Select Committee on Work and Pensions Third Report


3  A REFORMED 'GATEWAY' ONTO INCAPACITY BENEFITS

The role of GPs and other health professionals

58. GPs are the first point of contact when someone becomes sick and, as the Green Paper points out, are seen as the 'gatekeepers' to sick pay and benefits.[46] The difficulty with GPs having this role was outlined in some of the evidence received during this inquiry. For example, UnumProvident said that under the current system the concern of the GP is whether their patient is sick - not whether they are capable of a return to work.[47] The Disability Rights Commission (DRC) commented that the expectations of GPs needed to be raised to include employment as an option for disabled people[48] and A4e argued that GPs needed to "embrace the concept of 'employment is good for you'."[49]

59. The Green Paper says that GPs and primary care teams can play a pivotal role in supporting and advising patients on their fitness for work. It sets out a range of strategies to help with this process. These include:

  • supporting GPs and primary care teams to help their patients back to work by identifying effective interventions and rewarding staff who take active steps to help their patients remain in or return to work;
  • supporting GPs in recording sickness certification and revising the medical certificate to make it more user-friendly and to include fitness for work advice;
  • piloting an occupational health advice line and developing training courses and online learning modules for GPs on fitness-for-work issues; and
  • piloting employment advisers in GP surgeries.

60. The last of these proposals was widely reported in the media prior to the publication of the Green Paper.[50] According to the Minister for Work, this proposal is based on existing practice where some non-governmental organisations have placed employment advisers in surgeries around the country. Based on this, the piloting of employment advisers in GP surgeries has already begun in two surgeries in Bridgend and Paisley.[51] The evidence received during the inquiry - both before and after the publication of the Green Paper - presented different views. Some supported the proposal as an effective way to bring different sectors together for the benefit of the client.[52] Others argued that it could compromise the patient/doctor relationship and cause patients to avoid attending the surgery for necessary health support.[53]

61. Leonard Cheshire - a large voluntary sector provider of support to disabled people - warned that GPs should not be excessively controlled by Government and "must retain the discretion to advise their patients to the best of their ability without any external pressure."[54] The Shaw Trust - a voluntary sector provider of employment services to disabled people - argued that GPs only have limited time to spend with their patients and did not consider the long-term implications of issuing a sick note to a patient. They stated that Occupational Health professionals should play a greater role in supporting people who become ill while at work and that this should be co-ordinated via the employer.[55]

62. The Chartered Institute of Personnel and Development (CIPD) took this further, stating that the Green Paper omitted any suggestions of how to improve the way GPs and employers work together so that individuals' rehabilitation return to work was managed in a co-ordinated way. They argued that further guidance or advice for employers and GPs should be available. The CIPD also said that involving occupational health professionals was acknowledged as the most effective means of managing employee absence, yet research which they conducted with more than 1,000 large organisations found that only 62% used occupational health services. [56]

63. Occupational health support can be provided to individuals in Pathways to Work areas and the Green Paper suggests this as an option in the 'work-activity plan' that each ESA claimant will be obliged to complete.[57]

64. The First Step Trust highlighted a tendency for mental health services to be risk averse, discouraging individuals from considering returning to work for fear of provoking a relapse.[58] In supplementary evidence to the Committee, Mind, the Royal College of Psychiatrists and Rethink recommended that the Government target a campaign at mental health service staff to ensure they understand the potential benefits of work and that training for staff emphasised the recovery model of mental illness.[59]

65. The Committee was keen to hear the views of GPs on the Green Paper and requested written evidence from the British Medical Association (BMA). The BMA's evidence stated:

    "The Green Paper fundamentally misrepresents the role of GPs by referring to their key role 'in helping people back to work'. The central purpose of the primary health care team in managing the sick is restoration of health, or where this is unrealistic, ensuring the best possible strategies for the patient to manage the chronic illness."[60]

66. We recommend that there should be clarification of the status, importance and relevance of sickness certification in the process of applying for Statutory Sick Pay and other benefits.

Reform of Statutory Sick Pay

67. Statutory Sick Pay (SSP) is payable to employees who are unable to work because of a health condition or disability that lasts for more than four days in a row. It is payable for up to 28 weeks, after which some people may move onto claiming Income Support or Incapacity Benefit. The current rate is £70.05, although some employees receive more from their employer's sick pay scheme.

68. The Green Paper sets out the Government's plans for reforming SSP. The aim is to simplify it to enable employers to manage sickness rates and to help employees stay in work. It proposes to do this by abolishing:

69. In oral evidence, Richard Exell, Senior Policy Officer at the Trades Union Congress (TUC), "wholeheartedly welcomed" the abolition of the waiting days in SSP as it would increase the benefits paid to people, especially in short periods of sickness.[62] The TUC's written evidence also welcomed the other aspects of the proposed reforms to SSP.[63] Marilyn Howard, representing the Disability Rights Commission (DRC), also acknowledged the improvements to SSP suggested in the Green Paper. She suggested that the SSP process could become more 'managed' to enable individuals and employers to work together at an early stage of someone becoming ill to identify what adjustments might be needed to enable the person to remain in their job.[64] A different view was given by the mental health organisation Mind, which said that changes to SSP could result in employers pressurising staff to return to work before they were ready or moving to dismiss staff.[65]

70. During the Committee's visit to the Netherlands we heard from a private employment reintegration provider that is contracted by employers to work with their employees who are on sick leave. These private service providers act as an intermediary between employers and employees, identifying what support is required to enable someone to move back into work as soon as possible and providing appropriate services.

