What are the implications for practice of assessing fluctuating needs under the Care Act ?

Making an accurate appraisal of any fluctuating needs for a person is a vital part of assessment, which will have an impact on the eligibility determination.

The benefits of an accurate appraisal of fluctuating needs

• It establishes a full picture of the needs of the person beyond a snapshot based on the conditions presenting at any one time and therefore helps to ensure a correct determination of eligibility.
• It allows for contingency to be built into eligible care plans to mitigate the impact of the fluctuation, preventing or delaying, as far as possible, the development or escalation of further needs in the future.

The challenges involved in making an accurate appraisal of fluctuating needs

• Making an accurate appraisal of fluctuating needs requires time to establish the full extent of the fluctuation.
• The person or their carer may not fully recognise the impact on their wellbeing of the fluctuations, thinking of them as something they cope with. Therefore, asking the right questions is vital to establish the extent of that impact.
• Accessing expert opinion to support any assessment of what can be reasonably expected of a person with a similar condition and circumstance. Most importantly, recognising that this is only indicative and cannot be used as an absolute.
• Ensuring any appraisal of needs is person-centred, based on person circumstances and not on previous experience of people with similar needs. 

Examples of practice

• Eligible fluctuating need (carer): a carer is a divorced parent who struggles to provide care when his children are with him, leaving him feeling a failure as a parent which is affecting his relationships. After determining that the carer is eligible, the local authority links the carer to a local carers’ support network which is able to offer ongoing support when it is needed as well as children’s and family activities during school holidays.
• An appropriate period of time: a person with mental illness has coped for the past eight months but their health deteriorates due to a change in circumstances. The local authority is recommended to consider their needs over the past 12 months to gain an accurate picture (see Care Act guidance, p 110). On a daily basis a person with, for example, Parkinson’s disease, a degenerative neurological condition, may find it difficult to get out of bed each morning due to stiffening-up overnight.
• Accounting for eligible fluctuating needs in care planning (Care Act guidance, p 176): Ms S has multiple sclerosis and requires a frame or wheelchair for mobility. She suffers badly with fatigue, but for the majority of the time she feels able to cope with daily life with a small amount of care and support. However, during relapses she has been unable to sit up, walk or transfer, has lost the use of an arm or lost her vision completely. This can last for a few weeks, and happens two or three times a year, requiring 24-hour support for all daily activities. In the past, Ms S was hospitalised during relapses as she was unable to cope at home. However, for the past three years, she has received a care and support package that includes direct payments which allow her to save up a month’s worth of 24-hour care for when she needs it; this is detailed in the care and support plan. She has not been hospitalised since.