32.PIP and ESA assessments are functional. They aim to assess the impact of a claimant’s impairments on their day-to-day life, rather than reaching a decision based on medical diagnosis. Dr Ian Gargan, Chief Medical Officer at Capita, explained:
I as an orthopaedic surgeon may look at a diseased hip and decide that I am going to replace that hip, but then as a PIP assessor that has gone through standard disability assessment training I would be looking to see how that hip pathology affects the activities of daily living, like how far that person can walk, whether they can leave the home, whether they can feed themselves, among all the other extant activities as set out by the PIP assessment.
Contractors told us that the functional nature of PIP and ESA assessments means assessors’ medical backgrounds need not correspond with the conditions of claimants they are assessing. Their training should enable them to accurately assess claimants with a range of conditions—including multiple conditions—that may manifest differently in different people. In carrying out assessments, HCPs should draw on insights from a range of different sources:
a)information shared by the claimant in the face-to-face assessment;
b)the outcomes of any examinations conducted, and observations of claimants during the assessment;
c)information shared by companions or advocates that claimants bring to assessments;
d)additional evidence submitted by claimants, including reports from medical professionals, carers, support workers or family members.; and
e)expert advice provided by their organisations. Atos, Capita and Maximus each have a limited number of specialist “champions” for common conditions.
33.We heard that the accuracy of the generalist assessor model is contingent on assessors having access to sufficient expert evidence. Without this, the assessment will, almost inevitably, be based on partial knowledge of the claimant’s condition, since assessors cannot hope to develop a deep understanding of all the conditions of claimants they assess. The evidence provided will vary from claimant to claimant. It can include reports from medical professionals, but there is an equally important place for evidence from people who see claimants every day, such as carers or family members. Although successive reviews of both PIP and ESA have emphasised the importance of ensuring a good supply of appropriate expert evidence, progress in achieving this has been slow.
34.Responsibility for providing evidence to support a claim lies primarily with claimants. DWP research on PIP found that 16% of claimants do not provide any additional evidence, falling to 9% amongst those who said they had read DWP’s guidance. We heard that although the PIP and ESA forms emphasise the importance of additional evidence, many claimants still fail to appreciate this fully. Zacchaeus 2000 Trust, a welfare support charity, told us claimants are aware that they will be assessed by a healthcare professional, and frequently assume this negates the need for supporting evidence. Some claimants erroneously believe that the Department will have access to their medical records, or will contact their GP directly in any case. Claimants also sometimes supply evidence that cannot be used in the assessment. 8% of PIP claimants, for example, provided appointment letters and 2% provided fact sheets about their conditions. Claimants are sometimes asked to pay fees and charges to obtain medical evidence, which may put the cost of obtaining this beyond them.
35.In some circumstances, assessors request further evidence. The PIP handbook sets out circumstances when this should take place. These include where further evidence might negate the need for a face-to-face assessment; where claimants have progressive or fluctuating conditions and have not supplied additional evidence; and, in the case of reassessments, where evidence might confirm whether or not there has been a change in the claimant’s health since the last assessment. The ESA Handbook is less prescriptive, stating that assessors should review all the evidence supplied and “may decide that further medical evidence is required” in addition to that provided by the claimant.
36.We heard that contractors’ efforts and success in obtaining additional evidence vary. Atos told us it only holds data on requests for some forms of medical evidence (rather than on requests to carers or family members). This data did not allow us to determine the overall proportion of assessments in which Atos requests additional evidence. Atos told us, however, that in the case of GP Reports “considerably more (an estimated 60–70%) are requested than returned”. Capita told us they request additional evidence from medical professionals, carers or family members in 38% of all assessments. They receive it back within 21 days in 21% of cases, and within 40 days in 45% of cases. In 33% of cases, the request is never returned. Both Atos and Capita stressed they use standard templates to request evidence, provided by the Department. Maximus told us that they request written evidence from medical and non-medical professionals in up to 46% of cases each year, receiving 82% of requests back within 20 days. Capita also told us that the evidence they receive is only relevant to the functional assessment in a very small proportion of cases. Neither Maximus nor Atos were able to offer any data on the usefulness of evidence received.
37.The MS Society explained that difficulties in obtaining useful expert evidence stem in part from confusion amongst claimants about what PIP and ESA assessments seek to measure. Several organisations told us that Department could do more to communicate to claimants what “good evidence” for a PIP or ESA claim looks like. This should include providing illustrative examples and case studies of good and poor quality evidence which, where possible, are directly related to descriptors and to different conditions.