71. The GP's perspective on SSP was provided by the BMA which argued that absence from work due to short-term sickness assessment was best assessed by employees and employers, with advice from occupational health professionals and factual information from GPs: "Absence management is a human resource issue not a medical issue, and thus it should not fall under the remit of GPs or even the NHS."

72. In oral evidence to the Committee, the Secretary of State said that the principal responsibility of the GP was to secure the best possible outcome for the patient and in some instances this was to support the person so that they could remain in work. He went on to say: "We are not trying to ask GPs to perform roles that are not consistent with their primary and over-arching responsibility to secure the wellbeing of their patients."[66]

73. We welcome the measures to reform Statutory Sick Pay as a necessary simplification that will improve the system for claimants and employers. The Committee is concerned, however, that further efforts need to be made to reconcile GPs with the changes that the Government proposes to make. The Committee recommends that the Department enters a close dialogue with health professionals, including those working for mental health services, GPs and their professional representatives in order to assess the most appropriate way that the Green Paper proposals on Statutory Sick Pay - and their wider role in helping ill or disabled people back to work - can be taken forward and to ensure full co-operation by all stakeholders.

Transferring from Jobseeker's Allowance

74. The Government also hopes to reduce the incapacity benefits caseload by making it more difficult for people to move from claiming JSA to incapacity benefits. From 1 June 2004 to 31 May 2005, 176,600 people transferred from claiming JSA to incapacity benefits.[67] The Green Paper proposes to make full use of the current rules where JSA claimants are allowed two spells of short-term sickness of two weeks within a 12 month period. JSA claimants will have to exhaust these permitted spells of short-term sickness before they can claim incapacity benefits. It is intended that more proactive sickness management arrangements will be introduced, such as 'return from illness' interviews, revision of the Jobseeker's Agreement and referral to specialist assistance.[68]

75. Little evidence was received by the Committee on this issue, with the exception of written evidence from Mind which argued:

    "the primary motivation for this change is to prevent movement from JSA to IB, rather than providing appropriate support for people to get back to work where they can do so. These proposed changes should only go ahead if JSA staff are provided with comprehensive, ongoing training on mental health issues."[69]

76. The inadequacy of staff training on mental health issues was frequently raised during the inquiry. We return to this issue in Chapter 5.

77. The Committee acknowledges that it is important to ensure that people are receiving the appropriate benefit for their situation and that it may be more suitable for some to remain on Jobseeker's Allowance rather than move to incapacity benefits. The Department should ensure that the distinction between the two is properly understood by Jobcentre Plus staff.

The current Personal Capability Assessment

78. Under the present system, incapacity for work is determined by the Personal Capability Assessment (PCA). The PCA does not distinguish between people who can or cannot work. Rather, it draws a line between people who should not be expected to seek work in return for benefit and those who can be expected to do so (and therefore claim Jobseeker's Allowance). The PCA was introduced in 2000, replacing the prior All Work Test.

79. The PCA usually takes place after someone has been claiming Statutory Sick Pay (SSP) for 28 weeks. The first stage of the PCA process is completion of a questionnaire (the IB50 form) which awards points according to the level of difficulty the individual has in performing certain physical and mental activities. The claimant may then be referred for a medical examination by a doctor at the DWP's Medical Service (currently contracted out to the private organisation, Atos Origin). The doctor prepares a report to be considered by a DWP decision maker along with the IB50 questionnaire and any other evidence provided by the claimant's GP. The decision maker then decides whether the claimant has 'passed' the PCA and so qualifies for incapacity benefits.[70]

Reforms to the Personal Capability Assessment

80. The Green Paper states that the 'gateway' to incapacity benefits will be improved by transforming the PCA so that it focuses on assessing people's capability for work in addition to their entitlement to benefits.[71] The reformed PCA will take place within 12 weeks of initial application and claimants will need to satisfy the PCA before they become eligible for the new benefit, Employment and Support Allowance (see chapter 4). Eligibility for benefit will be based on evidence provided by medical practitioners and capability for work may be assessed by other health professionals. Once the PCA has been completed, the report will include a recommendation on the timescale for review. This will be within 12 months of the first assessment, unless the person's condition suggests that a review within that timescale is inappropriate.

81. The other significant difference between the current PCA and the reformed PCA is how it will assess those with more severe disabilities. Under the current system certain groups are exempt from the PCA, usually due to the nature of an individual's illness or disability. This includes: those who are registered blind, people with tetraplegia or paraplegia, those receiving the highest rate of the care component of Disability Living Allowance, and people who are terminally ill. The Green Paper proposes to replace the 'exempt' category with an assessment of "the severity of the impact of that condition on the individual's ability to function."[72] This group currently has a working title of 'reserved circumstances.' Most claimants of the new benefit will have to take part in 'work-related activity.' Those in the reserved circumstances category will not be obliged to undertake such activity but can volunteer, if they so wish.

82. The Green Paper also commits the Government to 'a comprehensive review' of the mental health component of the PCA. This will be carried out "by a group of experts in the field" with the intention of ensuring that the reformed PCA reflects "the type of [mental health] conditions prevalent today."[73] We discuss this further in paras 99-108 below.

