Written evidence from the University of Salford (HAB00567)
This written evidence is submitted on behalf of the Sanctions, Support and Service Leavers project [hereafter SSSL project] which is led by the University of Salford in collaboration with the University of Central Lancashire and University of York. The SSSL project is funded by the Forces in Mind Trust (FiMT) and represents the first substantive qualitative research in the UK to focus on the experiences of military veterans within the social security benefits system. The research is being delivered through two methods: repeat qualitative longitudinal interviews with veterans; and consultations with key national, regional and local policy and practice stakeholders. SSSL initially ran from 2017-2019. However, with the support of FiMT the project is continuing until September 2023, providing a focal point for policy makers and practitioners in relation to veterans and the benefits system during a period of significant reform. The findings presented here draw upon the longitudinal data collected 2017-2021 (n=178 interviews). As such the project is uniquely placed to provide insights into how the social security benefits system is functioning for this specific cohort of claimants.
In addition to our responses to the Committee’s specific questions below, we would be very happy to provide any supplementary information that may be of use. We would also be happy to provide oral evidence to the Committee.
Our submission focussed on some key areas highlighted through our research that would help improve health assessments for benefits. These are:
How could DWP improve the quality of assessments for health-related benefits?
1.1 A significant proportion of our respondents had mental and/or physical health impairments that were attributed to their time in the Armed Forces. Given their impairments, part of their experience of moving into and through the social security system included having to undergo a benefits assessment. Our research documents a number of profoundly negative experiences, which related to (1) the perceived focus on physical rather than mental health; (2) the perceived lack of qualification of the assessors to assess Service-related ill health and disabilities; (3) inconsistencies in the use of Service medical records and other relevant medical information; and (4) the impact of the assessment process on people’s health. Most commonly, these negative experiences related to the Work Capability Assessment (WCA) for Employment and Support Allowance (ESA) or, more recently, for Universal Credit (UC), although a small number of respondents also referred to negative experiences of Personal Independence Payment (PIP). Below we provide further detail about each issue in turn.
1.2 For those veterans who had undergone a WCA, a key concern relating to the assessment process was the ability of the assessor to appropriately consider mental health needs. For some respondents, the perceived focus on physical capability had resulted in them wrongly being assessed as ‘fit for work’. Overall, it was felt that there was a focus on physical functional capabilities, with limited attention paid to mental health issues.
It was more disabilities with more physical symptoms. It wasn't – it didn't feel like they were asking me anything about mental symptoms. So you're answering the questions and you feel like it doesn't apply to me. 'Can you walk more than 20 yards unaided?' and things like that. Which, obviously, I can do that, but it's different because it's mental symptoms (ESA claimant)
Respondent: They didn't ask me anything about my PTSD at all.
Interviewer: What's the main reason you're on ESA?
Respondent: For PTSD. At my work [capability] assessment they were asking me about how far I could walk and could I move my arms and legs, and pretty much that was it. There was nothing at all about mental health mentioned within it (ESA claimant)
1.3 A number of the accounts within our study highlighted that there was sometimes a lack of understanding about the specific mental health issues relating to Service in the Armed Forces. A number of participants had PTSD, for example, and it was felt that the assessment processes were not always able to capture the episodic nature of some mental health conditions:
I got a letter back from PIP saying I got no points… So I rang them up, I said, 'Look, I'm not being funny‘, I said, 'but I've got no points, I'm not getting my PIP‘, and I said, 'my ESA's been reduced to the standard rate'. I sent all the information regards my medical condition, and they said, 'What evidence have you sent in?' So I said, 'Well, it's about ten pages long, from [Armed Forces charity], signed and all the rest of it'… I said to them, 'Do you understand the mental health condition I've got?' They said, 'Yes, we looked at it, but we can't understand how that's affecting your daily life‘, and I thought, but surely, if you're assessing me on a medical, on mental health issues, you should understand the different mental health conditions. 'So, for example‘, I said, 'on my bad days I do need prompting to have a wash. I do need prompting to feed myself, because sometimes I just sit there and fester and do absolutely nothing‘, I said, 'and sometimes, if I'm cooking something and I've got the cooker on‘, I said, 'if I have a flashback, that flashback could last ten minutes, 15 minutes, and when I come round it could be on fire'. 'Yes, but we don't understand how your mental [health] affects you' (ESA claimant)
1.4 Another key concern raised in our research was whether the person undertaking the assessment was suitably qualified. A number of respondents were under the care of a doctor or a specialist, who had deemed them to be unfit for work because of their impairments. It was therefore difficult for people to understand how a WCA had led to a different outcome from that recommended by the medical professional who was treating them.
