Written evidence submitted jointly by
Centre for Mental Health, Hafal, Mind, Rethink, the Royal College
of Psychiatrists and SAMH (the Scottish Association for Mental
Health)
ABOUT US
Centre for Mental Health
Centre for Mental Health is an independent, national
charity that aims to help to create a society in which people
with mental health problems enjoy equal chances in life to those
without. We aim to find practical and effective ways of overcoming
barriers to a fulfilling life so that people with mental health
problems can make their own lives better with good quality support
from the services they need to achieve their aspirations. Through
focused research, development and analysis, we identify the barriers
to equality for people with mental health problems, we explore
ways to overcome those and we advocate for change across the UK.
Hafal
Hafal is run by its 1,000 members—people with
a serious mental illness and their families and carers. Every
day our 160 staff and 150 volunteers provide help to over 1,000
people affected by serious mental illness across all the 22 counties
of Wales. The charity is founded on the belief that people who
have direct experience of mental illness know best how services
can be delivered. In practice this means that at every project
our clients meet to make decisions about how the service will
move forward and the charity itself is led by a board of elected
Trustees, most of whom either have serious mental illness themselves
or are carers of a person with a mental illness. "Hafal"
means equal. Our mission is to empower people with serious mental
illness and their families to enjoy equal access to health and
social care, housing, income, education, and employment, and to
achieve a better quality of life, fulfil their ambitions for recovery,
and fight discrimination.
Mind
Mind is the leading mental health charity in England
and Wales. We work to create a better life for everyone with experience
of mental distress by:
— Campaigning
for people's rights.
— Challenging
poor practice in mental health.
— Informing
and supporting thousands of people on a daily basis.
A fundamental part of Mind's work is provided though
our network of over 180 local Mind associations who last year
worked with over 220,000 people running around 1,600 services
locally. Services on offer include supported housing, crisis help
lines, drop-in centres, counselling, befriending, advocacy, and
employment and training schemes. Over 30,000 people are supported
by our national telephone help lines. Welfare reform is a key
issue for many of the people Mind has contact with. We also work
extensively with the Disability Benefits Consortium (DBC) on issues
of welfare and benefits.
Rethink
Rethink Mental Illness, the leading national mental
health membership charity, works to help everyone affected by
severe mental illness recover a better quality of life. We help
over 52,000 people each year through our services and support
groups and by providing information on mental health problems.
Our website receives over 600,000 visitors every year. Rethink's
Advice and Information Service helps almost 8,000 people each
year and advises people daily with benefit claims.
Royal College of Psychiatrists
The Royal College of Psychiatrists is the leading
medical authority on mental health in the United Kingdom and is
the professional and educational organisation for doctors specialising
in psychiatry.
SAMH (Scottish Association for Mental Health)
SAMH is the biggest mental health charity in Scotland,
providing an independent voice on all matters of relevance to
people with mental health and related problems and delivering
direct support to around 3,000 people through over 80 services
across Scotland. SAMH provides direct line-management to respectme
(Scotland's anti-bullying service) and "see me" (Scotland's
anti-stigma campaign).
1. Summary
1.1 Our organisations understand the motivation
for moving claimants off existing Incapacity Benefits (IB), which
is seen as a "passive" benefit, onto Employment and
Support Allowance (ESA), which is seen as more "active benefit".
Around 43% of those people due to be migrated are claiming primarily
due to a mental health problem,[10]
and many more will have experienced mental distress. We welcome
efforts to help people with mental health problems back to work,
where appropriate and if done in a supportive and understanding
manner. However, we are concerned that the process will not be
fair; will cause substantial distress; and will lead to many people
receiving inadequate support and being subject to inappropriate
and potentially harmful requirements.
1.2 All of our organisations have received substantial
feedback, from people with mental health problems who have experienced
the WCA and from professionals who work with them, that the assessment
is unsuitable for gauging the impact of mental health problems
on an individual's ability to work. Some of our organisations
have also been involved in various stages of creating and reviewing
the assessment, but have often felt that our perspectives and
objections have been largely disregarded. We do not believe the
assessment is working fairly and effectively and we do not think
migration should go ahead until these issues are resolved.
1.3 We are also concerned about the way in which
the process will be communicated to IB claimants; the timescale
of the migration; and the outcome of the process for those claimants
reassessed.
2. The Department's communications to customers
going through the assessment and whether the information, guidance
and advice provided by the Department and Jobcentre Plus is effective
in supporting customers through the process
2.1 It is clear that, in response to Professor
Harrington's Independent Review, the Department and Jobcentre
Plus in particular is paying considerable attention to how the
process of migration is communicated. We welcome recent innovations
in the customer journey, such as additional phone calls during
the process to ensure that the customer is kept informed and up-to-date.
2.2 However, we are keen that, throughout the
process, customers are regularly reminded of their rights at each
stage of the process around submitting additional evidence; being
accompanied during the assessment; accessing their report from
the assessment questioning the Decision Makers verdict; and appealing
the final decision. We would be very concerned if any of the additional
contact established with the customer resulted in a sense that
it wasn't worth questioning or appealing a decision that they
were not happy with.
2.3 We are not confident that people feel well
informed about the process of migration and we are concerned that
uncertainty and anxiety about the process is having a detrimental
effect on people's health. In a recent survey on the Mind website
of over 300 current IB claimants:
— 78%
did not feel well informed about the process.
— Only
20% had received their information from the Department (62% had
picked up their information from the media).
— 75%
said concern about the WCA had made their mental health worse
and 51% reported it had made them have suicidal thoughts.
— 95%
do not think that they will be believed at their assessment and
89% believe that they will be forced back to work before they
are ready or able.
2.4 Although we understand that a huge number
of people are due to be reassessed over a significant period of
time, we do feel that it would be helpful if the Department could
indicate to people when they are likely to be reassessed. The
knowledge that you are due to go through a process that could
have a profound impact on your life, along with the uncertainty
of when this will occur in the next three years, is an unpleasant
combination for those concerned. The ongoing anxiety this situation
is causing may well worsen people's mental health and could place
them even further from the job market.
"I was due to be re-assessed for IB last September,
nothing has happened yet except for a daily dread of brown envelopes."
