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Our response to the Litchfield review

13 December 2013

Dr Paul Litchfield has published the fourth independent review of the Work Capability Assessment (WCA), as required by section 10 of the Welfare Reform Act 2007.

While Disability Rights UK welcomes some of the review’s recommendations we are disappointed that Dr. Litchfield’s belief is that the WCA is a “reasonable pragmatic tool”.

There is little or no recognition by Dr. Litchfield of the widespread anger and criticism of the poor standard of medical assessments carried out by Atos Healthcare Professionals. Instead, he advises that DWP Decision Makers “view Atos HCPs as trusted advisers”. He also sees as problematic that 15% of Atos fit for work recommendations are revised to those of limited capability for work as opposed to 0.1% revised from eligible to fit for work.

In fact, given the high proportion of disabled people successfully appealing WCA decisions the 15% of revised decisions by Decision Makers is clearly too low.

We believe, more fundamentally, that tinkering with the WCA will not make it work and that the Government should start from scratch on the Work Capability Assessment as part of a wider strategy to transform employment support.

“The vehicle via which disabled people are directed towards these ineffective programmes is the Work Capability Assessment.  Ironically, the very last thing the WCA is capable of is assessing whether or not someone is capable of work. Companies like BT and Barclays have long abandoned using pre-employment health questionnaires to test someone’s capabilities to work prior to starting – not least because they are not worth the money spent on them. They tell you nothing useful about the person’s potential performance in work.  Research evidence is clear: the best predictors of someone’s employment success are self efficacy (a sense of choice and control), support and adjustments that are right for you – that are individualised – and motivation.”

[excerpt from “Towards a fair contract with disabled people: why Government should start from scratch on the Work Capability Assessment and transform employment support” – a blog by Liz Sayce]

You can download the report at https://www.gov.uk/government/publications/work-capability-assessment-independent-review-year-4.

The Government’s response to Dr Litchfield’s report will be published next year.

The report’s key recommendations are:

Effectiveness of the WCA

  • The Department should review its use of WCA scores, and use the calculation simply to determine whether the threshold for benefit has been reached (not consider the points as a scientific measure of levels of disability).
  • Any further changes to the descriptors, as a result of the evidence based review (EBR) or otherwise, should be considered in the light of their overall impact on the effectiveness of the WCA in achieving its purpose of discriminating between the different categories of people assessed.

The face to face assessment

  • The Department should specify an assessment format that facilitates better rapport, such as the Health Care Professional (HCP) and person being assessed sitting side by side. T
  • The assessor should avoid reporting inferences from indirect questioning as factual statements of capability.
  • The guidance on companions should be made clearer and applied consistently.
  • The person being assessed should be able to see what is being written during the assessment.

Staff Guidance and Training

  • The Department should update documentation and training to ensure that:
  1. There is clear differentiation between the purpose statements for HCPs and Decision Makers.
  2. A simple narrative explaining the differences is used consistently internally and externally.
  3. The distress that people can experience when things go wrong is recognised and acknowledged appropriately by staff.

Written Communications

  • The ESA50 and all letters and forms are comprehensively reviewed with the input of the Behavioural Insights Unit at the Cabinet Office, to ensure that:
  1. all letters and forms meet Plain English standards.
  2. information is presented at the right point in the process.
  3. the person making a claim is clear about their rights and responsibilities at each stage of the process.
  4. decision letters set out clearly what the outcome means for the person concerned ideally in the opening section: the period that will elapse before the receive the benefit; what they will need to do to continue to receive the benefit; and what they will not need to do

Reassessment Post Appeal

  • Apply any Tribunal recommendations on review periods as the default and should only be altered where there is strong justification.
  • Consider a minimum period (e.g. 6 months) between a successful appeal decision and a recall notice unless there are good grounds for believing that an earlier review is indicated.

Decision Making

  • Give greater clarity about the role and parameters of Decision Makers with a particular focus on the meaning of “empowerment”.
  • Review the Quality assurance Framework (QAF) so that existing strengths in process adherence are supplemented by measures to examine other elements of Decision Maker quality.  In particular, the outcome of decisions and the logic underpinning them should be monitored more closely.
  • Build a better relationship between HCPs and Decision Makers to engender more team spirit and to help Decision Makers view HCPs as their trusted advisers.
  • Improve Decision Maker training to recognise the strengths and weaknesses of further medical evidence and other information on capability to supplement the Health Assessment Provider (HAP) report.
  • That more senior staff consider “borderline” cases (e.g. 6 – 21 points) and more junior staff process all others.

Simplifying the Process

  • DWP continues to work with BMA to develop and co-design a revised electronic ESA113 with the aim of simplifying the process for GPs and improving the quality of evidence available.
  • The Department carries out a full impact assessment on an alternative process whereby DWP Decision Makers triage cases;
  1. 1 DWP, rather than the HAP, issues the ESA50 and reviews the response with any supporting evidence supplied;
  2. 2 the Decision Maker determines (with the help of decision support materials) whether further evidence is required and, if so whether to obtain that by face to face assessment or other means;
  3. 3 where suitable and sufficient evidence is available on paper and a face-to-face assessment would provide no additional value, the Department should make a decision without referral to its HAP;
  4. 4 where a person is found Fit for Work on paper without a face-to-face assessment and subsequently disagrees with the decision, a second Decision Maker then reconsiders the need for a face to face assessment as part of the new mandatory reconsideration process.
  • The Department should carry out a full impact assessment on the feasibility of a DWP Decision Maker being collocated with the HCP undertaking a face-to-face assessment and either seeing the person making a claim jointly or separately.

Mental Health

  • The Department strengthen its requirements for HCPs working on the contract to have suitable and sufficient previous experience of dealing with people with mental health problems so that they can contextualise their findings at assessment.
  • The current training in mental health that HCPs receive should be reviewed to ensure that it is adequate and the evaluation results for these and other key modules should be considered by the Department before approving any individual HCP.  Approvals should be reviewed on a periodic basis and reaccreditation should be dependent upon effective refresher training in key subject matter areas.
  • Mental Health training for Decision Makers should include dealing on the telephone with distressed people, interpreting warning signs of potential self-harm and signposting to appropriate sources of help.
  • The ESA50 is redesigned to make it clear that evidence, particularly in mental health cases, from CPNs, Support Workers, Carers etc is valuable and giving guidance on the functional aspect that will help Decision Makers.
  • Consideration is given to a new reassessment period extending to 5 years in the Support Group for people who have very severe incapacity resulting from brain disorders that are degenerative or which will not realistically improve.