Hang on, you're either fit for work or you're not. I don't understand how a [benefits assessor], no matter how qualified they are, they're not medical practitioners… my shrink's a professor… I think he's more qualified to say whether I can do work than someone working in the [DWP] (UC claimant)
1.5 Good practice was evident, particularly where people were interacting with an assessor who was understanding of issues related to the Armed Forces:
The young girl that did it, she was really nice because she did inform me, she said, over the last couple of months she had had a lot of ex-Service personnel going in and stuff, so she was really nice, but I know in the past, they're just blunt (ESA claimant)
However, overall there appeared to be significant inconsistency between the approaches of assessors.
1.7 In our 2019 report we made a recommendation that the DWP “urgently review the assessment process applied to those claiming working-age incapacity benefits to ensure that assessors are suitably qualified to assess the specific mental and physical health issues related to Service in the Armed Forces”.
1.8 A further concern raised in the research related to the fact that Service medical records and other relevant supporting medical information were not routinely being included within the benefit-related assessment processes. This omission was often only rectified when a third party, such as a GP or Armed Forces charity, advocated on behalf of a claimant when appealing against an assessment that had deemed them ‘fit for work’.
1.9 Although there is a process in place for the most severely disabled military personnel whereby the DWP uses evidence from the Service Medical Board, this process does not appear to be widely known. Only a small number of respondents explicitly mentioned that Service medical information and other relevant documentation had been used to support the assessment process. In our 2019 report, we made a recommendation for the DWP “to ensure that Service medical records and other relevant supporting medical information are consistently included within any work capability or impairment assessment process”.
1.10 Additionally, there appears to be a lack of clarity on when supporting medical information should be brought into the process. For example, the respondent below describes bringing medical information to his assessment. However, it should have been made clear that this information is needed much earlier in the process rather than getting to the appeal stage:
The ESA went to appeal…the two-person appeals panel suggested that the person assessing me on the day was not familiar with service-related injuries. They advised the ESA, the DWP to leave my ESA alone … that extra documentation [Service medical information] was provided to the appeal, they took all of that on board and questioned why it wasn't used at the assessment… I was scored zero out of 15… The Appeal Board have said that the person assessing me wasn't qualified to assess me. There needs to be a system in place that if we do attend, as I did, these assessments, the information that we brought with us, which we felt, I felt was relevant, is looked at. It wasn't even taken off me… I went in for an ESA assessment with both a medical record and a mental health record. Neither were looked at. Was that person qualified to score me zero without looking at the documents? The military document? (ESA claimant)
Policy and practice stakeholders also expressed frustration that Service Medical evidence did not always appear to be taken into account in the assessment of benefit claims.
1.11 In addition to issues around the skills of assessors and the ability of the process to appropriately consider mental health, the interviews highlighted a broader issue around the process itself having a negative impact on people’s mental health. For many respondents it was evident that the process was very stressful, and people were often nervous when talking about a pending assessment or fearful when awaiting the outcome. In some of the more extreme examples within our study, the anxiety created by the assessment process had significantly exacerbated existing conditions, with devastating consequences for the claimant and their families.
[The DWP need] to maybe just comprehend the level of risk and threat that come along with that for the family. So the DWP have no concerns in having [him] waiting in an incredibly stressful environment with somebody that wasn't qualified to manage him and then go through an appeals process. This is somebody that's heavily medicated for a serious mental health condition, and that had repercussions within my family unit when he came home [from his assessment]. His behaviour does sometimes become unmanageable. We have come very close to [him] having to be sectioned… I'm not asking for special treatment. I'm just asking for somebody to think, 'Is this the most appropriate course of action with this person, and what are the possible repercussions and ramifications for that?' (spouse of ESA claimant)
I had a letter come through the letterbox… [DWP] wanted me to go in for an assessment… I rang them up and I say, 'I'm unfit to travel to an assessment', and they said to me, 'No, but you've got to come in for an assessment… You've got to provide evidence that you've got PTSD'. I said, 'Doesn't my War Pension evidence count?' He says, 'No, because you're claiming for a different benefit'. Unfortunately, I put the phone down, and my anxiety levels were so high I tried popping a couple of diazepam and that wouldn't work… I took a serrated knife to my arm… After I'd calmed down I spoke to my doctor surgery and they says, 'Well, come straight down' … (ESA claimant)
1.12 Many respondents had launched appeals to challenge the initial outcomes of their assessments and the attendant decisions about fitness to work, often with the support of their doctors, other agencies and family members. A number of respondents also talked about taking people with them to their assessments as a form of support, referring to workers from various agencies. Having this support during an assessment was vital for many, and, indeed, some of the respondents who had gone to their assessments alone perceived that this was sometimes detrimental to the outcome.
