlikely to change in a way that would impact their entitlement, despite them having a number of conditions that change over time.
The individual’s condition, and how that condition can be categorized, is only one factor when establishing whether an indefinite award or a review period would be appropriate. You should also consider the other factors set out in this chapter.
This means that, even if an individual has a condition that might change over time, you may become aware of additional factors, that when taken together, suggest a review would be inappropriate. In that case you should consider making an indefinite award.
Example: an individual is eligible for an indefinite award due to the combined impact of their conditions on their life
Blair is 62 and has been struggling with Osteoarthritis for the past 20 years. His osteoarthritis mainly affects upper (hands and shoulders) and lower joints (hips and knees). Blair therefore finds bending, for example to wash his lower half and when getting dressed, to be difficult. He requires frequent attention when attempting to perform these tasks independently. Blair also needs assistance when getting in and out of bed and to get settled, as he is unable to lift his legs into bed.
Blair is prescribed high dose pain medications, including co-codamol 30/500mg (4x daily) and Naproxen 50mmg (2x daily). Despite this he continues to experience chronic pain and limitations to his ability to move around in his home making it challenging to manage daily life and activities.
He struggles with removing medications from their packets due to osteoarthritis in his fingers, and his family manage this using a Dossett box.
Before transferring to Scottish Adult DLA, he had been in receipt of an indefinite DLA award of the lowest rate of the care component.
Blair submits a change of circumstances, as he has recently been diagnosed with stage 3 Chronic Obstructive Pulmonary Disease (COPD) which has been worsening progressively over time. These comorbidities significantly impact his care needs and overall quality of life.
Blair explains that, during the day, he now experiences increased levels of pain, as well as breathlessness and fatigue, which cause difficulty with washing. When he has a bath, he requires assistance to get in and out of the tub. He has a raised toilet seat at home, and handrails in the bathroom to help with toileting, however it still takes Blair a lot of time to use the toilet, and he needs to take around 20 minutes to recover from breathlessness each time.
Blair is currently prescribed triple inhaler therapy (3 different inhalers) to help alleviate his breathlessness. Despite this Blair often experiences frequent exacerbations of COPD leading to hospitalisation (last admission 6 weeks ago for 5 days).
Blair has to sleep sitting up as he experiences increased breathlessness lying down. He also requires use of his inhaler 1-2 times per night.
Blair’s pillow will slip during the night and his family have to get him comfortable in bed and fix his pillows to ensure he remains upright. Due to his Osteoarthritis he is unable to manage this himself.
Blair gets breathless walking around the home and outside and holds on to furniture when walking within the home. When walking outside, Blair holds on to fences or walls and has to sit down regularly to catch his breath. Due to the pain, he will shuffle when walking and has had instances of trips and falls. He generally cannot walk far and is relying on taxis, or lifts from family when he has check-up appointments with his doctor. Taking public transport is not possible for him as walking to the bus stop and getting on and off the bus is too exhausting for him.
The case manager determines that Blair is entitled to the highest rate of the care component and the higher rate of the mobility component.
From reading medical guidance to find out more about COPD and osteoarthritis, as well as from prior training run by practitioners, the case manager understands that the combination of osteoarthritis and stage 3 COPD is highly likely to significantly impact Blair’s daily living. Despite receiving treatments and interventions, his conditions are highly unlikely to substantially improve over time and may continue to deteriorate. The case manager awards an indefinite award due to the long-term and challenging nature of his conditions.
Where it is unclear from the information available how the individual’s condition and needs might develop over time, and how other factors might impact the likelihood of changes occurring, you should use medical guidance or request a case discussion.
Fluctuating conditions
If the individual has a fluctuating condition, they are likely to experience short term periods of change in the level of need.
If the individual’s needs are highly unlikely to fluctuate beyond what can be expected based on their condition the case manager should consider giving an indefinite award.
Progressive condition
A progressive condition is a disease or health condition that gets worse over time, resulting in a general decline in health or function. A progressive condition is different from a relapsing and remitting condition (see below). Depending on the condition, a progressive condition may progress quickly or very slowly. Examples of progressive conditions are dementia, frailty, and Parkinson’s disease.
If the individual is entitled to the maximum level Scottish Adult DLA award (i.e. highest care rate, higher mobility rate) and they have a progressive condition, you should consider whether an indefinite award would be appropriate.
If the individual is entitled to any other level of Scottish Adult DLA award, a progressive condition can change their level of entitlement over time. For example, they might develop night-time care needs in addition to their existing daytime care needs, or develop mobility needs in addition to their existing care needs. Therefore, setting a review period to a point in time when their entitlement will have changed is likely to be appropriate.
Relapsing and remitting conditions
In a relapsing and remitting condition, there is often a period when the condition is stable for a while or is in remission. As an example, an individual with Multiple Sclerosis (MS) may experience symptoms, both existing or new, that arise or worsen for a period of time, followed by recovery.
In contrast, a progressive condition does not have these breaks. It is also possible for relapsing and remitting conditions to become progressive over time as symptoms may remain to some extent during the recovery period.
Permanent
A permanent condition is a condition that will not change and for which there is no treatment or cure. Examples are blindness, severe spinal injury, or severe brain injury.
If the needs resulting from a permanent condition are highly unlikely to change in the long term, an indefinite award is likely to be appropriate for the individual. You should also consider the other factors outlined in this chapter to determine whether that’s the case.
Example: a lifelong condition that may have changing levels of need
Kellie has a diagnosis of Parkinson's disease (PD). This condition was first diagnosed age 63 and Kellie has been in receipt of the middle rate of the DLA care component since shortly after her diagnosis. She requires assistance with a number of bodily functions during the day, including preparing food and eating, dressing and undressing, and taking medication.
Kellie now is 75 years old and lives with her family who support her on a daily basis. As Parkinson’s disease is a progressive neurological condition which affects movement, Kellie’s award is undergoing a scheduled review to ensure she is still receiving the appropriate level of assistance.
On Kellie’s review form, she notes that some of her needs have increased. Kellie now has a urinary catheter and on the majority of days she requires assistance to empty this.
Kellie also reports that she has started a new course of treatment and is hoping that this, together with her successful management of symptoms and her family’s support, can reduce the impact on daily life.
Based on Kellie’s review form, the case manager establishes that Kellie currently does not have night-time needs or mobility needs.
The case manager therefore determines that Kellie entitlement remains the same. This is because, despite her now requiring a catheter, she still requires frequent attention throughout the day in connection with her bodily functions.
They move on to considering whether a review period or an indefinite award would be appropriate for Kellie. The case manager knows that PD is a progressive disease and that Kellie’s needs are highly unlikely to improve. An indefinite award might be appropriate. However, as she is entitled to the middle rate of the care component only, the case manager wants to understand whether her needs are also unlikely to increase in a way that would impact on her entitlement. This is to avoid Kellie missing out on payments she might be entitled to if she fails to report a change of circumstances after starting to have night-time needs.
The case manager seeks the input of a practitioner. The practitioner confirms that Parkinson's disease is a progressive condition. However, they advise that there is indication of Kellie responding to treatment. Therefore, it is likely that the treatment will
- improve Kellie’s ability to manage her condition within the medium term.
- slow the deterioration of Kellie’s condition.
However, as Kellie’s condition is progressive, it is more likely than not that the treatment will not reverse the overall effects PD has on her needs.
The case manager decides against awarding an indefinite award and sets a review period of 5 years. This is because: Kellie’s needs will
- remain significant enough for her to continue to satisfy the daytime condition
- will increase slowly which makes it likely that she will meet the night-time condition of the care component and the higher rate of the mobility component in the future.