38.The Disability Benefit Consortium, a coalition of over 80 non-profit organisations, said that the Department should complement efforts to engage claimants with greater efforts to engage with medical professionals. This should aim to enhance their awareness of what assessments seek to measure, and what kind of evidence they should provide in response to contractor and claimant requests. The MS Society agreed that GPs and other health professionals do not always understand what they should provide. They attributed this in part to the standard request forms being “confusing”. The MS Society noted that one assessor had been engaging with GPs, and was already seeing the benefits in turns of both return rates and usefulness. This is presumably Maximus, who attributed their return rates to “substantial investment in engagement with GPs”. To spread this good practice more widely and ensure a consistent approach between contractors and across the different benefits, the Disability Benefits Consortium recommended the Department commission independent research on the use of evidence. This should consider:
a)how best to educate health and social care professionals on providing relevant supporting evidence;
b)how to ensure the duties and responsibilities of the assessor, DWP and claimant with regard to evidence are clear and observed;
c)how to consistently and clearly articulate to claimants what evidence will be most useful for their claim; and
d)the timescales needed to provide useful evidence.
39.Atos, Capita and Maximus all use a generalist assessor model. They pay no regard to the specialist expertise of individual assessors in assigning cases. They therefore assess claimants with the full gamut of conditions. The success of this model depends on a consistent supply of high quality, relevant expert evidence. There is ongoing confusion amongst claimants and those supporting them alike about what constitutes “good evidence” for functional purposes. We recommend that the Department sets out in response to this Report its approach to improving understanding amongst health and social care professionals and claimants of what constitutes good evidence for PIP and ESA claims. This should include setting out how it will measure, monitor and report on the supply of evidence into PIP and ESA assessments.
40.We heard that for most claimants, the face-to-face assessment is by far the most stressful part of the PIP or ESA process. Witnesses suggested that concern about this element of assessment is at the root of lack of trust in both processes. A common complaint is that assessors cannot be trusted to record accurately what took place during the assessment. Claimants worry this will produce an inaccurate basis for the Department to make decisions on entitlement to benefit. Our previous report set out several examples of these kinds of errors. They fall into two broad types:
Some witnesses told us errors were likely attributable to assessors confusing different claimants, forgetting details, or “copy and pasting” between reports, especially when they write up several appointments in one block. Amongst claimants, however, there is a prevalent belief that such mistakes are deliberate attempts to prevent them receiving benefits. Turn2us told us that amongst people they support, this belief is “near universal”.
41.The Department told us that in the interests of improving trust, claimants can opt to have their assessments audio recorded. For both benefits this request must be made in advance. For ESA, it is subject to recording equipment being available. For PIP, claimants must provide their own equipment which meets specified standards. Requests to record are sometimes declined, and equipment is not always available or easy for claimants to obtain. In the case of PIP, it can be very expensive. Paul Gray described this approach as “incredibly clunky”, noting that recording rates are consequentially very low.
42.This means that for most claimants, the only record of their assessment is the assessor’s report. If they disagree with statements contained relating to the face-to-face assessment, they have little evidential basis from which to challenge these. Even if they come to their assessment accompanied, disputing the report will be a case of their word against the assessor’s. We heard overwhelmingly that providing audio recording as default would go a long way to improving trust in face-to-face assessments, providing claimants were able to opt out if they would prefer not to be recorded. Some witnesses also suggested the Department should look to introduce video recording. Paul Gray, in both his reviews and in evidence to us, was convinced that recording by default would “significantly improve people’s trust in the system”. Claimants would be reassured that there was an objective record of the assessment against which to compare their report and challenge any perceived errors. Assessors, too, could feel confident that they were protected in case of allegations of dishonesty.
43.The Department “partially accepted” Paul Gray’s recommendation on implementing audio recording. It responded, however, that the results of a not yet-published pilot evaluation suggested audio recording had a “limited impact” on measures that appeared not to include claimant trust. Paul Gray told us that, having read the response “two or three times”, he wondered “whether it was largely rejection rather than partial acceptance”. The Department committed, however, to a “further feasibility study” on the costs and benefits of recording. The Minister told us that she was unhappy with current barriers which stopped claimants recording their assessment. In contrast to her Department’s official response to the Review, she told us she saw great benefits in extending the use of recording:
I have just come from the Home Office, where we went through several years of looking at whether police officers should wear body-worn cameras, and a huge amount of debate about that, as you would imagine. It has proven itself to be extremely invaluable, both to the police officer and to the people that are interacting with the police officer [ … ] I approach this with a very positive attitude towards wanting to record the assessments, because I think it will be of huge benefit to the person doing the assessment and to the person who is being assessed, in terms of accuracy, in terms of using the information.