1.13 Many of the issues raised above are consistent with a range of evidence that has highlighted the wider inadequacies of the WCA process. It has been heavily criticised for propagating an individual ‘deficit model’ of disability[1] that deflects attention away from the barriers to work that disabled people face and also for focusing more on physical mobility issues, with inadequate consideration of mental ill health[2]. Although there was some evidence of the WCA and allied assessments within the benefits system leading to appropriate outcomes for the veterans who took part in our research, this was not the case for the majority.
1.14 In our 2021 Journal of Social Policy article[3], we recommended that trauma informed care approaches – that are used in a range of other human services – would lead to significant improvements in relation to benefits assessments (and other benefits interactions) (see section 2 below for further information).
A) Have you seen any specific improvements in the process since the Committee last reported on PIP and ESA assessments, in 2018?
1.15 As a qualitative longitudinal project we are able to track the experiences of benefit claimants over time. A small number of our respondents have described more recent assessment as being more positive than previous experiences of the WCA. These positive reflections related to the perception that the person undertaking their more recent assessment had been better qualified and approached the assessment in a more personalised manner than in previous assessments.
This one [WCA] went better… he said he was a doctor, and he was pleasant and not confrontational or sarky at all. It was a lot nicer than the last one I had, when I had a woman that was really sarky and I had a go at her. It's still not pleasant… (ESA claimant)
The majority view remained that there was inconsistency and it was very much dependent on who was undertaking the assessment, how qualified they were and the nature of that interaction.
2.1 In our 2021 Journal of Social Policy article[4] we recommend that the social security system (including benefits assessments) should adopt trauma informed care approaches. Trauma informed care has been used internationally to examine health, homelessness, prison and childcare services. It originated in the USA and subsequently moved to Australia, New Zealand and Canada, among other countries. Although applied to many human services in the UK (the NHS, for example), the benefits system has not adopted such approaches.
2.2 Trauma informed care adopts the principles of safety, collaboration, choice, trustworthiness and respect. This involves recognising that how services treat clients can impact on whether they can heal and recover from their trauma and enables services to anticipate and overcome the barriers which can prevent clients from engaging fully.
2.3 Our findings suggests that there is much to be gained from the application of trauma-informed approaches to the social security system. Although some DWP and benefits assessment staff have an understanding of mental health issues linked to Service in the Armed Forces and are consequently able to deliver services which are experienced as safe, supportive, understanding and empowering, at present, this appears to be the exception rather than the rule and there was no evidence that this was driven by trauma-informed care principles. Indeed, overall, the current approach appeared to be ‘trauma- blind’[5]. A trauma-informed approach would improve not only the social and emotional well-being of the individual claimant but also family members (such as spouses and children). Additionally, there are potential employment gains, as many of the veterans within our study identify unresolved trauma as a barrier to sustaining paid work. Making social security services more trauma- informed is also likely to improve the workplace safety of DWP staff/benefits assessors by reducing the level of aggression they may encounter from clients.
3. Do the descriptors for PIP accurately assess functional impairment? If not, how should they be changed?
3.1 As highlighted above, participants perceived there to be a focus physical function rather than mental health.
4. Do the descriptors for ESA accurately assess claimants’ ability to work? If not, how should they be changed?
4.1 As highlighted above, participants perceived there to be a focus physical function rather than mental health. When referring to the WCA, a number of participants described it as a ‘tick box’ exercise that did not allow for any nuance or could not fully accommodate the episodic nature of people’s conditions.
5. DLA (for children under the age of 16) and Attendance Allowance usually use paper-based rather than face-to-face assessments. How well is this working?
a. Before PIP replaced DLA for adults, DLA was also assessed using a paper-based system. What were the benefits and drawbacks of this approach?
5.1 Our recent interviews with participants during Covid-19 have highlighted the importance of providing choice to people in relation to how their assessments are undertaken (see section 10 below).
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?
6.1 For many respondents it was evident that they were reliant on the support of a range of healthcare professionals and Armed Forces charities to navigate the WCA (and other assessments). The importance of this support cannot be understated; however, it also highlights significant ‘displacement’ effects of the current system, whereby the cost of supporting people is borne by a wider range of organisations. Relying on clinical input require significant resources for these experts, which can lead to clinical hours being used for benefits assessments and processes. There would be a need to ensure that this clinical input was appropriately resourced but also that it didn’t create further inconsistencies i.e. different approaches of different clinicians leading to different outcomes for claimants.