"I dread the post coming each morning just in
case there is a brown envelope with DWP printed on it and can
no longer listen to news reports on the radio about anything to
do with benefit changes."[11]
2.5 Informing people would not need to involve
sending letters out to all those due to be reassessed, or even
identifying specific dates. It could simply consist of a webpage
where people can check the month or quarter when they are likely
to be called in for reassessment. This webpage could be promoted
to third sector organisations who could assist those without direct
access to the internet. We feel that this would prove beneficial
to a huge number of people.
3. The Work Capability Assessment including:
the assessment criteria; the service provided by Atos staff; the
suitability of assessment centres; and customers' overall experience
of the process
3.1 Our organisations have, between us, worked
extensively on the WCA: from involvement in the meetings that
led to the creation of the assessment and two reviews of its functioning,
to listening to the concerns of people with mental health problems
going through the process and feeding these concerns back to government.
However, we do not feel that the DWP or successive governments
have been particularly responsive. We believe that the assessment
is not fit for the purpose of gauging the impact of mental health
problems on an individual's ability to work.
3.2 Professor Harrington's Independent Review
in 2010 vindicated the vast majority of the criticisms of the
WCA that we had been expressing. We do not go into detail here
about all of these criticisms, as the majority are well known.
However, we have summarised our concerns below and have also enclosed
our joint submission to the Harrington review, which explains
these concerns in more detail:
— Many
people with mental health problems that pose a serious barrier
to them finding employment are being found "fit for work"
and that many of these people are scoring zero points.
— A huge
number "fit for work" verdicts are being successfully
overturned at appeal, suggesting that these cases are not initially
being assessed fairly or effectively.
— The
process is impersonal and mechanistic and does not allow the applicant
to express the extent of their impairments and the details of
their circumstances.
— Applicants
often feel that they have been treated unfairly and that this
can cause distress that can both worsen their mental health and
put them further away from the job market
— The
assessment does not take sufficient account of fluctuations in
conditions, which is vital to understanding the impact of mental
health conditions.
— The
assessors do not have adequate expertise or training to understand
mental health problems and the impact they have on an individual's
ability to work.
— Too
much weight is given to the verdict of the assessment and not
enough to the perspective of clinicians who have a more complex
and nuanced understanding of the applicant's condition.
3.3 We are pleased that the Department has now
taken some of these criticisms on board and is looking to implement
Professor Harrington's recommendations. We support these recommendations
and believe that they should help to significantly improve the
WCA for people with mental health problems. We are also pleased
that Professor Harrington has been kept on to perform a subsequent
review which will include monitoring the implementation and effectiveness
of his initial recommendations.
3.4 However, we do have some remaining concerns
about the assessment that were not fully addressed by Professor
Harrington's review:
3.4.1 We do not feel that there has ever been
a rigorous evaluation of whether the WCA is both valid (ie it
correctly measures what it is intended to measure) and reliable
(ie it provides consistent and reproducible results). The high
rate of successful appeals suggests that there is poor reliability
and validity. We recommend that a thorough and scientifically
rigorous evaluation of the WCA is undertaken, with a view to a
more scientific approach to redesign if necessary.
3.4.2 We are concerned that the format and content
of the current descriptors drives the behaviour of assessors in
terms of only requiring them to seek a minimal amount of information
from an applicant before assigning them to a particular category.
The descriptors tend to try and measure complex impairments with
multiple dimensions on a linear scale and we believe this fundamentally
undermines their capacity to assess mental health problems. An
example of this would be the descriptor on "coping with social
situations" which primarily measures the frequency of this
impairment but doesn't treat severity or duration as a variable.
Professor Harrington has asked Mind to make proposals on improving
the descriptors along with Mencap and the National Autistic Society.
These proposals have been submitted to Professor Harrington and
should go before Ministers around June 2011. We believe that these
proposals would help to alleviate the limitations of the current
descriptors but nonetheless call for fundamental review of assessment
format.
3.4.3 The Government recently began implementing
the recommendations of a previous, internal review of the WCA.
Our organisations have significant concerns about both the process
of this review and the outcomes. We are particularly concerned
about the reduction in descriptors around mental, intellectual
and cognitive function from 10 to seven and we believe that this
will render the assessment even less fair and effective for gauging
the impact of mental health on an individual's ability to work.
3.4.4 We believe that the guidance given to assessors
compounds the problems with the descriptors by suggesting that
they should look for sufficient cause to disqualify the
applicant rather than rigorously assessing for reasons to qualify
them. For example, there are a number of descriptors where simply
turning up alone for the assessment is seen as cause for scoring
zero points for the area impairment. This is particularly problematic
for mental health where the impairments may not be obvious from
appearance or even behaviour and where people's condition as presented
on the day of assessment may not be representative of their usual
or worst states of fluctuation. The guidance often cites the most
extreme example of impairment, rather than providing suggestions
around more borderline cases which may allow assessors to make
more balanced decisions. For example, descriptor 15 (execution
of tasks) has the following guidance:
"The pattern of typical day activity should
really reflect a person who should struggle to get through the
basics of a day due to their mental disablement as a result of
tasks taking so long to complete that they would be unable to
cope with work due to the length of time required for basic tasks.
For example those who have severe and continuous disabling anxiety
where they struggle to even get out of their bedroom may come
into this category".
By citing such an extreme case, it can overshadow
less extreme, but still serious, cases and may lead to people
being "under-assessed".
4. The decision-making process and how it
could be improved to ensure that customers are confident that
the outcome of their assessment is a fair and transparent reflection
of their capacity for work
4.1 As stated in our joint submission to Professor
Harrington (see attached) we believe more weighting should be
given to the professional opinion of those clinicians in contact
with the individual making the claim. This would help not only
to reduce the number of people erroneously judged to be "fit
for work" but would assist in dealing with some of the problems
of fluctuating conditions and symptoms and of combined mental
and physical disorders. These clinicians would also have a greater
understanding of how the condition affects the individual and
how it might impact on their ability to work. The process would
be more transparent if DWP Decision Makers were obliged to explain
to the applicant why they had contradicted the opinion of the
clinician, where relevant.
4.2 We are pleased that Professor Harrington
recognised the problems in this area and we hope that his recommendations
on this issue are fully implemented. Since this will involve retraining
Decision Makers and a culture-shift in their approach to balancing
different sources of information it is likely to be a lengthy
process.