44.Successive evidence-based reviews conducted on behalf of the Department have identified a pervasive culture of mistrust around PIP and ESA processes. This culminates in fear of the face-to-face assessments. This has implications far beyond the minority of claimants who directly experience poor decision making. It can add to claimant anxiety even among those for whom the process works fairly. While that culture prevails, assessors risk being viewed as, at best lacking in competence and at worst, actively deceitful. Addressing this is a vital step in restoring confidence in PIP and ESA. The case for improving trust through implementing default audio recording of assessments has been strongly made. We recommend the Department implement this measure for both benefits without delay. In the longer term, the Department should look to provide video recording for all assessments.
45.PIP claimants who have undergone assessments report their experiences are “broadly positive”. 81% felt that they understood what was being asked of them, and 74% felt they had enough time to explain how their condition affects them. Prior to the assessment, many claimants nonetheless had concerns. Common concerns included:
a)not being able to explain fully the impact of a condition or conditions. This is a particular problem for claimants with learning disabilities or conditions that cause cognitive difficulty. Departmental research suggests this concern is reflected in claimants’ views after assessment: 39% of PIP claimants in the Department’s research reported that there were things they wanted to explain at assessment but were unable to;
b)that the assessor would not accurately record what had happened during the assessment. This includes fears that assessors deliberately misrepresent assessments, and concerns that assessors will lack the expertise to identify and report information relevant to the impact of their conditions; and
c)that the assessor would not listen to their answers, or that they would find the assessment or assessor intimidating or scary;
Mencap commented that concerns may be heightened for claimants who have had a previous, negative experience of being assessed for disability or incapacity benefit. They explained that such experiences contribute to “eroding confidence and trust”.
46.These concerns may prompt claimants to bring a companion with them to assessment. Very limited sampling exercises by Capita and Atos, conducted in response to our inquiry, suggested a large majority of claimants are accompanied to assessment. Maximus told us it does not collect data on this point, but that “many” claimants bring a companion. The companion may be a professional advocate. More usually, they will be a carer, friend or family member. Companions can attend simply to reassure and provide moral support to the claimant. They can also play an active role in the assessment. The Department’s guidance to PIP and ESA assessors makes clear this is permitted. The ESA Handbook for Assessors states that companions:
Will be able to give useful information, particularly in cases where the claimant has mental function problems, learning difficulties, cognitive problems or communication problems, or people who stoically understate their problems. In individuals with learning disability or cognitive impairment the role of the carer may be essential to establish their functional capabilities.
The PIP guidance is similar. Companions should be permitted to play an “active role” in assessments, and this may be particularly important where the claimant has a “mental, cognitive or intellectual impairment”. The standard appointment letters sent by all three contractors to claimants clearly state that they can be accompanied.
47.Assessors must use their discretion in determining what weight to give companion comments in their report. The PIP handbook alerts HCPs to the need to judge whether the claimant or companion “are understating or overstating” the claimant’s needs, and whether the companion’s presence is proving “disruptive” to the consultation. The ESA assessor guide contains similar wording. It alerts HCPs to the risk that companions “may wish to give too forcefully their own opinion on the claimant’s disability, perhaps giving a biased view”, and points out that the claimant “must be allowed to express their own view”. Assessor training schedules received from the three contractors did not indicate any specific training on the role of companions in assessments or on weighting their contributions.
48.Contrary to the official guidance, we heard that companions are routinely fully or partially prevented from participating in the assessment. Halton Housing told us, for example, of cases where the companion had been told to wait outside. The assessment report subsequently stated that the claimant attended alone. Some witnesses reported that while companions were allowed to participate, their contributions seemed to have been disregarded by the HCP in the report. This led to what was felt to be an inaccurate representation of the assessment, and of the impact of their condition. Organisations including the Down’s Syndrome Association, which supports people who may benefit considerably from companion input, also reported that assessors fail to encourage contributions or verify claimant statements with companions. Kayley Hignell, Head of Policy at Citizens Advice, told us that there is an overall “lack of clarity” about the role of companions. She suggested this stems from a lack of clarity in the guidance to assessors. Rob Holland, Public Affairs Manager at Mencap, explained further:
The guidance for assessors breeds the variation, because it says that ultimately it is up to the health practitioner’s discretion. That seems to mean that companions may not be involved. Making it very clear to the assessor that companions play a really valuable role so that they understand why they are important is critical.