6.2 As mentioned previously, the veterans in our study expressed concern that supporting medical documents and opinions were overridden or not taken into consideration during assessments. This led to stressful (and costly) appeals, that could have been avoided if better use was made of supporting medical documents in the early stages of the assessment process.
7. Appeals data shows that, for some health-related benefits, up to 76% of tribunals find in favour of the claimant. Why is that?
a. What could DWP change earlier in the process to ensure that fewer cases go to appeal?
7.1 As highlighted above, within our study, it was evident that successful appeals related to supporting medical evidence being used and/or an appropriate advocate intervening to support the claimant. As above, there needs to be greater clarity in relation to how and when supporting medical feeds into the process (i.e. to ensure that it feeds into the process right from the outset) but also how people can access appropriate support to navigate the process (if required).
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)?
8.1 Participants within our study raised concerns about having to undergo multiple assessments (e.g. PIP, WCA, Armed Forces Compensation). Although these are all different benefits and systems, from the perspective of our participants they all required the same medical information. As such there is a strong case for looking at how to ensure sharing of medical information across these processes. Many participants found the processes of applying stressful, so this would ensure that applicants are not repeating themselves (this risking re- traumatisation) and submitting the same supporting evidence for each type of benefit, thus easing the burden and stress on applicants.
9. What are your views on the Department’s “Health Transformation Programme”? What changes would you like to see under the programme?
a. (For people claiming) Would you like to be able to manage your benefit claim online?
b. What would be the benefits and drawbacks of DWP bringing assessments “in house”, rather than contracting them to external organisations (Capita, Atos and Maximus)? In particular, would this help to increase trust in the process?
9.1 As above, key issues raised in our research related to the skills and qualifications of assessors, how medical information was used within processes and inconsistencies in the approaches of individual assessors. The importance of staff training was evident – whether an in-house service or multiple providers, the key issues is ensuring that the service provided is consistent for all claimants.
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?
a. Is there a case for making some of the changes permanent?
10.1 As a qualitative longitudinal research project, we have been able to explore the experiences and impacts of Covid-19 on our participants[6]. This includes looking at how our participants experienced on some of the changes that occurred to the benefits system during Covid-19 (albeit temporary). This included the suspension of, or changes to, benefit assessment processes. We acknowledge that experiences of these particular (and sometimes challenging) aspects of the benefits system apply equally to non-veterans. However, by drawing on the accounts of our cohort of veterans with complex needs, we can provide important insights in relation to the need for careful consideration of when, how (or indeed whether) we return to ‘business as usual’ within the benefits system.
10.2 A number of our participants described the suspension, cancellation or delay of benefits assessment processes during Covid-19 and indicted that original categorisations and payments had been extended. Given some of the negative experiences highlighted above, one might assume that the suspension of assessments would be a welcome intervention. However, although there was evidence of some ‘relief’ at the suspension of assessments, overall, the interviews suggested that more commonly there was anxiety around the uncertainty of when and how they would take place. Additionally, for those who were making new claims or those who were hoping that a re- assessment would increase their payment level, such delays were articulated as having financial repercussions.
10.3 Our interviews during Covid-19 also revealed issues relating to the shifted to remote methods of assessment, with some participants experiencing a telephone assessment, where previously it had been face-to-face. The interviews highlighted mixed views on this method. Although some welcomed the removal of the requirement to attend a face-to-face assessment at an assessment centre (for example those who experienced anxiety when leaving the house), for others telephone assessments were problematic. This was primarily due to the inability to judge how the assessor was reacting to the conversation, to make a connection with the assessor, or not knowing if other people were present in the background:
I like to try and get my point across to someone on a personal level, so you can see people, you can gauge people's reactions. It's a lot easier to do it by body language and stuff when you see people than it is over the phone because you don't know … it could be a party call sort of thing where they've got their bosses listening in, or other people prompting them, or it might be a trainee on their first day. You've no idea, do you, it's just a voice? It's very hard to build up any sort of connection over the telephone (UC claimant).
10.4 Overall, there was significant uncertainty and anxiety about when and how benefits assessments would resume, which needs addressing through clearer communication. With regards to how the assessments would be carried out when they did resume, although telephone methods had been welcomed by some, they were not appropriate for all participants, with face-to-face interactions still important for many. We therefore recommend giving choice to people in relation to how their assessments are undertaken.
10.5 This would apply equally to other benefits interactions (e.g. work focused interviews at Jobcentre Plus), where providing choice to claimants about how those interactions take place would improve their experiences.