4.3 We would also like to see applicants regularly
reminded during the process that they can submit additional evidence;
that they can request a copy of their report from the WCA to check
for accuracy; and that they can ask for reconsideration of their
decision or go to appeal.
4.4 To support this it would be helpful to have
a named person from the DWP system to be responsible for each
claimant's benefits claim who could be contacted by the claimant
or clinicians when queries are required and who can assist in
guiding the claimant through the benefits system.
5. The appeals process, including the time
taken for the appeals process to be completed; and whether customers
who decide to appeal the outcome of their assessment have all
the necessary guidance, information and advice to support them
through the process
5.1 A number of Community Mental Health Teams
(CMHTs) have reported that many of their service users have been
winning their appeals. Under the old Incapacity Benefit system,
the fact that they were using a CMHT would be an indicator of
a severe mental health condition and so the benefit would be awarded.
The fact that the WCA no longer has this feature increases the
likelihood of people being assessed and placed in the wrong groups
as well as the cost/trauma of subsequent successful appeals.
5.2 We are also concerned that clients who have
won their appeals are being reassessed through the WCA within
a very short time frame. We have been in touch with a claimant
who was initially declared "fit for work", but overturned
this verdict at appeal. He was sent an ESA50 form within months
of the appeal being settled, and has now been called for a further
medical assessment. This is causing him great distress and could
potentially impact on his health, causing unnecessary expense
for the NHS; particularly as he was assured it would be at least
a year before he is reassessed.
5.3 Success rates for appeals are much higher
when appellants are accompanied by an advocate or companion, suggesting
that people appealing alone may not be able to adequately represent
their case. People need to be encouraged to bring support to appeals.
5.4 We would like to see evidence from appeals
being fed into the WCA system to ensure that those whom a tribunal
has found to be eligible for ESA do not have to suffer the distress
of presenting the same information to a different part of the
system shortly afterwards, and that the DWP learns from these
cases for future reference. This would also allow Decision Makers
to understand why their decision was overturned, which should
lead in time to a reduction in the need for appeals. At present,
there is no systematic method for Decision Makers to learn from
the decisions of Appeals Tribunals.
6. The outcome of the migration process and
the different paths taken by the various client groups
6.1 1.6 million IB claimants will be migrated
onto ESA by March 2014. We are concerned that many of these people
may drop out of the benefits system due to the stress of the process
or because they are not eligible for other benefits. Even if people
are found to be legitimately "fit for work", they will
have been on benefits for many years, often without the right
support to find paid work, and thus will take time to adjust to
the demands being made of them and will in the interim face distress
and hardship. As the current system of assessment is presently
not sufficiently efficient they will be doubly disadvantaged.
Policy will need adjusting to allow the long-term IB claimants
who are found to be "fit for work" to have a period
of time on ESA before being moved to JSA.
7. The time-scale for the national roll-out
for the migration process, including the Department's capacity
to introduce changes identified as necessary in the Aberdeen and
Burnley trials
7.1 We have been aware for several years that
the WCA is a flawed process and often denies people with mental
health problems the benefits and support that they are entitled
to. The Harrington review has highlighted many of the problems
in the process of assessment that contribute to this. The number
and extent of the recommendations from this review demonstrate
that the assessment is not functioning fairly and effectively.
These recommendations need to be implemented in full, and their
impact assessed to ensure they have had the desired effect, before
the migration of existing IB claimants goes ahead.
7.2 We understand that it would be extremely
complicated to halt new assessments of ESA applicants while reforming
the assessment. However, there is no such imperative to begin
migration at this precise moment. The average duration of claim
for those due to be reassessed is nine years. We agree that it
is hugely regrettable that so many people have been left for so
long without active support, but it is absurd to claim that starting
migration now should take priority over ensuring that the assessment
process is fair and effective. A delay of a few months to ensure
that the recommendations are implemented and have taken effect
is clearly preferable to a more immediate migration with a flawed
assessment.
April 2011
Annex
THE WORK CAPABILITY ASSESSMENT—A CALL
FOR EVIDENCE. DEPARTMENT FOR WORK AND PENSIONS, JULY 2010
Joint response from Centre for Mental
Health, Mind, Rethink and the Royal College of Psychiatrists
INTRODUCTION
We welcome the opportunity to respond to this consultation.
As leading organisations in the mental health field
we know that the great majority of people who experience mental
ill health, even those with serious conditions, see some paid
employment as a contribution to and a marker of their recovery.
We also know that there is good evidence that given
the right conditions and the right support, for most people work
is a realistic ambition. In our response we will focus on the
ways in which the WCA as it is presently constituted and delivered
creates the wrong conditions for people with mental health conditions
to (re)launch themselves into the world of work by creating uncertainty,
anxiety and unfairness. This is a matter of great concern to us
and the people we represent because it not only impacts on quality
of life and hope for a better future, but can also lead to worsening
mental health for which mental health services will have to pick
up the tab.
"We know that people with mental health conditions
can and do pursue successful careers. We know that the majority
would dearly love to be gainfully employed—in fact, people
with a mental health problem have the highest 'want to work' rate
of all disabled groups. We know that appropriate employment improves
mental health and can protect against relapse. There is a wealth
of research evidence showing how we can help many people with
a mental health condition to realise their ambitions, yet, in
most areas, we have failed to provide this support. And the number
of people with a mental health condition who are workless continues
to rise". (Perkins et al, 2009)
RECOMMENDATIONS
In our evidence we are aware that in many ways the
problems that existed for the PCA are still being replicated in
the WCA process, particularly the problems with the Atos clinicians
and the accuracy of the WCA medical assessment.
Centre for Mental Health, Mind, Rethink, and The
Royal College of Psychiatrists recommend the following:
— Greater
use of treating clinician's opinions should be made throughout
the WCA process.
— A claimant's
exemption should be based on the recommendation of the medical
professionals who work with them that the assessment process would
cause harm to health, rather than being prescribed for any particular
health conditions.
— The
overall assessment of claimants requires a more realistic approach
to functionality, reflecting more accurately how a disability
affects someone's entire life, rather than identifying which tasks
they can perform in isolation.