Reactions to the proposed reforms

83. Evidence received by the Committee prior to the publication of the Green Paper was fairly consistent in criticising the existing PCA and calling for it to be reformed.[74] Following publication of the Green Paper, the evidence we received could be described as cautiously welcoming the suggested reforms to the PCA. The different issues that were raised in the evidence are set out below. However, it is worth noting that several witnesses pointed out that the Green Paper lacks detail on a number of areas, including the content of the PCA, making it difficult to give specific comments on such issues.[75]

CONTENT OF THE NEW PERSONAL CAPABILITY ASSESSMENT

84. Basing eligibility for incapacity benefits on an assessment of people's capability for work rather than on the severity of their impairment marks a significant shift in the gateway to incapacity benefits. In oral evidence, Richard Exell from the Trades Union Congress (TUC) described this as "one of the more radical and welcome elements of the Green Paper."[76]

85. A number of suggestions were made to the Committee regarding the possible content and design of the new PCA. Lorna Reith, Chief Executive of Disability Alliance, commented that medical evidence would still be an important part of the new PCA. She argued that such evidence needed to be placed in the context of, for example, a person's education and employment background.[77] Richard Exell of the TUC said that an individual's personal history should be taken into account[78] and Mark Baker, Head of Social Research and Policy at the Royal National Institute for the Deaf (RNID), commented:

    "we need a much more holistic assessment of the person's ability to do paid work and how much paid work they can do, as well as the local job market. We know other considerations that ought to be taken into account as well, including local transport infrastructure for a person getting to and from work, or whether a person has parenting or caring responsibilities as well."[79]

86. Dave Simmonds of the Centre for Economic and Social Inclusion (CESI) also argued for a more individualised approach but pointed out that it would be more expensive and require more personal adviser time.[80]

87. Cliff Prior, Chief Executive of Rethink, argued that the new assessment should consider the additional disadvantages faced by those with mental health conditions, because of the way in which they are perceived in society:

    "If you can imagine a society in which there were no wheelchair ramps and the state did not provide people with wheelchairs; it rather thought that people who could not walk were slackers and shirkers; that they probably brought it on themselves and frankly it was their own responsibility to - not get on their bike but get themselves to work. They were thought of as dangerous people, always at risk of causing some trouble or maybe even serious violence, and 80% of the newspaper headlines were about supposed connections with violence. Now, in that sort of world you could not just assess somebody who could not use their legs; you would have to take into account all those different social constructs, all those various stigmas and prejudices, and that is what we have in mental health."[81]

88. Marilyn Howard, representing the DRC argued that disabled people should be at the centre of the assessment process and that it should be based firstly on "the individual's aspirations and where they want to get to." She warned that those carrying out assessments should "not have the same kinds of low expectations of disabled people that we have seen for years and years hitherto."[82] She also said:

    "I think it would be far better to look at means of assessing people to look at what kinds of job options would be suitable for them and what kinds of arrangements with support, adjustments in employment, that people would need to have. Probably there is a difference between looking at eligibility for benefit and what people need to do in order to move towards work and it is not very clear from the Green Paper how those two different things would interrelate. There seems to be a suggestion that the Personal Capability Assessment in some way would be recalibrated but remain the gateway to benefit, but in addition there is a Capability Assessment which is looking at the wider issues about what people need to do in order to move back towards work. The underpinning basis of the benefit needs to be able to accommodate both of those."[83]

89. The points raised above suggest that there remains considerable work for DWP to do in finalising the detail of the PCA.

Replacing the PCA 'exempt' category

90. Although the lack of detail on how the Department intends to identify the reserved circumstances group was commented upon,[84] the proposal to abolish the PCA 'exempt' category was largely welcomed in the evidence received by the Committee for not 'writing-off' certain claimants because of their disability. For example, TUC stated that they:

    "strongly support the Government's refusal to write anyone off for paid work: in particular, we would oppose any attempt to establish a medically-defined group of 'unemployable' disabled people, who are not offered any return-to-work support."[85]

91. The group of disabled people who currently fall into the 'exempt' category that were mentioned most frequently in the evidence the Committee received were blind people. In evidence, the Royal National Institute for the Blind (RNIB) welcomed the removal of the 'exempt' category but said that they "would like some assurance from Government that systems will be in place to support blind people to work as a result of the exemption being removed."[86] This issue will be considered later in the report in Chapters 5 and 6.

92. Under the current rules, the number of people who are now 'PCA exempt' has increased by a significant number since the introduction of Incapacity Benefit. There are currently 461,000 claimants who are exempt from the PCA compared with just 59,000 in May 1995 - an increase from 2% of the working-age caseload to 17%.[87] Commenting on this increase, Dr Peter Kenway, Director of the New Policy Institute, said that the current PCA was seen as a hurdle to cross in order to get a higher level of benefit. He stressed that any new assessment would continue to be viewed in this way, if the reforms introduced a two-tier system with a higher benefit rate.[88]

93. In evidence, we asked the Secretary of State whether he thought that the reforms would build in an incentive for people to try to get into the 'reserved circumstances' group and thus move into the higher rate of the new benefit, with no work-related conditions attached. He responded that the Department had decided that it was right to provide people who are more seriously disabled with more financial help but that this brought about a debate on where the line should be drawn. He went on to say:

    "I am confident we will be able to do that and we should do it without doing what we currently do, which is to designate people simply because of the condition they might have, so blind or deaf people are automatically assumed to be currently incapable of work and treated accordingly. I think that is absolutely appalling. […] I think there is a way of making the system more refined and more discerning and discriminating but yes, it does create a problem and create potential for an argument around where the line should be drawn. We will have to try and get that right as far as we possibly can, and I suspect this is something that we will have to reflect on very carefully in the Green Paper consultation […]"[89]

94. Finally, it is worth pointing to evidence submitted from Professor Richard Berthoud. He provided us with early findings on his research on the labour market position of disabled people (which was subsequently published by the DWP).[90] His research found that disabled people's employment prospects are strongly influenced by the type and severity of their disability. But they are much less disadvantaged by their impairments if they live in a prosperous area and if they have had a good education. Importantly, these characteristics are more relevant to disabled people than to the rest of the population. His analysis also suggested that it will be very difficult for the Department to distinguish between disabled people who can and cannot work.

