Written evidence from Citizens Advice Scotland HAB155

 

 

Key Points
 

         CAS is pleased to respond to this call for evidence on health assessments. We have long been calling for fairer processes which put people’s rights at the heart of it, and we want to see a fairer system of dignified, accessible, timely, and fair medical assessments that provide disabled people with the support they are entitled to.

         Although there will be no new claims for PIP due to the full implementation of Adult Disability Payment across Scotland from 29 August, we have responded to the questions relating to the future of PIP as we have a wealth of data and experience on the administration of PIP.

         CAS has restricted its responses to those where we have robust data to inform our responses.

Recommendations

         A range of assessment types should be available, face-to-face, telephone and in person, and the client should be able to choose their preferred method. Outcomes for each method should be monitored to ensure parity.

         Descriptors for both PIP and ESA should be reviewed to better reflect social and human rights models of disability and move beyond assessing a lack of functionality.

         The use of lived experience panels and user groups involved in the design and development of any changes made to the claims and assessment processes.

         Consideration should be given to the Social Security Scotland approach to assessment, in particular:

 

 

Scotland’s Citizens Advice Network is an essential community service that empowers people through our local bureaux and national services by providing free, confidential and independent advice. We use people’s real-life experiences to influence policy and drive positive change. We are on the side of people in Scotland who need help and we change lives for the better.

Citizens Advice Scotland (CAS), our 59-member Citizen Advice Bureaux (CAB) and the Extra Help Unit, form Scotland’s largest independent advice network. Advice provided by our service is free, independent, confidential, impartial and available to everyone. Our self-help website Advice for Scotland provides information on rights and helps people solve their problems. During 2020-21, the entire Citizens Advice network provided advice and assistance to over 171,000 individuals; this equates to one in every 26 adults living in Scotland. The network put almost £147 million back into people’s pockets during this time, with every £1 invested in core advice funding returning £14 in gains for people. Our extensive footprint is important in helping us understand how issues impact locally and nationally across the country and the different impacts that policies can have in different areas.

 

Our data

Disability and ill health benefits are the largest area of advice need across the Citizens Advice network.[1] Benefits advice accounts for nearly half (48%) of all advice given out by the network, and of that Benefits advice around 45% concerns disability benefits like Attendance Allowance, DLA, ESA, PIP, and devolved Adult Disability Payment (ADP) and Child Disability Payment (CDP). Note that this 45% figure does not include advice on Work Capability Assessments and other forms of medical evidence for Universal Credit, which accounts for around 10% of all Universal Credit advice.[2]

 

Chart 1. Disability benefits as a percentage of all benefits advice (selected data, 2021/22)

Table 1. Disability benefits as a percentage of all benefits advice (2021/22)

 

Q1

Q2

Q3

Q4

Adult Disability Payment (Daily Living)

0%

0%

0%

0%

Adult Disability Payment (Mobility)

0%

0%

0%

0%

Attendance Allowance

4%

4%

4%

4%

Child Disability Payment (Care)

1%

0%

0%

1%

Child Disability Payment (Mobility)

0%

0%

0%

0%

DLA (Care)

2%

1%

1%

1%

DLA (Mobility)

1%

1%

1%

1%

Employment and Support Allowance

2%

2%

2%

2%

Employment and Support Allowance - Contributory

3%

4%

4%

3%

PIP (Daily living)

18%

18%

20%

19%

PIP (Mobility)

14%

14%

14%

14%

Total of disability benefits
as a proportion of all benefits advice

44%

45%

47%

45%

 

Response to questions

Suitability of assessments

1. How could DWP improve the quality of assessments for health-related benefits?

 

CAS supports improving the quality of assessments for health-related benefits and has advocated on this issue for a long time. In our response to the Health and Disability Green Paper[3] in October 2021, we identified specific improvements which should be made to the assessment process: unnecessary assessments should be minimised where possible, people should have a choice over the format of their assessment, and assessments should be carried out promptly (delays are particularly an issue for people living in remote and rural areas of Scotland).[4] Additionally, assessment descriptors and criteria urgently need to be reviewed and in particular, the 50% rule and 20 metre rule should be scrapped. There should be greater emphasis on providing proactive direct referrals and warm handovers, rather than relying solely on signposting.