— Policy
will need adjusting to allow the long-term IB claimants who are
found to be fit for work to have a period of time on ESA before
being moved to JSA.
— We
recommend that regular thorough and scientifically rigorous evaluations
of the WCA medical assessment are undertaken to ensure that it
reflects new health conditions and evidence.
— The
current WCA interview and associated assessments should be reconsidered
and the views of clinical, service user and third sector experts
used to reconsider the current interview process, the descriptors
and additional ratings.
— The
current descriptors should be supplemented by an additional rating
that assesses the overall impact on functionality caused by claimants'
conditions. These subjective aspects of distress could be used
to determine an overall score of the claimant's current functioning
in addition to the current descriptors. We recommend that serious
consideration is given to this proposal.
— The
assessment should take account of how the illness or impairment
affects an individual's chances of finding work in the context
of the workplace environment. We recommend that the WCA takes
them into account for those people who may have reasonable functioning
and may not automatically qualify for benefit, but have reduced
chances of being able to work. This includes issues such as employer
stigma.
— We
recommend that improvements are made to the clarity of the WCA
medical assessment. The WCA interview could be made into a semi-structured
interview which would aid the systematic collection of data and
may also help improve the interaction of the assessing doctor
and claimant.
— We
recommend that a thorough evaluation of the ability of the medical
assessors is undertaken.
— The
guidance given to WCA assessors should be improved, giving more
and less extreme examples.
— For
fluctuating conditions we recommend that the assessment differentiates
between variable conditions and variable symptoms. Assessors should
be asked to evaluate the variability in several ways and use these
methods to develop a judgement as to the combined effects of these
fluctuations.
— The
contribution of multiple conditions may be managed by improving
the assessment by the Atos clinicians, making it more reliable
and valid. The process should assume at least an additive model
such that the scores on the individual mental and physical descriptors
are summated to provide the final score.
— Evidence
from the appeal should be fed into the WCA systems to ensure that
those whom a tribunal has found should be on ESA do not have to
present the same information to a different part of the system
shortly afterwards. This would save time and reduce stress for
claimants, which can cause relapse.
RESPONSE TO
QUESTIONS
In our response, we will concentrate on the effects
of the Work Capability Assessment (WCA) on people with mental
health problems. We are aware that this group of people form a
significant proportion of those on welfare benefits. We believe
that the process that assesses the eligibility of people for welfare
benefits should be fair, accurate and just. It should not discriminate
against any particular group and the benefits should offer protection
to people when vulnerable and should offer a means of support
to improve their opportunities when they are able to do so.
1(a) How effectively does the WCA correctly
identify those claimants whose condition is such that they are
unable to undertake any from of work related activity (the Support
Group)
Current DWP figures for ESA claims to November 2009
show that 6.8% of those with mental health problems assessed through
the WCA were placed in the Support Group and 24% in the Work-Related
Activity Group, whilst 69.2% were found to be "fit for work".[12]
The equivalent figures for those with physical problems are 11.6%,
23.7% and 64.7% (Department for Work and Pensions, 2010a). It
is not known how appropriate this figure is as we know of no evaluations
that assess the accuracy for the assessments of people entering
the Support group, but the figure for those being found "fit
for work" is much higher than that of 49% originally estimated
by the DWP (Citizens Advice Bureau, 2010).
However Mind, Rethink and The Royal College of Psychiatrists
are aware through their support work that many with mental health
conditions who should be placed in the Support Group are inaccurately
placed in other groups. Due to limitations of the current WCA,
it is likely in our experience that people who are too disabled
by their condition to work, and should be in the Support Group,
are assessed as ready to engage with work-related activity.
The assessment for ESA does include "special
circumstances" in which claimants can automatically be considered
as having limited capability, and therefore eligible for the benefit.
However, these "special circumstances" cover far fewer
situations than for the Personal Capability Assessment (PCA),
which was used to determine eligibility for Incapacity Benefit
(IB). One exemption from the PCA that is not now included in the
"special circumstances" for ESA is medical evidence
to show: "A severe mental illness which severely and adversely
affects mood or behaviour and which severely restricts social
functioning or awareness of the immediate environment". We
will return to this point in our response to question two.
It is now very common to employ Benefits Advisors
in Community Mental Health Teams to advise and assist service
users in making claims. These advisors, along with clinicians
working in these teams, report an increase in problems with those
people with severe mental illness who should be placed in the
Support Group being called for assessment and being refused ESA
(Citizens Advice Bureau, 2010). They also report that it is less
common now for clinicians to be sent the form ESA 113 than it
was to be sent IB50 forms under the previous system. These errors
are damaging to the patients' mental health and costly in terms
of money and resources. This means that the system ignores the
expertise of mental health practitioners to accurately assess
the capabilities and any support needs of their patients. The
CAB report also finds that seriously sick and disabled people
are being found ineligible for ESA. It is generally recognised
that people who move off benefits but do not enter work show deterioration
in their health (Waddell and Burton, 2006). One example from the
CAB illustrates this:
An adviser from a community mental health team reported
that almost all their new clients applying for ESA are being refused
benefit. In the last few months, she has helped 10 clients appeal
ESA decisions: three have been resolved, and the other seven are
all waiting to go to tribunal. None of these clients would be
getting the very significant resources of the community mental
health team if they were not seriously mentally ill. Under the
IB rules, this would be used as an indicator that there was a
severe mental health problem and the benefit would be awarded.
The stress and worry of the ESA process is damaging the clients'
mental health and delaying recovery and the possibility of an
eventual return to work.
1(b) How effectively does the WCA correctly
identify those claimants whose condition is such that they are
currently unable to work due to illness or disability (the limited
capability for work group?
Without further evaluation of the accuracy of the
WCA to place people in the correct eligibility groups it is not
possible to give a firm answer to this. However, from the official
statistics we are aware that of the overall appeals against the
decision of fitness to work, 40% of the decisions are overturned.[13]
Up until November 2009, 66% of those assessed were found to be
"fit for work"[14]
so if the 40% error rate were applied across all those people
then a further 131,400 would be found to be eligible giving a
total rate of eligibility of 60%, and would account for some of
the overall rates of eligibility being 20% less than the government
originally expected (Citizens Advice Bureau, 2010).