95. Professor Berthoud's analysis of statistical data between 1985 and 1997 also led him to suggest that disability as an 'economic identity' has now become more accepted. However, he concluded that the approach taken by the Government in Pathways to Work is still appropriate as it "aims to reduce employment disadvantage through a combination of rehabilitation, labour market engagement and financial incentives, and […] is already showing some clear signs of success."[91]

96. Further issues around the distinctions between the 'reserved circumstances' and other claimants are addressed in the rest of this chapter.

The Capability Report

97. The scope of the new PCA bears some resemblance to the Capability Report that is currently used in the Pathways pilot areas. The Capability Report looks at the employment recently undertaken by the claimant and provides a more work-focused assessment. It is prepared by the DWP Medical Services doctor and sent to the claimant's Personal Adviser at Jobcentre Plus. Findings from the evaluation of the Pathways pilots suggest that the Capability Reports have little value for the Personal Advisers working with incapacity benefits clients for two reasons. First, they tend to arrive too late for them to be of much use to the adviser and their client - rarely arriving in time for the client's second work-focused interview. Second, the report tends to contain information that personal advisers describe as "generic, standardised and repetitive" that is of minimal use and tells them nothing beyond what they gather themselves during a work-focused interview.[92] In oral evidence, Marilyn Howard, representing the DRC, pointed to this evidence from the Pathways evaluation and said that it would be necessary to find out more about how well the Capability Report was working to establish whether there is a future role for it as currently designed.[93]

98. The Committee welcomes the shift in eligibility criteria that the reformed Personal Capability Assessment will bring. However, the absence of detail in the Green Paper suggests that the Department has not made much progress in redesigning the PCA. This makes it difficult to consider how the reformed system will work in practice as we do not know what the new assessment will contain. We recommend that the Department carefully considers the evidence received during this inquiry, its own consultation, and the findings from the Pathways evaluation to ensure that the new assessment takes account of the complexity and reality of disabled people's lives, as well as the social elements of their disability, rather than simply whether they are entitled to benefit.

THE MENTAL HEALTH COMPONENT OF THE PCA

The current assessment

99. The current mental health component of the PCA was criticised in evidence to the Committee by both organisations representing those with mental health conditions and others.[94] Witnesses felt that neither the IB50 questionnaire nor the medical examination adequately addressed mental health conditions.

100. The current IB50 questionnaire assesses entitlement to incapacity benefits by awarding a client points on the basis of the difficulty she or he has in completing a series of 'descriptors', or descriptions of activities. It has a separate physical and mental health assessment. Evidence we received raised concerns that this questionnaire is weighted against mental incapacity.[95] The physical assessment is scored on the basis of 89 possible descriptors across 14 groups of conditions. Each descriptor is allotted between 3 and 15 points, with a total score of 15 being needed to qualify. By contrast the mental health assessment contains only 25 possible descriptors across only 4 conditions. The mental health descriptors are allocated only 1 or 2 points each, with a minimum of 10 needed to qualify.

101. Rethink argued that many of the descriptors allocated one point represented "very serious symptoms indeed, which would severely impact on an individual's ability to perform work."[96] Dr Jed Boardman, from the Royal College of Psychiatrists, gave the Committee one such example: "agitation, confusion, forgetfulness that has resulted in potentially dangerous accidents in the past three months". He stressed: "Now, it is a pretty high level of lack of functioning to get to that, and you can imagine […] you can still not be able to work at much lower levels."[97] Dr Boardman also argued that the current PCA,

    "does not cover the range of capabilities for specified activities that I think should be covered for a more comprehensive look at somebody with a mental health problem because, of course, they are not a homogenous group and they have a lot of different symptomatic and incapacity experiences."[98]

102. Under the current system, after completion of an IB50 questionnaire, claimants may then be referred for a medical examination. Respondents to our inquiry told us that this stage in the process was also failing those with mental health conditions. Rethink argued that assessors lacked knowledge of mental health issues and also suggested that claimants sometimes overmedicated before an assessment so therefore did not present their usual condition.[99] Sue Christoforou, Policy Officer at Mind, argued that doctors conducting the new assessment, and decision-makers, should have at least NVQ level three mental health training.[100] Dr Jed Boardman told the Committee that he had frequently heard complaints that assessors were "inappropriate", "uncaring", "unregarding" and failed to listen.[101]

103. In addition, Mind, the Royal College of Psychiatrists and Citizens Advice Scotland expressed concern that the medical report prepared by doctors following completion of a medical assessment did not fully explore mental health problems, commonly under-estimating their severity.[102] The quality of medical assessments across all conditions is discussed further in paras 125-134.

