Shorter review periods (2 to 5 years)

Nancy is 55 years old and has autism. She has been in receipt of a DLA indefinite award on the lowest rate of the DLA care component and the lower rate of the mobility component for 25 years.

A year after her award transferred to Scottish Adult DLA, Nancy experiences a significant impact to her health when she experiences a heart attack, resulting in severe complications, including infection following a stent, which further complicated her recovery process. Nancy reports a change of circumstances four months after her heart attack.

In her change of circumstances form, she states that she currently receives treatment of Intra-venous antibiotics, which will last for a total of 6 months. Once the infection has cleared she might be a candidate for valve replacement, as the infection damaged her heart valve. She has an appointment with a cardiologist specialist monthly.

Due to her cardiac issues Nancy experiences low blood pressure, which causes nausea and dizziness. She requires assistance when standing and to balance when she has to get up from the chair as this makes it worse. She is exhausted with the slightest tasks, and requires assistance with getting washed and dressed. She has to nap following this due to the exertion.

She experiences insomnia, which adds to her severe fatigue, and cannot sleep at night as her bones ache. She has leg cramps every night and her husband has to massage her legs for at least 30 minutes before bed and then again through the night.

Her diet is restricted to prevent overloading on fluids and she has to follow a dietary fluid restriction, as she has developed kidney problems associated.

Due to her symptoms, is currently not able to move around outdoors beyond a few steps from her front door to the car, and only if she is supported by her husband.

Nancy explains that, according to her doctors, Nancy’s recovery from the heart attack is expected to be longer than conventional recovery and requiring close monitoring.

The case manager determines that, once she has met the backwards test, Nancy will be entitled to the highest rate of the care component, as she satisfies the daytime and the night-time condition. She will also be entitled to the higher rate of the mobility component.

In order to set an appropriate review period, the case manager requests a case discussion to find out more about Nancy’s likely recovery time. The Health & Social Care practitioner explains that it is expected that stabilisation of Nancy’s heart is to be achieved by 6-9 months. Nancy will then require cardiac rehabilitation to regain strength and function with the hope of a successful recovery over the next 12-18 months.

The case manager decides that a review period of 21 months, starting when her new entitlement starts, is appropriate. If Nancy’s needs decrease before her scheduled review, she would have to report another change of circumstance. The case manager expects Nancy’s needs to ultimately reduce to a degree where she will once again be entitled to the lowest rate of the care component only.

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. 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 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 highest rate of the care component and the highest rate of the mobility component. They set a review period of 3 years.

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 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 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 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.