A potential error rate of up to 40% in the WCA process
implies some serious inaccuracies in the assessment system. If
there was a more accurate assessment of people's eligibility for
benefit, this would result in a reduction in the number of appeals
to the decision, and ultimate cost savings to the DWP, and a reduction
in distress for those making the appeal (Department for Work and
Pensions, 2008). Where decisions are not appealed, inaccurate
assessment has a detrimental effect on the wellbeing of the person
with mental illness, as they are put through a programme which
is not suited to their needs or denied support tailored to their
situation, further damaging their confidence and ability to work.
"I have had to appeal a decision for my benefits
that said, after a medical assessment, that I did not qualify
due to the points system on certain issues they use. I did win
my appeal though went through a lot of stress which was hard to
deal with, particularly with a mental health condition. Now, only
months after winning the appeal, I have been called to another
medical assessment"—Rethink Supporter with severe mental
illness
This not only results in worsened health but also
denies appropriately tailored support to those who most need it.
Within a competitive job market and where employers still hold
stigmatising attitudes towards those with mental illnesses, this
can increase rather than reduce an individual's distance from
the job market.
Our responses to questions 1a and 1b indicate that
there is overall evidence that the WCA is not sufficiently accurate
in identifying people with ill-health who are eligible for ESA.
This suggests that the WCA process is not efficient in providing
a structure in which information is processed and it is likely
that the medical assessment is not being carried out adequately
and is not able to identify people who are unable to work due
to ill health or disability. However we know of no published data
that allows us to examine differences in outcome (correct identification
of eligibility for ESA) between people who have mental health
problems and those with physical impairments or disabilities.
Such data would be essential to examine any bias or inaccuracy
in the WCA process.
1(c) What are the main characteristics that
should identify claimants for each group, where these may differ
from the current assessment?
Identification of all claimants needs a more realistic
and evidence-based approach to functionality. The test needs to
more accurately reflect how a disability affects someone's entire
life, rather than identifying which tasks they can perform in
isolation. This should take into account how their quality of
life, and health would be impacted, both in the short and long
term, by any work that they are performing. Clinical practitioners
who know an individual well, such as their GP or psychiatrist,
could play a vital role in providing this contextual information
and in reducing the risk of inaccurate assessments and subsequent
appeals or loss of income.
The assessment also needs to take into account the
quality of the support that will be available to individuals in
the different groups and the external barriers they may face in
finding work. Particularly for existing IB claimants, many of
whom will not have worked for a long time, a "fit for work"
decision based on a purely functional assessment does not address
the fact that they will inevitably face difficulties in actually
returning to the workplace after such a long time away from it.
These claimants in reality may not be able to access the support
that would be necessary to overcome these realities—it is
unfair for the system to work as though this support is available
when in many localities it is not and claimants should not be
penalised for this lack of provision.
2. What evidence is there to suggest that
any issues with the operation of the WCA are as a result of the
policy design and what evidence is there to suggest that they
are a result of delivery?
Policy design
Current policy affects the operation of the WCA in
several ways:
1. Migration from Incapacity Benefit
Policy suggests that 1.6 million
IB claimants will be migrated onto ESA by March 2014. None of
this group are likely to be eligible for contribution-based JSA
if they are found fit for work and the majority who are not eligible
for a top-up on their current sickness benefit are not likely
to qualify for income-related JSA. Thus, many of those migrating
who are then found ineligible for ESA will have no benefit to
replace the income they have lost as a result of their illness
or disability. Many of these people, even if they are found to
be legitimately fit for work, will have been on benefits for many
years, often without the right support to find paid work, and
thus will take time to adjust to the demands being made of them
and will in the interim face distress and hardship. As the current
system of assessment is presently not sufficiently efficient they
will be doubly disadvantaged. Policy will need adjusting to allow
the long-term IB claimants who are found to be fit for work to
have a period of time on ESA before being moved to JSA.
In addition there are concerns
that there may not be the capacity to process the migration from
IB to ESA. The House of Lords Merits of Statutory Instruments
Committee (2010) notes that the DWP has revised its estimates
of those likely to be found to be fit for work during phase two
from 15% to 23% but they comment that there is no indication of
how robust is this assumption. They also have concerns about the
lack of evidence to support the methods of migration:
".... the Committee's view that, from the limited
evidence we have seen, a major project with a potential impact
on the lives of some of the most vulnerable in the community is
being conducted in a rather ad hoc fashion. The second phase is
being rolled out before the first has been evaluated and although
better information will be sought on the outcomes, the Department's
intended course of action, and evidence to support it, all seem
rather vague." House of Lords Merits of Statutory Instruments
Committee (2010).
The Social Security Advisory
Committee report (2010) echoes this concern:
"It is of particular concern to the Committee
that the Department is moving ahead with the migration of existing
claimants of incapacity benefits without a solid evidence base
for either the decision to migrate or the proposed migration arrangements.
The Committee notes that the evaluation of ESA for new claimant
is not planned to be complete until 2011 by which time the proposed
migration arrangements will have commenced."
2. Greater areas for exemption
Some people with mental health
conditions, particularly those being seen by Community Mental
Health teams may be too unwell to work. In addition, participating
in the process of the WCA itself is further detrimental to their
mental health. Under the previous IB system those with severe
mental illnesses were exempt from having to undertake the PCA
(see: our response to Q1(a)). There are also specific problems
for the group of people with mental health conditions who have
limited awareness into the nature of their illness and who may
complete the self-assessment ESA50 form on the basis of this and
thus not be found eligible for ESA despite being unable to work.
Rethink have collected many
examples of cases of people attending Community Mental Health
Teams (CMHTs) for whom the WCA process does not work well. These
have been highlighted in the CAB Not Working report (Citizens
Advice Bureau, 2010), for example:
"A client with a diagnosis of schizophrenia
who lacked insight into his mental health and was non-compliant
with treatment. He had paranoid thoughts, had hallucinations and
heard voices, and had suicidal thoughts, having previously attempted
suicide. He claimed DLA and was awarded higher rate care and lower
rate mobility. He was detained under Section 3 of the Mental Health
Act 1983 (MHA83). Regulations state that a claimant should be
treated as having limited capability for work on any day that
they are receiving hospital treatment—thus he should have
been automatically placed in the Support Group. He received the
ESA50 in hospital and returned it while he will still detained.