104. In oral evidence to the Committee, Ms Natascha Peter, a former Incapacity Benefit claimant, told us of her own experience of the current assessment:

    "it was not until I received the documentation stating why I had had my Incapacity Benefit stopped that it was evident that the doctor I had spoken to had no understanding of mental health issues and had not taken anything I had said into account. He had not taken into account that I had to leave work due to stress and that I found it difficult if my routine was disrupted and he did not take anything in to account of my background. Because of the way I come across it may not necessarily be evident that I am an anxious person and he did not take into account the fact that it would take quite a lot of effort for me to attend the PCA in the first place and present myself." [103]

The reformed assessment

105. In the Green Paper the Government acknowledges the need to make changes to the current mental health component of the PCA. It states:

    "Given the changing pattern of mental health, we need to ensure that the new medical assessment reflects the type of conditions prevalent today. Accordingly we are convening a group of experts in this field to undertake a comprehensive review of this and make recommendations." [104]

106. Organisations representing those with mental health conditions welcomed the redesign, but warned that it would not be successful unless all stakeholders were involved from the outset, rather than consulted at a secondary stage. (The further involvement of external stakeholders in the wider design of the PCA is addressed in paras 135-137). They also expressed concern that there were no definite plans to pilot the newly designed PCA before implementation.[105] A report published in February 2006 by Citizens Advice on medical assessments for incapacity and disability benefits argued that DWP should appoint a mental health champion, to provide a greater focus within the Department on providing a better service to those with mental health problems and to improve the assessment of mental health conditions.[106]

107. The Secretary of State told the Committee:

    "I think it is perfectly possible to devise a sensible test in relation to mental health, of course. It will need to rely very heavily, of course, on expert medical opinion but I am sure it will need to go wider than that, and those are, again, discussions we will need to have with mental health interest groups and others who have an interest in this…Just as it is important in relation to physical disability, it is just as important in relation to mental health that we get a broad consensus about a sensible way forward."[107]

108. We welcome the Government's decision to review the mental health component of the Personal Capability Assessment. However, in order to ensure that concerns with the current assessment are adequately addressed, the expert panel tasked with the review of the PCA for those with mental health conditions must include people with mental health problems, their carers and organisations representing them. The new assessment should also be piloted with those with mental health conditions to ensure it is suitable.

DELIVERY OF THE PCA

Who should carry out the PCA

109. A key issue raised by several organisations was the extent of the involvement of GPs in the new PCA. Bert Massie, Chairman of the DRC, pointed out that the medical profession might be able to establish someone's impairment, but not necessarily their capability for work. Therefore a broader team of specialists was required.[108]

110. The Green Paper suggests that, under the reformed PCA, eligibility for benefit would continue to be assessed by GPs and capability for work could be considered by other health professionals. During the Committee's visit to the Netherlands, we heard of its similar assessment process where medical assessments are conducted by doctors employed by the government agency that assesses benefits, followed by an assessment of capacity to work carried out by labour specialists. Each aspect of the assessment takes around an hour and is accompanied by other medical information and a statement by the claimant's most recent employer.

111. It is notable that there are very different figures on the length of medical assessment in the UK. A recent report published by Citizens Advice on medical assessments for incapacity and disability benefits criticised them as too short, with clients reporting rushed or incomplete assessments. Citizens Advice collected evidence from a review of 96 cases that had failed the PCA and found that the average assessment took 25 minutes (a range of 15 to 69 minutes).[109] A recent parliamentary answer put the average assessment time at 38 minutes.[110]

112. Rethink argued that a "workable mechanism" for the new PCA "would at the very least need to be based on a more holistic model of disability, rather than the medical model currently used" and "would need to involve a far wider variety of health professionals, including occupational therapists and advocates."[111] Mind went further than most organisations and questioned whether there was a need for a medical assessment to form part of the new PCA at all. Ms Christoforou, Policy Officer for the organisation, argued,

    "Certainly the employment advisers that deliver our local Mind association employment services are not doctors and they will need to make an assessment in order to determine whether people are appropriate for the services that they provide, and they will look at factors […] such as educational background, employment background, […] and […] the whole issues about stigma and discrimination […] So it is not necessarily about having the label of depression or bipolar disorder; it is about how all the relevant factors impact on a person's ability to move into the work place."[112]

113. In oral evidence, the Secretary of State pointed out that the current contract for delivery of the PCA did not end until 2012 and therefore the current contractor, Atos Origin, would continue to carry out the medical assessments. In terms of the involvement of other health professionals in the PCA, he went on to say:

    "my understanding is that people agree that we should involve the skills and expertise of a wider relevant range of healthcare professionals to help us do this. There will be a list of people, I am sure, occupational therapists and physiotherapists and others, but who actually is involved in individual assessments I think is going to have to be something we discuss with people over the next few months." [113]

Timing of the PCA

114. The Green Paper states that the revised PCA will take place within 12 weeks of a new claim for benefit. Highlighting the importance of this aim, Richard Exell, of the TUC said:

    "one of the things that makes a difference to getting people into jobs is carrying out quickly an assessment of their needs. If you can do that before changes in their attitudes to work have settled in then you are far more likely to be able to help them into jobs. If the Government really can meet this 12 week target for its PCAs, that is going to have a beneficial effect as well."[114]

115. A recent parliamentary question asked whether the Department had made an assessment of the merits of conducting the assessment as soon as an initial claim for the new benefit is made. The response highlighted the importance of an early assessment in maximising the claimants' chance of returning to work and stated:

    "However, many people will be on Employment and Support Allowance for very short periods of time and so carrying out assessments too early in a claim could lead to nugatory assessments taking place."[115]