2. Are there any international examples of good practice that the Department could draw on to improve the application and assessment processes for health-related benefits?

 

As we set out in our response to Question 15 there are opportunities for the DWP to learn from the delivery of the newly devolved Child and Adult Disability Payments in Scotland. In particular, the Scottish Government’s commitment to carry over the underlying eligibility rules of PIP and Child DLA, in order that people have a ‘safe and secure’ transition between the two systems, means that the impact of different approaches to the administration of these rules can be directly compared. In addition to this, Social Security Scotland’s approach to medical assessments should result in a process less stressful to the claimant while potentially providing richer supporting information.

3. Do the descriptors for PIP accurately assess functional impairment? If not, how should they be changed?

 

In Beyond a Safe and Secure Transition – A Long-term Vision for Disability Assistance in Scotland, the Scottish Campaign on Rights to Social Security (SCoRSS), of which CAS is a member, called for disability assistance to better reflect social and human rights models of disability.[5] We recommend taking a human rights-based approach to the development of social security for disabled people, focusing on removing the barriers to people’s rights to equal participation in society and independent living. This should replace the current medical and needs-based models.

CAB advisers identify three areas of mobility support that cause particular issues for clients:

         the 20m rule for the enhanced mobility component;

         the 50% rule for descriptors; and

         the lack of mobility support for people over state pension age.

In a recent survey,[6] carried out over February 2021, the majority of CAB advisers surveyed agreed that the 20m rule should be increased to 50m to qualify for enhanced mobility. The intended purpose of PIP is to provide for the additional cost of living as a disabled person whereas the descriptors measure functional limitations. Our position is that the criteria for entitlement to the enhanced mobility component should be increased from 20 metres to at least 50 metres, while criteria more fitting with the social model of disability is developed, one that adequately enables disabled people to participate in social and economic activities.

It is raised consistently by CAB clients and advisers that the PIP descriptors and points system are not as suitable for people with fluctuating conditions and mental health conditions. The 50% rule contributes to this, as it can be difficult to accurately gauge and assess whether a person’s condition affects them on 50% of days. Additionally, the rule is problematic for fluctuating conditions where a person is occasionally but intensely affected by their condition when it occurs (for example, for people with epilepsy or Multiple Sclerosis). In these circumstances, the need for daily living and mobility support is necessary due to the barriers people face on their “worst days”, but this support is not currently provided because of the 50% rule. CAS would recommend this rule is reconsidered to ensure it does not create a barrier to people with fluctuating conditions or mental health conditions from qualifying for support.

Citizens Alert: A North of Scotland client with numerous health conditions who has been refused both daily living and mobility aspects of PIP. His conditions include cancer for which he is receiving chemotherapy as well as being suicidal and may be a risk to others. He has two good supporting letters from his GP and Macmillan nurse and has had a decision from Universal Credit that he has limited capability for work. The CAB and client have submitted a Mandatory Reconsideration.

In research in 2015,[7] prior to the creation of Social Security Scotland, CAS asked clients and advisers what disability benefits in Scotland should look like. The research showed that many participants thought that a lower rate for daily living should be reintroduced to PIP and that removing this rate was excluding people who face additional costs. People perceived to have lower-level support needs would get no support from PIP, which could lead to higher health and social care costs in the long term. The preventative and supportive role played by the lowest rate of the care component under DLA was lost under PIP. Not including a low rate of care goes against the purpose of ADP being to support working age people with a disability or long-term ill-health and to mitigate some of the extra costs they incur as a result of having a disability or long-term condition.

A subsequent online survey of CAB advisers[8] echoed the view that there was a need to review the points-based system in PIP to make the ADP system more flexible for all impairments and health conditions, particularly for fluctuating conditions.

4. Do the descriptors for ESA accurately assess claimants’ ability to work? If not, how should they be changed?

 

Similar to our response to qu.3, we recommend taking a human rights-based approach to the development of social security for disabled people, focusing on removing the barriers to people’s rights to equal participation in society and independent living. As we set out in response to qu.14, people often have to wait many months for a Work Capability Assessment, leaving them unable to take up training and support to move back into work if this is suitable for them. At an absolute minimum, no conditionality or obligations or pressures to find or carry out work, or work-related activity, should be in place before a WCA has been concluded. However, if a person wants to work and is seeking support with this, that support should be offered. Any activity undertaken or support given before a WCA takes place should not prejudice the outcome or be considered as part of the WCA. Where a person is interested in work, volunteering, training, or education and appropriate information and support is available, it can be offered, so long as any activity does not prejudice the outcome of the WCA.

