Shorter review periods (2 to 5 years)

Ted (79 years old) has been struggling with severe depression for the last 15 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. Ted has been in receipt of the lowest rate of the care component of DLA for just over 10 years before transferring to Scottish Adult DLA. He is on an indefinite award. 

His wife passed away 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. Ted has refused to engage with any services and refuses medications. His family have now convinced Ted to report a change of circumstances, as they believe that Ted’s needs have increased significantly since first applying for DLA.  

Ted’s change of circumstances form 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. He requires prompting with eating as he has no interest and often skips meals with no appetite. This has led to weight loss. Ted frequently expresses that he would be better not here, indicating a risk to self. The family has become reluctant to leave him unsupervised. 

The case manager notices that the form is vague on whether this is during the day or also throughout the night. In order to establish Ted’s new level of need, they reach out to Ted. Ted says that he doesn’t feel able to answer follow-up questions over the phone. However, he is able to pass on his family’s contact details and the case manager reaches out for additional supporting information. 

In their supporting information, 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, after a case discussion, 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.  

Due to his age, Ted would not be able to be considered for the mobility component as the change occurred after he reached the relevant age, however the case manager awards Ted the highest rate of the care component 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. 

The determination letter noted that a review had been scheduled for 5 years. This timeframe would allow Ted space to potentially engage with professional support services. The case manager did not identify any specific updates Ted should provide at his next review, and noted that should Ted’s needs improve sooner, he is required to report a change of circumstances.

Jack (58) has cerebral palsy and has been in receipt of an indefinite award of the lowest rate of the care component and the lower rate of the mobility component for 40 years. 

He was involved in a serious accident 7 months ago that resulted in substantial skeletal injuries including multiple fractures to his legs, pelvis and ribs.  

His appointee reports a change of circumstance, which describes that Jack requires assistance with washing, as he is now 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.  Jack currently also has difficulties moving around outdoors. He struggles with using aids and, due to pain levels and exhaustion, has to rest after only a few minutes.

He tends to shuffle when walking, due to his pain levels and reduced range of motion. He therefore is prone to tripping and falling. In order to avoid further trauma to his still healing injuries, Jack therefore only walks outdoors when necessary and only for short distances, for example when walking to the car. 

The discharge and referral letters Jack’s legal representative sent with the change of circumstances form tell the case manager that Jack was reviewed by an Orthopaedic 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 highest rate of the care component and the highest rate of the mobility component. They set a review period of 3 years. 

The determination letter issued to Jack explained that, as he had been referred for surgeries and would require time to rehabilitate, his award would be reviewed in 3 years. The case manager noted that, we would need an update on Jack’s care needs during the day and night and his mobility needs at his next review as we expect these might change following his surgeries and physiotherapy.

Gertrud is 59 years old with a diagnosis of sciatica and has a number of care needs. She has been in receipt of the middle rate of the care component for 12 years. 

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’s scheduled review is coming up. In her review form, she indicates that her needs have not changed. However, she explains that she has been advised of further surgery she will need to have and that she has been placed on the surgery waiting list. The consultant specialist is hoping she can have the surgery within the next 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 remains entitled to the middle rate of the care component, 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 and a half years would be appropriate after taking into account: 

• the waiting time for surgery 
• the recovery period 
• the treatment post-surgery 
• whilst she does not currently meet the criteria for the lower rate of the mobility component, Gertrud may develop mobility needs in the coming years

The determination letter noted that a review had been scheduled for 4 and a half years. This timeframe should allow Gertrud to undergo surgery and make a full recovery. The case manager explained that Gertrud would likely need to provide an update on how the surgery and physiotherapy had impacted her daytime care needs relating to sciatica.