Specific review scenarios: Reported change (either as part of a scheduled or unscheduled review)

An individual reports a change of circumstance to a condition or their level of needs we are aware of. Based on what we already know about the individual, this change was expected.

(i.e. one piece of supporting information from a professional to broadly confirm the individual’s conditions, disability or needs) or good cause for not having confirmation from a professional (i.e. the ‘one piece’) has previously been established. Here, we wouldn’t want to see confirmation from a professional (i.e. one piece of supporting information from a professional to broadly confirm the individual’s conditions, disability or needs). You can go on and establish the individual’s new level of need and make a determination of entitlement.

(i.e. one piece of supporting information from a professional to broadly confirm the individual’s conditions, disability or needs) that had been previously provided does not relate to the condition the reported change relates to.

Here, there are two possible outcomes:

Firstly, if the reported change is not likely to lead to a change in their award level, we would not want to see confirmation from a professional (i.e. one piece of supporting information from a professional to broadly confirm the individual’s conditions, disability or needs). You can go on to make a determination of entitlement. If more detail on the individual’s new level of need is required, you should take the steps set out in the section ‘Needing more detail to establish the new level of need’ outlined above.

Secondly, if the reported change is likely to lead to a change in their level of award, we would want to see confirmation from a professional (i.e. one piece of supporting information from a professional to broadly confirm the individual’s conditions, disability or needs). For example, their level of award could change from the middle to the highest rate of the care component. The change of circumstance reported by the individual could, for example, be a change that turns a previously minor condition with low to no impact on an individual’s level of award into a condition that now significantly impacts their level of entitlement. However, before reaching out for confirmation from a professional you should discuss with a practitioner. It is possible the ‘new’ condition is a complication / progression from the original condition. If this is the case, confirmation from a professional is not necessary. Practitioners input should be sought before reaching out for confirmation from a professional.

Once:

• confirmation from a professional has been provided
• good cause for not having confirmation from a professional has been established or
• it has been established the new condition is linked or a likely progression given the previous condition you can go on and establish the individual’s new level of need and make a determination of entitlement. If more detail on the individual’s new level of need is required, you should take the steps outlined above.

An individual reports a change of circumstance to a condition or needs we are aware of. Based on what we already know about the individual, this change was not expected, for example because:

• we expected the condition or their needs to not change, or
• we weren’t expecting a change of this nature.

Previously, either:

• the individual has provided confirmation from a professional (i.e. one piece of supporting information from a professional to broadly confirm the individual’s conditions, disability or needs) on this condition
• good cause for not having confirmation from a professional (i.e. the ‘one piece’) has been established.

Here, we would not want to see confirmation from a professional (i.e. one piece of supporting information from a professional to broadly confirm the individual’s conditions, disability or needs).

You should both:

• treat this as an inconsistency
• proceed as usual when exploring inconsistencies in information to establish whether the inconsistency is relevant.

This could, for example, involve checking guidance or requesting a case discussion. If the inconsistency is indeed relevant, you should choose from the set of options below to explore and resolve it:

• Contact the individual or their client representative to ask follow-up questions. Here, you must ensure that this phone call does not become, or feel to the individual like, a de-facto consultation. Consultations exist for Adult Disability Payment only. For more details, see operational guidance on contacting individuals with follow-up questions.
• Choose the decision-making tool that is most appropriate/ most likely to provide the information you need.

There are a number of decision-making tools for you to use:

• Consulting guidance (DMG, Operational Guidance, Medical Guidance)
• Case discussion
• Requesting supporting information

Supporting information:

• is just one of several decision-making tools
• should not be the default step to take

when establishing the individual’s level of need.

Rather, you should choose the action based on what’s most appropriate in the review at hand. As part of that consideration, you should consider what’s best for the individual. For example, a quick phone call to ask a follow-up question might be better than the individual having to

• collect supporting information from their wider support network
• wait a number of weeks until your request for supporting information has been answered by the contact the individual has provided.

If you decide that gathering supporting information is the most appropriate decision making tool, you need to decide which source would be best-placed to provide the information you need. This can be a professional or a member of the individual’s wider support network. Crucially, requesting supporting information should be done with the goal of more fully understand the individual’s new level of needs. The aim here is not to “verify” what the individual has told us.

An individual reports a change of circumstance. The change is a new condition that Agency wasn’t previously aware of.

Here, we would not want to see confirmation from a professional (i.e. one piece of supporting information from a professional to broadly confirm the individual’s conditions, disability or needs) to confirm the individual’s new condition. We can make a determination based on what we have available.

It is possible that you

initially think that the reported change will not impact on the individual’s level of entitlement

further along the decision-making process understand that the individual’s award will change after all.

If this is the case, you should move to Scenario 5b below and seek confirmation from a professional (i.e. one piece of supporting information from a professional to broadly confirm the individual’s conditions, disability or needs) in relation to that condition.

Here, you should seek confirmation from a professional (i.e. one piece of supporting information from a professional to broadly confirm the individual’s conditions, disability or needs) in relation to that condition. If that’s not possible, then you should see whether good cause can be established.

However, before reaching out for confirmation from a professional you should discuss with a practitioner. It is possible the ‘new’ condition is a complication / progression from the original condition. If this is the case, confirmation from a professional is not necessary. Practitioner’s input should be sought before reaching out for confirmation from a professional.

If more information is needed to understand the individual’s new level of need, you should take the appropriate steps outlined above