CAS would welcome better understanding of how some kinds of volunteering, social activities, hobbies, education, or training may be experienced very differently by disabled people, compared to work that may superficially appear similar. Some adjustments, obligations, and expectations can be more flexible in the former than in the latter and this can make a big difference to whether the activity is possible for a claimant.

6. How practical would it be for DWP’s decision makers to rely on clinician input, without a separate assessment, to make decisions on benefit entitlement? What are the benefits and the drawbacks of such an approach?

 

Our response to this question is informed by our work influencing the development of disability assistance in Scotland and how Social Security Scotland (SSS) has implemented decision making processes. CAS inputted extensively into consultations and working groups to inform how SSS should approach medical assessments and how it should collect medical evidence which in some cases could eliminate the need for a separate assessment. We advocated for the onus to be on SSS, rather than the client, when it comes to collecting supporting information or evidence.

Further medical evidence not being sought by decision-makers, causing clients to be charged by GPs for evidence to be provided, was identified early on by CAS as a priority for the new Scottish disability payments and we felt that SSS should be responsible for gathering this information and covering any associated costs. The agency should ensure it routinely gathers medical evidence from a wide range of relevant health and social care professionals as well as people who know the client well. The responsibility should not solely fall to GPs, as in many cases where a person has a long-term condition they may not often see their GP, and a GP may not be best placed to comment on the functional impact of a client’s condition.

Medical evidence should be gathered at the initial assessment phase to inform the decision regarding the claimant’s eligibility. This would improve the accuracy of decisions and therefore avoid the administrative costs associated with reconsiderations and appeals. The key message that emerged from participants in CAS’s consultations with CAB clients and advisers was that, in assessing people’s eligibility for disability benefits, much greater emphasis should be given to evidence from people who know the claimant, such as carers, family and friends, support workers, social workers, occupational therapists, community psychiatric nurses, employers, as well as GPs etc. It was widely thought that evidence from such sources gave a much better insight into how a person’s disability or health condition affects them than a one-off face-to-face assessment.

7. Appeals data shows that, for some health-related benefits, up to 76% of tribunals find in favour of the claimant. Why is that?

 

This rate of success for claimants who have appealed indicates that the accuracy of decision making first time is not good enough and proper consideration has not been given to cases.

Citizens Alert: A West of Scotland CAB reports a client whose ESA appeal was overturned at First Tier Tribunal without the need for further evidence. The evidence given in the papers was sufficient for the Tribunal to overturn the decision. However, the client has experienced unnecessary stress and anxiety as a result of missing 6 months of ESA payments.

Tribunals consist of people expert in their field a judge and a doctor in LCW appeals, a judge, doctor and person with experience of disability for PIP appeals. The knowledge and expertise they can bring to the case means that claimants can be asked tailored, nuanced questions about their condition and how it affects them that can result in a more rounded understanding of the claimant’s circumstances.

In addition, claimants often provide additional information at this stage which can add to the understanding of their circumstances. Claimants are often also represented and expert representation such as that provided by CABx ensures all relevant information is brought before the Tribunal in a way that best supports the client and enables the Tribunal to best understand the client’s circumstances.

a. What could DWP change earlier in the process to ensure that fewer cases go to appeal?

The data for mandatory reconsiderations for PIP show that changes to awards following an MR is low – between 2013 and 2018 only 1 in 5 MR’s resulted in a change of award. This has increased since, to 40% in February 2020 and 44% in March 2020 to 57% in April 2020.[9]

A similar situation can be seen for ESA WCA MRs – between October 2013 to October 2019, more than half of requests to reconsider ESA WCA outcomes were not revised at MR stage. Although in the month to January 2022, 51% of ESA WCA decisions going to MR were consequently revised.[10]

This suggests that the MR process could be improved.

Citizens Alert: A North of Scotland CAB reports a client who had her decision overturned and was awarded the higher rate, prior to the case going to tribunal. The client was initially offered standard rate but once they began tribunal proceedings, this was then changed to enhanced rate before the tribunal went ahead.