The ESA50 was not completed accurately as he was acutely unwell,
but he attended a WCA a few months later and was found fit for
work."
"An adviser with a Community Mental Health Team
recorded grave concerns about a client diagnosed with bipolar
disorder but who had no insight into his condition. He had a WCA
and was found fit for work. The client signed on and was delighted
because he believed that is showed he was right all along and
was not ill. The psychiatrist wanted this decision to be challenged
but it was not possible because the client did not want to appeal."
Considerable amounts of money
and resources are invested in treating and supporting the patients
of CMHTs, who are mainly diagnosed as being seriously ill. CMHTs
have expert and often long-term knowledge of the people they see
and it is this expertise and knowledge that should be sought,
rather than decisions made on the basis of an assessment by a
generalist health care professional. Greater weight should be
given to supplementary evidence provided by the claimants' own
physicians and carers. Incorrect decisions are damaging the work
done by the CMHTs, thus costing further resources to the public
purse.
We believe that this aspect
of current regulations should be changed to protect those using
secondary mental health services from being subject to unnecessarily
entering the WCA process and being allowed to enter the Support
Group at an early stage. We suggest that this group are exempt
from the process as they were for the PCA under the IB system.
We recommend that their exemption should be based on the recommendation
of the medical professionals who work with them, rather than being
prescribed to any particular conditions.
3. The WCA process re-starts too soon after
settlement of an appeal
We are also concerned that
clients who have won their appeals are being reassessed through
the WCA within a very short time frame. Rethink has been in touch
with a supporter who was initially put onto JSA, but who appealed
and had won his appeal. He was sent an ESA50 form within months
of the appeal being settled, and has now been called for a further
medical assessment. This is causing him great distress and could
potentially impact on his health, causing unnecessary expense
for the NHS; particularly as he was assured it would be at least
a year before he is reassessed.
We would like to see evidence
from appeals being fed into the WCA system to ensure that those
whom a tribunal has found to be eligible for ESA do not have to
suffer the distress of presenting the same information to a different
part of the system shortly afterwards.
Delivery
There are several problems with the current delivery
of the WCA process:
1. The medical assessment interview of the
WCA has never been subjected to scientific scrutiny
For any test to be able to
correctly identify individuals as experiencing any problem (in
this case having reduced functioning that impairs their ability
to work) it must be both valid (correctly measuring what it is
intended to measure) and reliable (provides consistent and reproducible
results). It should also be comprehensive and easy to administer.
The WCA was a revision of the PCA and claimed to be a more robust,
accurate and fair assessment than its predecessor (Department
for Work and Pensions, 2006). The WCA has been re-assessed (Department
for Work and Pensions, 2009; 2010c) but it has never been exposed
to any rigorous evaluation and its validity and reliability is
not known (Verbeek and van Dijk, 2008).
The evidence given above (Questions
1(a) and 1(b)) shows that the current WCA is subject to a high
rate of errors suggesting poor reliability and validity. There
is much at stake for the WCA. Not only does it dominate the provision
of sickness benefits, it also determines the financial survival
of many people with incapacities owing to illness. As it stands,
the WCA does not yet pass the test of a fair and just process.
We recommend that a thorough and scientifically rigorous evaluation
of the WCA is undertaken, with a view to a more scientific approach
to redesign if necessary.
2. Current content of the medical assessment
The medical assessment interview
component of the WCA currently contains 10 descriptors relating
to mental health but the DWP's internal review proposes to reduce
the descriptors to seven (Department for Work and Pensions, 2010c).
These represent a much revised version of the original WCA (Department
for Work and Pensions, 2006) and have not yet been evaluated.
In addition to the lack of
evaluation, these specific descriptors are limited as they do
not assess the overall impact of performing the tasks mentioned
in the descriptors. This could be addressed by the overall assessment
process by paying greater attention to the "subjective"
experience of the claimant, which the current score of ability
to perform tasks or present well does not capture. These subjective
experiences potentially include: overall distress experienced;
chaotic thinking, difficulty organizing self or routine; feeling
overwhelmed; tolerance for frustration; self confidence; fear
of others' expectations; debilitating side effects of medication;
and difficulty coping with stress. We need assurance that these
things are considered when assessing people's ability against
the descriptors. We are told by our beneficiaries that these aspects
of their condition are not taken into account. Data on these issues
is currently being collated through a major survey being conducted
by Rethink on behalf of the Disability Benefits Consortium and
we will be able to report results in October this year. We recommend
that serious consideration is given to this proposal.
In addition, the WCA has further problems that need
to be addressed:
(a) Evaluation of variability
The WCA is not sufficiently
robust to deal with either the variation of the conditions, or
the variability of symptoms. For example, a person with a mental
health problem may find that 30% of the time their mood is low
and at other times they cannot concentrate or at other times they
are irritable or have to withdraw to deal with their auditory
hallucinations. Perhaps none of these factors, on their own, may
affect the items on the WCA sufficiently to achieve the desired
points, but together they are sufficient to affect their overall
functioning. The same may apply to the variation of these individual
symptoms.
The present guidance states
that "For conditions which vary from day to day a reasonable
approach would be to choose the functional descriptors which apply
for the majority of the days." However, for those with variable
conditions this is not sufficient or reasonable as they may be
fit for work on their better days, but on their bad days they
may not be able to work. Symptoms may be so severe on the minority
of days that they need to be given greater weighting.
(b) Combining physical and mental descriptors
For people with more than
one condition, the evidence suggests that the combined effect
may be more than the sum of the two conditions (Scott et al,
2009). Many people with mental health problems also have physical
problems and their combination is not taken into account in the
WCA. These combined problems often make adaptation to work difficult.
This is a particular concern
for those with mental health conditions where some elements of
the condition can impact on others. For example, if a person is
unable to cope well with change and is also unable to deal well
with other people, they are likely to become worse at dealing
with other people in times of change. This will then compound
the anxiety about the change and create a problem which is greater
than the WCA would reflect.
