Making robust decisions – example section

Esther is 63 years old and lives alone. She has been entitled to the lowest rate of the care component for Scottish Adult DLA for a number of years. Esther recently experienced a further decline in her health. Her daughter prompts her to report a change of circumstances to Social Security Scotland. Esther’s daughter and Esther’s neighbours were already supporting her by providing attention throughout the day with washing, dressing and preparing meals. Esther’s daughter now has moved Esther in with her and her partner in order to provide more continual support and supervision.

In her review form, Esther explains that she contracted Covid about 8 months ago and has not managed to fully regain her fitness and strength since. Esther can become breathless very easily from minimal activity and needs continual supervision from another person in relation to her bodily functions. For example, she is prone to dizziness and overexertion when moving around indoors and then can stumble and fall if no-one helps her to steady herself. This is because doing so can leave her breathless. When this happens, it can take between 5 to 10 minutes to recover. 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 also reports that as a result of this, she has had a number falls over the past few months. 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 now also needs frequent supervision throughout the day as she can find it impossible to getting to and from the toilet independently. She requires support to lower herself to and lift herself from the toilet. She also used to change her incontinence pads independently, but she now requires support with this task.

Esther reports that she uses the toilet before bed and in the morning when she wakes up and so this is not a night-time need. She doesn’t report any other night time needs.

Esther explains that she now also has difficulties moving around outdoors. She used to be fine walking on her own using a walking stick, but due to her general exhaustion and breathlessness, Esther now struggles to walk more than a few minutes before she needs to sit down to rest. It takes her about 10 minutes to feel rested enough to continue walking, but the period of rest required for her to continue walking increases from break to break. If she is unable to sit and rest, she can start to feel dizzy, due to breathlessness, and stumble.

Esther also reports that she has been struggling with keeping herself safe outdoors, as most of her attention is now occupied with moving slowly and carefully and making sure she breathes normally. She explains that there have been a few near misses with traffic. Additionally, when she feels exhausted and breathless, Esther can also become disoriented and overwhelmed, which in turn causes her to worry about being lost. As a result, Esther doesn’t feel safe venturing outside alone. She only leaves the house occasionally and only when accompanied by her daughter, her daughter’s partner, or a neighbour.

Esther does not take any medication and has not been to see her GP since her covid infection. She does not provide any supporting information with her change of circumstances form.

The case manager reviews Esther’s change of circumstances form. From the information provided they establish that Esther has symptoms of frailty and requires support 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
• moving around outdoors

There are no significant inconsistencies or gaps in Esther’s form. The case manager therefore proceeds to making a determination without requiring confirmation from a professional or using any decision-making tools.

They establish that Esther has satisfied the daytime condition of the care component, and she is therefore entitled to receive the middle rate. Esther’s difficulties with moving around outside also meet the eligibility criteria for the lower rate of the mobility component.

The duration of Long Covid and other post-Covid conditions are still largely unknown. However, frailty is a degenerative condition. It is therefore unclear how Esther’s needs are going to develop over time. The case manager therefore determines that an indefinite award is not appropriate for Esther. They set a review period of 5 years.

Sandy (aged 68) is in receipt of the lowest rate of the care component of Scottish Adult Disability Living Allowance due to depression and is now due a scheduled review.

They regularly struggle with motivation and low energy. Sandy regularly doesn’t manage to prepare food or get dressed and ends up missing meals and wears the same clothes for days and nights on end. They take Duloxetine, which the case manager uses medical guidance to confirm is an anti-depressant.

In the review form, Sandy indicates that they have experienced changes since their last determination, and they request a change of circumstances form. On the change of circumstances form, Sandy describes now also experiencing difficulty with taking care of themselves and experiencing fluctuations in how they are impacted by their condition. They also mention that their GP has increased the dosage of their medication in response to their increased symptoms. However, the form 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 review 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 change of circumstances form.

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 and that their symptoms have become more severe over the last 6 months. 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.

With this additional supporting information the case manager is able to draw conclusions about Sandy’s new level of needs. 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 find it hard to admit the severity of their needs. 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 middle rate of Scottish Adult Disability Living Allowance care component as they have satisfied the daytime condition through requiring continual support throughout the day.

Imran, 58, is in receipt of the lowest rate of the care component of Scottish Adult Disability Living Allowance due to his asthma. He reports a change of circumstances. Imran describes significantly worsened symptoms. His now poorly controlled asthma 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 increased 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 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 has regular check-ups with his GP.

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. They do not see any reasonable explanation for the inconsistency.

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.
• depending on what information can be established as fact, Imran’s entitlement would differ. Imran’s symptoms, as described in his application form, mean that he is likely to satisfy both the daytime and night-time conditions. However, his medication would typically be prescribed to people with mild asthma, who would likely only satisfy the daytime or night-time condition.

The case manager therefore decides that a confirmation from a professional is required. They ask Imran to provide his GP’s contact details and 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 once he has met the backwards test Imran is entitled to the higher rate of the care component of Scottish Adult DLA, 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. 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) has been in receipt of the lower rate of the care component for Scottish Adult DLA for three years due to back pain which he has had since a bad cycling accident four years ago. His scheduled review is coming up.

James 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. This because, although the hairline fracture caused to one of his vertebrae healed as expected, the pain in his back has only slightly improved since his accident. James also has mechanical back pain and is prescribed co-codamol as required for pain.

In his review form, James states that he now requires his partner 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’ review form and what the case manager knows about James’ circumstances: Based on the information available, James’ need for prompting is more likely than not to be unrelated to his accident, but it is unclear what causes this care need and how significant it is.

The case manager considers whether the existing inconsistencies in James’ review form are relevant, i.e. whether they would prevent them from establishing James’ level of needs and therefore would have to be explored. They consult the Decision Making Guidance chapters setting out the care component criteria for Scottish Adult DLA.

They know from James’ case file that James requires assistance with several bodily functions during the day, caused by his accident. James has not provided any information indicating a change to these needs. He therefore still satisfies the daytime condition for the care component for Scottish Adult DLA as he requires frequent attention throughout the day. His need for prompting, which currently is unexplained, would not impact on James’ entitlement. Therefore the case manager decides that this inconsistency is not relevant.

They determine that James continues to be entitled to the lower rate of the care component and set a review period of three years.