Citizens Alert: A West of Scotland CAB reports a client whose PIP decision was overturned at tribunal. The client is unable to lead any kind of independent life without the support of her family. The client has been awarded around £14,000 in backdated payment. Due to the delays to accessing appeals and tribunal, the client missed out on receipt of £151.40 a week and was denied appropriate support for her condition over the duration of the process.

CAS suggests that improvements could be made to how evidence is gathered and used – using the evidence that is most appropriate to the case, rather than evidence from a consultant. For example, a consultant will have medical knowledge of a client, but not necessarily an understanding of how the claimant lives with this on a daily basis. Evidence from a carer or family member may be more appropriate.

The use of specialist medical assessors to support the decision-making process would likely improve decision making, particularly in areas that can be harder to evidence due to fluctuating conditions such as MS.

Providing clients with the medical report after assessment would demonstrate transparency and equip them with the correct information to challenge a decision appropriately.

8. Is there a case for combining the assessment processes for different benefits? If not, how else could the Department streamline the application processes for people claiming more than one benefit (eg. PIP and ESA)?

 

Yes, CAS believes that there is a case for combining assessment processes where appropriate. Where the same evidence (e.g. confirming a particular condition) is required for more than one benefit and someone has already applied for one of the benefits, it would be helpful if this could be shared internally within DWP to prevent someone having to gather and resend information. Pre-populating any application with known information from a claimant would also save time and resources for the individual and the department.

However, CAS would be opposed to the conflation of PIP with means-tested benefits like UC and ESA, as proposed in the UK Government’s Disability Green Paper.[11] As CAS set out in our response to the Green Paper[12] and in our support for SCoRSS’s Beyond a Safe and Secure Transition report,[13] such a move would conflate means-tested social security support with ‘extra costs’ disability assistance which is available to all disabled people, regardless of a person’s employment status, income, or savings. While PIP has now been devolved in Scotland, any change to its structure would impact the financial settlement which funds ADP in Scotland. Both means-tested and ‘extra costs’ support are essential to preventing poverty and promoting participation for disabled people and should be retained as distinct forms of social security support.

The impact of the pandemic

10. What lessons should the Department learn from the way that it handled claims for health-related benefit claims during the pandemic: for example, relying to a greater extent on paper-based assessments, or using remote/telephone assessments?

 

CAS believes that people should have a choice about how they apply for and manage benefits. This should include online, by telephone, on paper and in person.

Citizens Alert: An East of Scotland CAB reports a client who was offered a medical assessment by telephone when the client is profoundly deaf.

CAS recommends that a ‘digital by default’ approach would be particularly inappropriate for disability benefits. This is based on CAS research with CAB clients[14] indicating that claimants of disability benefits find it harder to use a computer and the internet when compared with all benefit claimants. For example, 35% of disability benefit claimants said that they could not use a computer at all, compared with 19% of all respondents. 52% of disability benefit claimants said that they could not make an application for benefits online, compared with 30% of all respondents. On this basis, whilst we would support an online option being available, CAS does not recommend a ‘digital by default’ approach is used for this purpose.

CAS has previously called for a substantial reduction in the proportion of people who have to undergo a face-to-face assessment. These assessments can often be distressing for claimants leaving them physically and emotionally tired. People should be able to choose what best suits them and their needs and should be able to change this over time. For some people, digital services and remote communication and assessments are most appropriate. For others, face to face support and assessments will be most appropriate. However, this may change over time as conditions worsen or improve, or as a person’s access to technology and internet access changes.

In addition, CAB advisers have told us that it has been harder to support people with video and telephone assessments due to delays and difficulties in setting up three-way calls and longer call slots (instead of specific appointment times) preventing advisers from being available at the right time.

Citizens Alert: A South of Scotland CAB reports of a client who had a telephone appointment for PIP. The client stated did not go well, due to problems with the microphone on the handset not working and the handset having to be passed between her and her son, and client states she did not feel she was given sufficient opportunity to speak for her son or ask questions of the assessor.

a. Is there a case for making some of the changes permanent?

There is a case for making changes permanent but CAS would suggest this is done cautiously. It should only be implemented following an assessment of client outcomes across the various assessment methods to ensure that clients are losing out by selecting a preferred method.