Citizens Advice (2010) found
that when there are physical problems as well as mental health
problems, the mental health problem is more likely to be ignored
in the WCA. They cite this example in their report:
"A Midlands bureau saw a client with a long
history of depression, as well as many other problems including
back problems and diabetes, and who was also having investigations
for possible epilepsy following a series of blackouts. The assessment
only seemed to have considered the physical problems and the client
was awarded no points. Yet at that point, the client's mental
health was causing more concern than the serious physical problems.
The client had made three suicide attempts that year, still had
suicidal thoughts and was unable to go out the house on their
own. The bureau noted that the client had a social worker who
confirmed all the details."
This point will be returned to in our response to
question four.
(c) Relating the assessment to the "real
world"
The current assessment takes
no account of how the illness or impairment affects an individual's
chances of finding work in the context of the workplace environment,
such as the impact of long-term unemployment, adapting to the
workplace and the barriers to getting into work. People with mental
health problems face particular prejudice and discrimination from
employers. The WCA does not take these factors into account. We
recommend that the WCA is expanded to take these factors into
account for those people who may have reasonable functioning and
may not automatically qualify for benefit.
3. The competence of the WCA medical assessors
to undertake effective assessments for people with mental health
problems
One possible reason for a
lack of reliability in the WCA system may be the ability of the
medical assessors to accurately assess the level of functioning
in this group of people.
There is no published data
on the quality of the assessments carried out by the WCA medical
assessors, but the reports of people who have been assessed suggest
that this is poor. In 2006, Citizens Advice questioned the quality
of the medical assessments for the PCA, reporting that these did
not give sufficient consideration to mental health problems, were
often hurried, that many clients reported encountering rude or
insensitive examining doctors, and that reports were inaccurate
and took answers out of context. (Citizens Advice, 2006). In their
latest report Citizens Advice paint a similar picture for people
with mental health problems (Citizens Advice, 2010). They found
repeated evidence of people with severe mental health problems
being found fit for work, that the impact of mental health problems
was being underestimated in the presence of co-existing physical
problems, and that people's mental health difficulties were downplayed.
There seems little doubt that
the medical assessors still have a poor awareness of mental health
problems. People attending consultation events facilitated by
Mind and Rethink, during the development of the original WCA in
2007, highlighted that assessors tend to make judgements on a
person's capability based on their appearance or ability to articulate
their problems rather than on their capability to work as measured
by the WCA.
There are reports of claimants
who are assessed being frequently confused about the purpose of
the medical assessment and not understanding why the doctors performing
the assessment reach a different conclusion to their own doctor.
Communication about the assessment needs to be more accessible
and provide a clear explanation of the purpose of the assessment
should be provided.
Further to this, the ability
of the medical assessors to carry out high-quality assessment
for all claimants has been questioned by the findings of the CAB
report (Citizens Advice, 2010). The report highlights several
important factors including: the accuracy of the medical history
in the clinician's report; distortions of what they were told
in the interview; poor questioning by the clinician; inadequate
recording of claimants' responses; a failure to observe accurately;
a lack of understanding of the criteria; poor recording of variable
conditions; the downplaying of the severity of conditions; and
overuse of referral for repeated medicals.
The evidence gathered by Citizens
Advice and others over the years points to the need to evaluate
formally the ability of the medical assessors to accurately assess
the functioning of the claimants. It also suggests that there
may be systematic problems in relation to those with mental health
problems. At present the process run by Atos is opaque and has
not been subject to external scrutiny. Some of this may be improved
by improvements in the clarity of the WCA medical assessment.
The WCA interview could be made into a semi-structured interview
which would aid the systematic collection of data (as with many
research interviews) and may also help improve the interaction
of the assessing doctor and claimant. Such an interview design
would also allow for improved training of the assessors and a
ready means of evaluating the quality of their interviews and
rating. We recommend that a thorough evaluation of the competence
of the medical assessors is undertaken.
4. Problems with the guidance
There are some areas where
the guidance to the assessing clinicians may contribute to underestimating
the degree of incapacity. The guidance often cites the most extreme
example of impairment, rather than providing suggestions around
more borderline cases which may allow assessors to make more balanced
decisions. For example, descriptor 15 (execution of tasks) has
the following guidance:
"The pattern of typical day activity should
really reflect a person who should struggle to get through the
basics of a day due to their mental disablement as a result of
tasks taking so long to complete that they would be unable to
cope with work due to the length of time required for basic tasks.
For example those who have severe and continuous disabling anxiety
where they struggle to even get out of their bedroom may come
into this category".
By citing such an extreme
case, it can overshadow less extreme, but still serious, cases
and may lead to them being under assessed.
3. What is the best way to ensure that the
effect of fluctuating conditions is reflected in the recommendation
of the WCA?
We have covered the problems with fluctuating conditions
and symptoms above.
While there seems no single reliable way of assessing
this, we recommend that the assessment distinguishes more clearly
between variable conditions and variable symptoms.
Assessors should be asked to evaluate variability
in several ways and use these methods to develop a judgement as
to the combined effects of these fluctuations. These multiple
ways could include not only the assessment of a "typical
day", but also a "typical week". A judgement should
also be made of the claimant's functioning at its worst. Each
of the functional descriptors rated could be assessed as to how
often they apply, and the worst case scenario could be used to
provide a reliable rating. The subjective components that we outlined
above could be assessed in a similar way. The use of a semi-structured
format to the interview as outlined above would also facilitate
this process.
We would like to see the WCA reflect the nature and
severity of variations in mental health conditions. At the very
least, we would like individuals to be provided with a greater
explanation of how the effect of fluctuating conditions is assessed
in the WCA. This would allow individuals to be clear in explaining
how their condition does vary.
4. What is the best way to ensure that the
effect of multiple conditions is reflected in the recommendation
of the WCA? Are there specific conditions that should be regarded
as contributing to or adding additional weight to others, where
both are present?
We know from past research that mental health problems
are at least as disabling as common physical conditions (Moussavi
et al, 2007) and that mental and physical disorders are known
to co-occur at greater than chance levels (Scott et al, 2009;
Buist-Bouwman et al, 2005). There are two main ways of considering
the effects of co-existing mental and physical disorders: first
that their effects are additive ie that the individual
components of these co-existing disorders have independent effects
on functioning and thus the total effects are equivalent to the
sum of the parts. The second view is that this co-existence is
interactive and is associated with significantly greater levels
of dysfunction than predicted by a simple sum of the main disorders
ie the total dysfunction is greater than the sum of the parts.