116. Evidence received from a variety of organisations argued that the 12 week target was a desirable aim but would be very demanding given the Department's current financial constraints. Witnesses also highlighted that the financial implications for claimants remaining at a lower level of benefit could be considerable.[116] Importantly, as Citizens Advice Scotland pointed out, there are no drivers to ensure that the assessments will take place within 12 weeks.[117]

117. In oral evidence to the Committee, the Secretary of State replied that he was "confident" that this target will be met.[118] He went on to say that the PCA should be carried out:

    "swiftly, efficiently and promptly. My advice is that we will be able to do that and, obviously, I regard that as a fundamental part of these reforms and I will be doing all that I can to make sure that happens."[119]

118. The Committee welcomes the Government's commitment to carry out the revised Personal Capability Assessment within 12 weeks but is concerned about how often this will be achieved in practice. Those who are not assessed within this period should not suffer financially as a result. The Committee therefore recommends that the Department establishes contingency measures for such an occurrence to ensure that ill or disabled people are not financially penalised.

EXISTING CLAIMANTS

119. The outline of the new PCA applies only to claimants of the new Employment and Support Allowance. The Green Paper explains that, for existing claimants of incapacity benefits, DWP is planning to complement its existing case review with ad hoc case checks by a dedicated new team: "Where these checks produce doubt about the nature or extent of an individual's incapacity, the Green Paper outlines, a fresh PCA will be required."[120] Mind's evidence to the Committee expressed concern that such ad hoc reviews would introduce fear and uncertainty, and were unnecessary since eligibility for benefit was already reviewed on a regular basis.[121]

120. The Committee recommends that, rather than carrying out ad hoc case checks of existing claimants, the Department should review claims systematically. Case reviews should not be random but based upon specific guidelines. We recommend that the Department re-examines the processes that currently govern case reviews and consult on the criteria upon which future checks would occur.

FLUCTUATING CONDITIONS

121. The current PCA was also criticised for failing to address the fluctuating nature of certain conditions, with organisations arguing that a one-off assessment provides an inadequate snapshot of a varying condition.[122] This was seen as a particular issue for those with mental health conditions. In oral evidence, Mr Shaun Hallam, Area Service Manager for Rethink, who has bipolar disorder, told us that he had failed the PCA four times "because at that time I was in a grandiose, fairly manic mood when you can be quite cheerful, quite chatty".[123]

122. The Green Paper acknowledges that health conditions can fluctuate in intensity.[124] However, it considers the 'scenarios' for those with fluctuating conditions only from the standpoint of advisers and employers, rather than also at the stage of assessment for incapacity benefits. This was criticised in evidence to the Committee. Richard Exell, from the TUC, told us:

    "I think that is possibly one of the weaker areas of the Green Paper…I know plenty of people who are able to work at 100 per cent of what everyone else can do this week, next week they can work at 500 per cent of what everyone else can do, incredibly effective, sleeping three hours a night and enthusing everyone else, and then for a month afterwards they can do no work at all. It is extraordinarily difficult for employers to cope with that and it is extraordinarily difficult to work out assessments that are going to fit in with that. Essentially the Green Paper promises that something wonderful is going to be done and they will tell us what it is later on."[125]

123. During the Committee's visit to the Netherlands, we learnt that individuals are assessed as having a percentage disability which then determines the number of hours of work they are expected to be able to carry out. However, this option was dismissed in evidence by Richard Exell as one that "would not necessarily get us further beyond the Personal Capability Assessment" because it appears to be embedded in a medical model of disability. He argued:

    "I think it would be far better to look at means of assessing people to look at what kinds of job options would be suitable for them and what kinds of arrangements with support, adjustments in employment, that people would need to have."[126]

124. We are disappointed that the Green Paper did not contain any detail on how the new Personal Capability Assessment will assess those with fluctuating conditions. This is a difficult area on which DWP should consult extensively with stakeholders, including employers, to ensure that those with fluctuating conditions receive the right assessment and do not continue to be excluded from the labour market.

APPEALS AGAINST A PCA DECISION

125. A number of those submitting evidence argued that the quality of medical assessments in the current PCA was poor and that this led to a high level of incorrect decisions being made.[127] The Report by the President of Appeal Tribunals found that, in 2004-05, 50% of Incapacity Benefit appeals cases surveyed were overturned and found in favour of the claimant. In comparison 28% of cases were overturned for JSA claimants, 35% for Income Support claimants and 48% in Disability Living Allowance cases.[128]

126. The main reason for overturned Incapacity Benefit cases was that the tribunal was given additional evidence not available to the decision maker (this occurred in 70% of cases). The report found that tribunal chairmen commonly commented that the presence of the appellant at the tribunal either produced new evidence or shed light on existing evidence. This was particularly the case when dealing with mental health issues.[129]

127. The second most reported reason for incapacity benefits cases being overturned was that the medical report under-estimated the severity of the disability. This occurred in 50% of overturned cases and increased from 37% in the previous year. Tribunal chairmen expressed concern that the length of time taken to complete medical examinations was inadequate, resulting in incomplete histories being taken (also see paragraph 111 above). [130]

128. One further problem was pointed out in a recent report from Citizens Advice, which found that those challenging decisions at a tribunal could face difficulties in obtaining further medical evidence as doctors might not find the time to do a report for an appeal tribunal and might also require payment which the claimant might not be able to afford.[131]