12. DWP believes that applications for some benefits dropped sharply at the start of the pandemic because claimants weren’t able to access support (for example, from third sector organisations) to complete their applications. What are the implications of this for how the Department ensures people are able to access health-related benefits consistently?

 

As a result of not being able to access support, people may be living without the help that they are entitled to and struggling both financially and to fully engage in society as a result. It is imperative that people are able to access support if they need it to apply for benefits and learning from pandemic experience is critical to this. The Citizens Advice network provides vital support to clients at all stages of the process, from the initial claim through to appeal. This expert advice and advocacy mean clients are informed and supported through every stage and are providing the information needed for a claim. This in turn supports the decision-making process and should lead to the correct decision for the client. Independent advice and advocacy are a crucial part of the process.

The impact of assessment/application on claimants

13. DWP recently published research on the impact of applying for PIP or ESA on claimants’ mental and physical health. What would be the best way of addressing this?

 

CAS would recommend that claimants, advisers and representatives are actively and genuinely involved in the design and development of any changes made to the claims and assessment processes, for instance, through lived experience panels or user groups. 

Disabled people and those with health conditions are not a homogenous group and any service should be flexible, adaptable and pro-active towards diverse needs. It is crucial that all aspects of the service design and delivery are designed in partnership with clients from a range of experiences, identities and backgrounds to ensure that services best meet the needs of those it is designed to support.  

We recommend that there are a variety of ways to claim, including face to face, online and on paper.

We would also recommend a broad approach to the accessibility of information and communication. This should also recognise other languages including BSL.

The assessment could be made less intimidating by being flexible to people’s needs and preferences e.g. a telephone assessment instead of an in-person assessment

Consideration should be given to how to reduce delays – as mentioned elsewhere in this response, there are significant wait times for ESA and PIP assessments which can have an enormously detrimental impact on a client’s financial situation but can negatively impact their ability to live independently.

Waits for assessments

14. What could the Department to do to shorten waits for health-related benefit assessments—especially for ESA/UC?

 

The Citizens Advice network in Scotland has extensive evidence of people waiting for unacceptable lengths of time for an assessment for health-related benefits. 

Citizens Alert: An East of Scotland CAB reports of a client who has been handing in sick notes for over 4 months and has not been invited for a work capability assessment. If she received a WCA sooner she may be granted a Work Allowance or additional premium. Since the client is on SSP even granting a Work Allowance would leave the client better off financially.

Recent statistics published by the DWP show that the median end-to-end clearance time for Work Capability Assessments for ESA have increased every month from December 2020 (93 weekdays to clear) to July 2021 (231 weekdays). While clearance times have begun to fall – from 176 weekdays in August 2021 to 149 weekdays in September 2021 – this still means client are waiting over six months for assessment.[15] The same statistics show that the majority of waiting time occurs during the assessment process itself, rather than with DWP decision-making processes.[16] Accordingly, DWP should work with Maximus to identify ways to improve the speed of Work Capability Assessments, including increased recruitment if necessary and a reduction in the number of reassessments to prioritise new requests for assessment.

Comparable statistics are not published for Universal Credit, despite statements by Ministers that such statistics would be published in due course.[17]

a. How effectively does the assessment rate for ESA cover disabled peoples’ living costs while they wait for an assessment? Is there a case for introducing an assessment rate for other health-related benefits?

The assessment rate is a positive feature of ESA. As highlighted above, clients often experience delays in their claims being decided and can experience financial hardship in the interim. CAS would suggest a review of the amount paid to clients, to better reflect the true cost of living as a disabled person.

PIP can also take a long time to process and while not an income replacement benefit, the lack of income from PIP can cause financial hardship to a disabled client. It can also have a wider impact, in that a carer may not be able to claim Carer’s Allowance or the disabled person may not be able to afford necessary equipment or transport that would support independent living. Implementing a similar provision for PIP would be welcome. It could be similar to the Short Term Assistance provided to claimants challenging a decision to reduce or stop entitlement to Adult Disability Payment.

Health assessments in the devolved administrations

15. The Scottish Government intends to introduce its own assessment process for the Adult Disability Payment, which will replace PIP in Scotland from 2022. What could DWP learn from the approach of the Scottish Government?