City of Wolverhampton Council explained that in their experience, failure to weight correctly and accurately report the contributions of companions (often carers) in assessments was a root cause of why such a high proportion of DWP decisions on PIP and ESA are overturned at Appeal.
49.Some claimants may be unable or embarrassed to explain the full implications of their condition to their assessor. Companions can help them to articulate these and support claimants during a potentially stressful process. Their role in assessments is vital. The Department’s recognition of this in its guidance to contractors is welcome. We are concerned, however, that this guidance is not consistently followed. There is no reference to companions in the Department’s auditing or contractor training programmes. That none of the contractors could even reliably tell us how many claimants are accompanied to assessment suggests this is not a priority.
50.We recommend that the Department develop detailed guidance on the role of companions, including case studies demonstrating when and how to use their evidence. Contractors should also incorporate specific training on companions into their standard assessor training. After implementing default recording of assessments, a sample of assessments where claimants are accompanied should be audited on a regular basis to ensure guidance is being followed.
99 (Ian Gargan)
100 Assessors working come from a range of backgrounds, including nursing, physiotherapy and occupational therapy. See Atos (), Capita (), Maximus ()
101 (Ian Gargan), (Paul Williams)
102 DWP, ; Maximus CDHA, , July 2017
103 (Ian Gargan and Barry McKillop), (Leslie Woolf and Paul Williams)
104 Auriga UK (), Citizens Advice North Lincolnshire (), Citizens Advice Richmond (), Leonard Cheshire Disability (), Muscular Dystrophy UK (), Motor Neurone Disease Association (), Mencap (), Understanding Autism North West (), Welfare Rights and Money Service (), NHS Health Scotland ()
105 Paul Gray, , March 2017, p.36–37
106 Dr Ben Baumberg Geiger (), Paul Gray, , p.55, Professor Malcolm Harrington, , November 2012
107 DWP ()
108 Carragher et al. , pp.25–27
109 Zacchaeus 2000 Trust (). See also: Action for ME (), Epilepsy Action (), Motor Neurone Disease Association (), Possability People (), PCS Union ()
110 Carragher et al. , p.28; Paul Gray, , p.38
111 Carragher et al., , p.28. See also: Citizens Advice (), Citizens Advice Camden (), Motor Neurone Disease Association (), PCS Union (), Royal College of Psychiatrists ()
112 Dundee North Law Centre (), Revolving Doors Agency (), Welfare Rights Team (), Zacchaeus 2000 Trust ()
113 DWP, , MS Society ()
114 ; Atos ()
115 Capita ()
116 Maximus ()
117 (Ian Gargan)
118 MS Society (). See also: Citizens Advice Camden (), Disability Benefits Consortium (), Greater Manchester Law Centre (), Muscular Dystophy UK ()
119 Disability Benefits Consortium (), Epilepsy Action (), Leonard Cheshire Disability (), Mencap (), MS Society ()
120 Disability Benefits Consortium, p.29
121 MS Society ()
122 Maximus (), MS Society ()
123 DBC report, Leonard Cheshire Disability (), Mencap ()
124 Citizens Advice (), CLIC Sargent (), Citizens Advice Sheffield (), Central and South Sussex Citizens Advice (), Disability Agenda Scotland (), Headway (), Leonard Cheshire Disability (), Mind and SAMH (), Mencap (), New Freedom Project (), NHS Health Scotland (), Shaw Trust (), Shine (), Understanding Autism North West (), Winvisible (), Rethink Mental Illness (), Royal College of Psychiatrists (), Banburyshire Advice Centre (), Community Union (), Public Law Project (PEA0439)
125 Auriga UK (), Aspire (), Citizens Advice Camden (), Citizens Advice Sheffield (), City of Wolverhamption Council (), Mind and SAMH (), Motor Neurone Disease Association (), Mencap (), Royal British Legion Industries (), Salford Welfare Rights and Debt Advice Service (), Scope (), Surrey Welfare Rights Unit (), Turn2us (), Understanding Autism North West (), Down’s Syndrome Association (), Advocard (), National Deaf Children’s Society (), Parkinson’s UK (), Zacchaeus 2000 Trust (), Disability Rights UK (), Citizens Advice Salford ()