By contrast there is no evidence that mental health and physical
health problems add up to less than the sum of their parts, yet
in the operation of the WCA this is often how they are interpreted.
There is evidence for both additive and interactive
effects when mental and physical disorders co-exist. A recent
large international survey (Scott et al, 2009) found that people
with depression and anxiety are more likely to be severely disabled
than those with physical disorders and that those with combined
physical and mental disorders are more likely to be severely disabled
than those with one condition alone. Those with combined disorders
also had higher levels of disability than predicted by the sum
of the disability attributable to the individual disorders.
The evidence suggests there may be an alternative
method of managing the contribution of multiple conditions. We
recommend making the assessment more reliable and valid by the
means suggested above and by ensuring that equal weight is given
to the assessment of mental and physical conditions.
5. What is the best way to give adequate weighting
to additional (or initial) evidence outside of that through the
WCA? How can any changes be achieved without placing a burden
on GPs and health care professionals, and without compromising
their relationships with their patients?
We believe more weighting should be given to the
professional opinion of those clinicians in contact with the individual
making the claim. This would help not only to reduce the number
of people erroneously judged to be fit for work but would assist
in dealing with some of the problems of fluctuating conditions
and symptoms and of combined mental and physical disorders. These
clinicians would also have a greater understanding of how the
condition affects the individual and how it might impact on their
ability to work.
We would suggest that clinicians are routinely sent
ESA 113 forms at the early stages of the process and that these
should be sent to CMHT clinicians if appropriate. The clinicians
who carry out the WCA assessments should also have sight of these
medical assessments when they see the claimants and should be
obliged to fully account for a decision which contradicts the
advice of the relevant clinicians in terms of the claimant's ability
to work.
While it could be argued that this may place an additional
burden on clinicians, we believe that supporting service users
in their employment aspirations should be a core function of NHS
workers. Many clinical teams already offer benefits advice and
where a service user is subject to an inaccurate WCA, this can
increase the burden on clinical teams. Therefore, involving professionals
up-front in getting the assessment right would be a more cost-effective
option than leaving them to pick up the pieces of a poorly administered
WCA.
To support this it would be helpful to have a named
person from the DWP system to be responsible for each claimant's
benefits claim who could be contacted by the claimant or clinicians
when queries are required and who can assist in guiding the claimant
through the benefits system.
6. Is there any evidence to show that there
has been particular problems with the WCA for any specific groups?
These groups may include, but are not limited to, men and women,
people from black and minority ethnic backgrounds, or people from
differing age groups
The information outlined above provides evidence
for the specific problems with the WCA faced by those with mental
health conditions.
7. Do you have any suggestions for how the
WCA process could be improved to better assign people with health
conditions to the most appropriate part of the benefits system?
In our evidence we are aware that in many ways the
problems that existed for the PCA are still being replicated in
the WCA process, particularly the problems with the Atos clinicians
and the accuracy of the WCA medical assessment.
Our recommendations are outlined at the beginning
of this document.
REFERENCES
Buist-Bouwman, M A, de Graaf, R, Vollebergh, W A
M, Ormel, J (2005) Comorbidity of physical and mental disorders
and the effects on work-loss days. Acta Psychiatrica Scandinavica
111, 436-443.
Citizens Advice Bureau (2006) What the doctor
ordered? CAB evidence on medical assessments for incapacity and
disability benefits. London:CAB.
Citizens Advice Bureau (2010) Not working. CAB
evidence on the ESA work capability assessment. London: CAB.
Department for Work and Pensions (2006) Transformation
of the Personal Capability assessment. Report of the Physical
Function and Mental Health Technical Working Groups. London:
Department for Work and Pensions.
Department for Work and Pensions (2008) Impact Assessment
of the Employment and Support allowance Regulations 2008—Public
Sector Impact only. London: Department for Work and Pensions.
http://www.dwp.gov.uk/docs/impactassessment180308.pdf.
Department for Work and Pensions (2009) Work Capability
Assessment Internal Review. Report of the Working Group London:
Department for Work and Pensions.
Department for Work and Pensions (2010a) Employment
and Support Allowance: Work Capability Assessment by Health Condition
and Functional Impairment. Official Statistics. London: DWP.
Department for Work and Pensions (2010b) Employment
and Support Allowance: Work Capability Assessment.. Official Statistics.
London: DWP
Department for Work and Pensions (2010c) Addendum
Work Capability Assessment Internal Review. Technical review by
the Chief Medical Adviser London: Department for Work and
Pensions
House of Lords Merits of Statutory Instruments Committee
(2010) First Report of Session 2010-11. HL Paper 7. London: The
Stationery Office.
Moussavi, S, Chatterji, S, Verdes, E, Tandon, A,
Patel, V, Ustun, B, Depression, chronic diseases and decrements
in health: results from the World Health surveys. Lancet
370, 851-858.
Perkins, R, Farmer, P, Litchfield, P (2009) Realising
ambitions: Better employment support for people with a mental
health condition. London Department for Work and Pensions.
Scott, K M, Von Korff, M, Alonso, J et al
(2009) Mental-physical comorbidity and its relationship with disability:
results from the World Mental Health Surveys, (2009), Psychological
Medicine, 39, 33-43.
Social Security Advisory Committee (2010) The Employment
and Support Allowance (Transitional Provisions, Housing Benefit
and Council Tax Benefit) (Existing Awards) Regulations 2010 (S.I. 2010
No 875). London: The Stationery Office.
Verbeek, J and van Dijk,F (2008) Assessing the ability
to work. British Medical Journal 336, 519-520.
Waddell, G & Burton, A (2006) Is work good
for your health and well-being? London: TSO.
10 DWP Incapacity Benefits Migration: Customer Segmentation
Programme Summary of Key Findings and Final Customer Segments,
April 2010, Government and Public Sector Consulting. Back
11
Quotes taken from claimants who have contacted our organisations. Back
12
Table 5, page 12, Department for Work and Pensions, 2010a. Back
13
Table 1, page 7, Department for Work and Pensions, 2010b. Back
14
Tables 3 and 4, pages 9, 10, Department for Work and Pensions,
2010b. Back
| 