The Scottish Government has developed an assessment system it intends will be a more person-centred approach that is less demanding of the client. It allows for different ways of claiming – online, over the phone and on paper. Social Security Scotland will use specialist assessors, who will then advise the decision maker. SSS will collect the medical evidence, review it and only then discuss it with the specialist adviser. An assessment will only take place if a decision can’t be made.

Our calls for changes to disability benefits on implementation into Scotland are also relevant here.

In Designing a Social Security System for Scotland: Consultation on the new powers[18] we called for a system which:

Additionally, we called for:

 

We continue to engage with Social Security Scotland to ensure that these calls are indeed realised in reality for claimants and consider that they have made good progress in embedding these in the new system.

 

 

May 2022

 


[1] All charts are based on advice code data. These are recorded by advisers every time advice in relation to a particular topic is issued. All figures are expressed as percentages of their “parent” advice code category: e.g. PIP (Daily living) is expressed as a proportion of all Benefits issues, and Medical Assessments advice is expressed as a proportion of all PIP (Daily living) advice. This allows for more effective comparisons between quarters when overall numbers of clients fluctuate and/or there are changes in advice provision (e.g. the shift to telephone and email at lockdown).

[2] Universal Credit advice accounts for around 29% of all Benefits advice.

[3] cas_response_to_shaping_future_support_green_paper.pdf

[4] Citizens Advice Scotland, Response to Shaping future support: The Health and Disability Green Paper, October 2021.

[5] Scottish Campaign on Rights to Social Security, Beyond a Safe and Secure Transition - A Long Term Vision for Disability Assistance in Scotland, August 2022.

[6] To inform a response to Scottish Commission on Social Security Adult Disability Payment Draft Regulations Call for Views, CAS carried out an online survey of CAB advisers on some of the areas in the consultation document. This included 10 questions about a number of aspects of the consultation document. The survey was answered by 61 CAB advisers from Bureaux across Scotland.

[7] Designing a Social Security System for Scotland: Disability and Carers’ Benefit – Citizens Advice Scotland, December 2015 https://www.cas.org.uk/publications/designing-social-security-system-scotland-disability-and-carers-benefit

[8] To inform a response to Scottish Commission on Social Security Adult Disability Payment Draft Regulations Call for Views, CAS carried out an online survey of CAB advisers on some of the areas in the consultation document. This included 10 questions about a number of aspects of the consultation document. The survey was answered by 61 CAB advisers from Bureaux across Scotland.

[9] https://www.gov.uk/government/statistics/personal-independence-payment-april-2013-to-april-2020/personal-independence-payment-official-statistics-to-april-2020

[10] https://www.gov.uk/government/statistics/esa-outcomes-of-work-capability-assessments-including-mandatory-reconsiderations-and-appeals-march-2022/esa-work-capability-assessments-mandatory-reconsiderations-and-appeals-march-2022#appeals-clearances-and-outcomes-for-initial-esa-claims-which-started-up-to-december-2020

[11] DWP, Shaping future support: the health and disability green paper, 20 July 2021, paras. 300–303.

[12] Citizens Advice Scotland, Response to Shaping future support: The Health and Disability Green Paper, October 2021, page 28.

[13] Scottish Campaign on Rights to Social Security, Beyond a Safe and Secure Transition - A Long Term Vision for Disability Assistance in Scotland, August 2022, page 30.

[14] This research was carried out in 2016 as part of the consultation on designing a new social security system for Scotland. This included consultation with 144 CAB clients with direct experience of the benefits due to be devolved, at events hosted by 14 local bureaux. Three regional consultation events were held with a total of 48 CAB advisers with frontline experience of the system. Two additional focus groups were held with 11 advisers and managers, complemented by an online survey of 43 CAB staff and volunteers. Full details of our consultation activity are attached as Appendix A.

[15] DWP, ESA: Work Capability Assessments, Mandatory Reconsiderations and Appeals: March 2022, 10 March 2022.

[16] DWP, ESA: Work Capability Assessments, Mandatory Reconsiderations and Appeals: March 2022, 10 March 2022, Section 10.

[17] For example, see Justin Tomlinson, Answer to Written Question UIN 128978, tabled on 14 December 2020. See also Office for Statistics Regulation, Letter from Deputy Director to the Chief Statistician of the DWP: Universal Credit Work Capability Assessment statistics, 8 April 2022.

[18] social_security_consultation_-_response_from_citizens_advice_scotland.pdf (cas.org.uk)