126 See Work and Pensions Committee, and evidence from: Action for ASD (), Action for ME (), Caring for Life (), Citizens Advice (), CLIC Sargent (), Citizens Advice North Lincolnshire (), Citizens Advice Sheffield (), City of Wolverhamption Council (), Disability Benefits Consortium (), Disability Rights UK (), Green Party Northern Ireland (), Inclusion London (), Kidney Care UK (), Leonard Cheshire Disability (), Mind and SAMH (), Muscular Dystrophy UK (), Motor Neurone Disease Association (), National Deaf Children’s Society (), Parkinson’s UK (), Start Ability Services and the Association of Disabled Professionals (), Shaw Trust (), Sense (), Scope (), Social Security Advisors in Local Government (), South London and Maudsley NHS Foundation Trust (), Spartacus Network (), Surrey Welfare Rights Unit (PEA0088), Zacchaeus 2000 Trust (), Greater Manchester Law Centre (), Cystic Fibrosis Trust (), Bath Mind and Citizens Advice (), Disability News Service (), Manchester Mind ()
127 Action for ASD (), Citizens Advice North Lincolnshire (), Citizens Advice Scarborough and District (), Inclusion London (), Understanding Autism North West (), West Norfolk Disability Information Service ()
128 Bath Mind and Citizens Advice (), Citizens Advice Isle of Wight (), Citizens Advice Scarborough and District (), Citizens Advice Sheffield (), Citizens Advice Wealden (), Disability News Service (), Green Party Northern Ireland (), Roma Support Group (), Turn2us ()
129 Turn2us ()
130 (Martin Richards) Inclusion London (), Start Ability Services and the Association of Disabled Professionals ()
131 Mind and SAMH ()
132 (Paul Gray). See also: Start Ability Services and the Association of Disabled Professionals ()
133 (Anna Bird, Rob Holland, Victoria Holloway, Kayley Hignell), Action for ME (), Age UK Bristol (), Circle Housing (), Citizens Advice (), Citizens Advice Eastbourne (), Citizens Advice Salford (), Community Union (), Disability News Service (), Disability Rights UK (), Green Party Northern Ireland (), Halton Housing (), Headway (), Inclusion London (), Mind and SAMH (), Motor Neurone Disease Association (), Rethink Mental Illness (), Revolving Doors Agency (), Roma Support Group (), Royal British Legion Industries (), South London and Maudsley NHS Foundation Trust (), Turn2us (), Welfare Rights Team (), Citizens Advice Norfolk (), Hammersmith and Fulham Mind ()
134 Citizens Advice (), Citizens Advice Eastbourne (), Inclusion London (),Roma Support Group ()
136 Headway ()
137 DWP, , p.13
138 (Paul Gray)
139 (Sarah Newton)
140 Margaret Blake, David Candy, Emma Carragher, Kate Duxbury, Lewis Hill, Emma Mee,
141 British Psychological Society and the British Association of Behavioural and Cognitive Psychotherapies (), Citizens Advice Sheffield (), Disability Benefits Consortium (), Headway (), Islington Law (), Mencap (), National AIDS Trust ()
142 Blake et al., , p.5
143 Bath Mind and Citizens Advice (), Citizens Advice Isle of Wight (), Citizens Advice Scarborough and District (), Citizens Advice Sheffield (), Citizens Advice Wealden (), Disability News Service (), Green Party Northern Ireland (), Roma Support Group (), Social Security Advisors in Local Government (), Understanding Autism North West ()
144 Blake et al, , p.14, National AIDS Trust (), Revolving Doors Agency ()
145 Mencap ()
146 , Capita (), Maximus ()
147 Several support organisations told us that due to limited resources they are unable to offer support or advocacy until a claimant has reached MR or Appeal. This results in claimants who would benefit from professional advocacy not being able to access this support for their initial assessment. See Citizens Advice (), Disability Benefits Consortium (), Mind and SAMH (), Mencap ()
148 Maximus, , p.56
149 DWP, p.30
150 Documents seen by Committee
151 DWP, , p.30; Maximus, , p.56
152 Capita (), Atos (), Maximus ()
153 (Rob Holland), (Kayley Hignell), Citizens Advice (), Citizens Advice Sheffield (), Halton Housing (), Mencap (), One Stop Advocacy (), Veterans Association ()
154 Halton Housing (). See also: Citizens Advice Scarborough and District ()
155 City of Wolverhampton Council (), North Wales Regional Assembly Cross-Party Working Group (), Headway (), Disability Agenda Scotland ()
156 The Down’s Syndrome Association (), Mencap (), Rethink Mental Illness (), Halton Housing (), Veterans Association ()
157 (Kayley Hignell)
158 (Rob Holland)
159 City of Wolverhamption Council () see also, Mencap (), National AIDS Trust ()
12 February 2018