129. The issue of poor quality medical assessments has been scrutinised by Parliament over recent years. Our predecessor Committee, the Social Security Committee, conducted an inquiry in 2000 examining the performance of Medical Services. [132] It concluded that the contract provider had failed to improve the quality of medical examinations and reports and that steps should be taken to renegotiate the contract so that performance to claimants was improved.[133]

130. In 2001 and 2003, the National Audit Office (NAO) produced reports on DWP medical services and, more recently, the Committee of Public Accounts looked at the medical assessments for Incapacity Benefit and Disability Living Allowance. The Committee found that improvements had been made in the medical assessment process but that the number of successful appeals continued to suggest that the performance of doctors and decision-makers needed to be improved and that the contractor should enforce rigorous standards. The Committee of Public Accounts also reiterated a recommendation made by the Social Security Committee: that the Department should provide regular feedback on appeal tribunal cases to doctors and decision-makers so that they knew the outcomes of the cases they examined.[134] In November 2005, the DWP issued new guidance which emphasised the role of reconsideration in the decision-making and appeal process.[135]

131. Nonetheless, the Green Paper acknowledges that further improvements to the decision-making and appeals process are needed and states:

    "We recognise that a robust and independent appeals process is an integral part of any fair system of assessment. The current system generates a very high number of appeals, many of which are successful. We believe that improvements can be made so that the need for appeals is minimised." [136]

132. The Department proposes to reduce the number of appeals by:

  • ensuring that claimants have a clearer understanding of the basis for the initial decision;
  • incorporating a comprehensive reconsideration process prior to an appeal moving to tribunal; and
  • ensuring that new evidence is included in the reconsideration process rather than at tribunal.

133. Finally it is worth considering a comment made by Richard Exell from the TUC. Referring to a reformed PCA, he said:

    "If there is going to be a new test then there are going to be masses of appeals, you can guarantee that. The effect of the new test will be the same as it always is, initially you get a big reduction in the numbers coming onto the benefit and then advice workers, and so on, find their way round the new system and the numbers start creeping up again, and a big load of appeals will almost certainly be part of that."[137]

134. The Committee welcomes the proposals in the Green Paper to reduce the number of appeals. However, we believe that further action is necessary to improve the quality of medical assessments. The Committee recommends that:

a)  a review of the length of time taken to complete medical assessments is undertaken by the Department;

b)  doctors should be encouraged to take the time to undertake assessments appropriately and should receive more training on best practice in performing assessments, particularly when dealing with mentally ill claimants; and

c)   more effort is made to gather medical evidence that may affect a case.

WORKING TO REFORM THE PCA

135. The Green Paper states that the Department will work with health professionals, disability groups and personal advisers to reform the PCA, yet several leading disability organisations and the Royal College of Psychiatrists told us that they had not yet been invited by the Department to take part in any such discussions.[138] In evidence, the Secretary of State reiterated the Government's intention to involve disability organisations, the voluntary sector, the medical profession and the BMA in redesigning the PCA, plus looking at international evidence and "the best medical and occupational health evidence that is available to us."[139] He did admit: "We have to crack on with this pretty soon, so if they have not got the invitations yet, they will be getting them very soon."[140] This suggested a worrying lack of momentum on the behalf of the Department.

136. Following the evidence session with the Secretary of State, we were contacted again by Rethink which informed the Committee that DWP had since confirmed that an 'expert panel' of health professionals, including psychiatrists, and occupational health professionals were going to meet to formulate possible policy options for the reform of the PCA. Disability organisations would then be consulted a month or so later. Understandably, Rethink said that they were "very disappointed by this process."[141]

137. The Committee acknowledges the importance of involving all stakeholders in reforming all aspects of the Personal Capability Assessment (PLA) and welcomes the Government's commitment in the Green Paper to do so. We are not, however, content with the process that we understand the Department has now begun. Disability organisations as well as medical experts must play a key role in advising the Department on the content and delivery of the PCA, the 'reserved circumstances' group and the reform of the appeals process and we recommend that they are included in all discussions with the Department, and not merely consulted as a secondary process. We are also concerned by the delay in producing detail on the PCA and recommend that the Department produces a possible model for the reformed PCA as soon as possible. Once the Department has completed its work on redesigning the PCA we intend to examine whether it is satisfactory or not.


46   DWP, A new deal for welfare: Empowering people to work, Cm 6730, January 2006, p 33 Back

47   Ev 99, vol 3 Back

48   Ev 26, vol 2 Back

49   Ev 91, vol 3 Back

50   See, for example: The Observer, GPs paid to send sick back to work, 22 Jan 2006; Sunday Times, Doctors set to get bonuses if they cut sicknotes, 22 Jan 2006; Daily Telegraph, Weakened Blair forced to water down benefit reform, 13 Dec 2005. Back

51   HC Deb 8 March 2006, col 1547W Back

52   Vol 2: Ev 170; and Vol 3: Ev 44; Ev 99; Ev 104  Back

53   Vol 2: Ev 166; Ev 170; and Vol 3: Ev 15; Ev 251 Back

54   Ev 60, vol 3 Back

55   Ev 27, vol 3 Back

56   Ev 250, vol 3 Back

57   DWP, A new deal for welfare: Empowering people to work, Cm 6730. Jan 2006, p 43 Back

58   Ev 34, vol 3 Back

59   Ev 205, vol 2 Back

60   Ev 268, vol 3 Back

61   DWP, A new deal for welfare: Empowering people to work, Cm 6730, Jan 2006, p 36-37 Back

62   Q 88 Back

63   Ev 81, vol 2 Back

64   Q 136 Back

65   Ev 170, vol 3 Back

66   Q 241 Back

67   HC Deb 18 April 2006, col 419W Back

68   DWP, A new deal for welfare: Empowering people to work, Cm 6730, January 2006, p 38 Back

69   Ev 170, vol 2 Back

70   Child Poverty Action Group, Welfare Benefits and Tax Credits Handbook 2005/06, p 772-786 Back

71   DWP, A new deal for welfare: Empowering people to work, Cm 6730, January 2006, p 38-39 Back

72   DWP, A new deal for welfare: Empowering people to work, Cm 6730, January 2006, p 39 Back

73   DWP, A new deal for welfare: Empowering people to work, Cm 6730, Jan 2006, p 40 Back

74   Vol 2: Ev 24; Ev 180; Ev 194; and Vol 3: Ev 67; Ev 136; Ev 165; Ev 186 Back

75   Qq 123-4, 150, 152, 160; Vol 2: Ev 109; Ev 140; and Vol 3, Ev 237 Back

76   Q 93 Back

77   Q 162 Back

78   Q 95 Back

79   Q 161  Back

80   Q 96 Back

81   Q 216 Back

82   Q 126 Back

83   Q 124 Back

84   See, for example, Q 150 [Mr Harrop]; Ev 109, vol 2; Ev 255, vol 3 Back

85   Ev 82, vol 2 Back

86   Q 149 Back

87   DWP, Work and Pensions Longitudinal Study, Incapacity Benefits Quarterly Statistics, May 1995 and August 2005  Back

88   Q 101 Back

89   Q 266 Back

90   Ev 189, vol 3 and Berthoud, R (2006) The Employment Rates of Disabled People, DWP Research Report No 298, Leeds: CDS Back

91   Ev 193, vol 3 Back

92   Knight, T et al, (2005) Incapacity Benefit reforms - the Personal Adviser role and practices: Stage 2, DWP Research Report No 278, Leeds: CDS, p 51 Back

93   Q 125 Back

94   For example, Vol 3: Ev 4, 21, 32, 143, 169, 186, 239, 249, 257 Back

95   For example, Vol 2: Ev 180 and Ev 200 Back

96   Ev 180 (vol 2) Back

97   Q 201 Back

98   Q 201 Back

99   Ev 180-181, Vol 2 Back

100   Q 210 Back

101   Q 202 Back

102   Vol 2: Ev 160, Ev 172 and Ev 201 Back

103   Q 203 Back

104   DWP, A new deal for welfare: Empowering people to work, Cm 6730, January 2006, p 40 Back

105   Vol 2, Ev 205 Back

106   Citizens Advice, What the doctor ordered? CAB evidence on medical assessments for incapacity and disability benefits, February 2006, p 2 Back

107   Q 253 Back

108   Q 125 Back

109   Citizens Advice, What the doctor ordered? CAB evidence on medical assessments for incapacity and disability benefits, February 2006, p 12 Back

110   HC Deb, 30 January 2006, col 291W Back

111   Vol 2, Ev 178 Back

112   Q 212 Back

113   Q 249 Back

114   Q 109 Back

115   HC Deb, 15 March 2006, 2255W Back

116   Vol 3, Ev 125, Vol 2: Ev 80 , Ev 185, Ev 242; Q 96; Q 104 and Q 208 [Ms Christoforou] Back

117   Vol 3, Ev 162 Back

118   Q 250 Back

119   Q 251 Back

120   DWP, A new deal for welfare: Empowering people to work, Cm 6730, January 2006, p 48 Back

121   Vol 2, Ev 173 Back

122   For example, Vol 2, Ev 162 Back

123   Q 203 Back

124   DWP, A new deal for welfare: Empowering people to work, Cm 6730, January 2006, p 44 Back

125   Q 97 Back

126   Q 124 Back

127   Vol 2, Ev 160, Vol 3, Ev 62, IB 63, Ev 164-165, Ev 186 and Ev 202 Back

128   The Appeals Service, Report by the President of Appeal Tribunals on the standards of decision-making by the Secretary of State 2004-05, July 2005, p 38-40 Back

129   The Appeals Service, Report by the President of Appeal Tribunals on the standards of decision-making by the Secretary of State 2004-05, July 2005, p 33 Back

130   The Appeals Service, Report by the President of Appeal Tribunals on the standards of decision-making by the Secretary of State 2004-05, July 2005, p 34 Back

131   Citizens Advice, What the doctor ordered? CAB evidence on medical assessments for incapacity and disability benefits, February 2006, p 14 Back

132   Social Security Committee, Third Report of 1999-2000, Medical Services,, HC 183 Back

133   The current provider (Atos Origin) was awarded a seven year contract to deliver medical services for DWP, worth £500m, in 2005 - the contract can be extended by up to five years, costing an additional £350m. (http://www.atosorigin.com/en-us/Newsroom/en-us/Press_Releases/2005/2005_03_16_02.htm) Back

134   Committee of Public Accounts, Sixteenth Report of 2003-04, Progress on improving the medical assessment of incapacity and disability benefits, HC 120 Back

135   DWP (2005) Decision Makers Guide Memo Vol 1, 11/05 Back

136   DWP, A new deal for welfare: Empowering people to work, Cm 6730, January 2006, p 40 Back

137   Q 121 Back

138   Qq 164-166, 205 Back

139   Q 246 Back

140   Q 247 Back

141   Vol 2, Ev 194 Back


 
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