11. Most assessments for Industrial Injuries Disablement Benefit were suspended during the pandemic. What has been the impact on people trying to claim IIDB?
a. Some IIDB claimants will receive a lower award than they might have, due to the suspension of assessments, because IIDB awards are linked to age. Should the Department compensate these claimants? How?
b. What lessons could the Department learn for how it deals with these claims in future, in the event of further disruption to normal services?
11.1 Not within the scope of our research.
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?
a. How can the Department best help the third sector to support claimants in their applications?
12.1 As highlighted in 6.1, many respondents were reliant on the support of a range of third sector organisations (particularly Armed Forces charities) navigate the benefits system (including benefits assessments processes). The importance of this support cannot be understated; however, it also highlights significant ‘displacement’ effects of the current system, whereby the cost of supporting people is borne by a wider range of organisations.
12.2 In relation to the benefits system more broadly, two of the authors (Scullion, Young) are involved in a national project focusing on the benefits system during Covid-19[7]. A report published from that project focused on benefits, employment and crisis support during the pandemic[8]. The report highlights that an ever-increasing range of external actors and organisations mediate the relationship between benefit claimants and the DWP, particularly assisting claimants complete their applications (with a survey suggesting a third of claimants receive some kind of external help). Based on interviews with third sector organisations in four geographical areas, the report highlighted how the pandemic not only resulted in a reduced capacity of third sector organisations to provide support, but also saw an increase in demand for some benefits. Local ecosystems of support available to claimants have therefore been under considerable pressure to adapt since the start of the pandemic. Funding to organisations is obviously a key issue and if there is an expectation that third sector organisations will support benefit claimants, then adequate resources are required for them to do so.
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?
13.1 As highlighted in section 1 and 2 above, we highlight how the benefits assessment process can have a negative impact on people’s mental health. Our study shows how stressful the process was, with people being visibly nervous when talking about a pending assessment or fearful when awaiting the outcome. As above, in some of the more extreme examples within our study, the anxiety created by the assessment process had significantly exacerbated existing mental health conditions.
13.2 In order to address this - and as recommended above – we advocate that trauma informed care approaches should be adopted. Trauma informed approaches are already used in many other human services. A trauma- informed approach would improve not only the social and emotional well-being of the claimant but also family members. As stated above, there are potential employment gains, as but also improvements to workplace safety of DWP staff/benefits assessors.
14. What could the Department to do to shorten waits for health-related benefit assessments—especially for ESA/UC?
14. As highlighted previously, many of our respondents felt as though they were repeating the same information when applying for different benefits, particularly when it came to sharing supporting medical documents. Respondents felt frustrated at the perception that different parts of the DWP did not appear to be in communication. As such, improving sharing of information across the different benefits may help shorten waits for health-related benefit assessments.
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?
14.1 Not within the scope of our research.
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?
15.1 As we highlight in our 2021 Journal of Social Policy paper treating clients with respect and empathy is a central part of trauma-informed care. Shame is a powerful part of the experience of trauma, so trauma-informed services seek to discourage shame and stigma. However, it is widely acknowledged that such feelings are common amongst benefit claimants and it was evident that veterans in our study were grappling with an intense sense of shame at moving from a position of respect in the Armed Forces to having to ask for financial support. This was amplified when staff appeared to demonstrate a lack of respect towards people’s experiences. The DWP could therefore learn from the Scottish Government emphasis on “treating everyone with dignity and respect”.
a. PIP started rolling out in Northern Ireland in 2016. Is there evidence that the Department learned from the experience of rolling out PIP in the rest of the UK?
15.2 Not within the scope of our research.
16. How effectively does DWP work with stakeholders—including disabled people—to develop policy and monitor operational concerns about health-related benefits?
a. What steps could the Department take to improve its engagement with stakeholders?
16.1 We can only comment on our own engagement with the DWP as a research team. We have had positive engagement with the DWP through our project. For example, the DWP have permitted us access to Armed Forces Champions and we have included questions of relevance to the DWP within our interview question guides. The DWP have also listened to, and responded to, our findings and recommendations (for example, the DWP recently introduced an Armed Forces Marker on UC and improved its DWP Armed Forces Champions network). We believe that being open to engage with different stakeholders and being willing to engage with research in this way is a significant step forward and provides invaluable opportunities for the DWP to work collaboratively with researchers and other stakeholders to understand the experiences of claimants.
November 2021
[1] Shakespeare, T., Watson, N. and Alghaib, O.A. (2017) ‘Blaming the victim, all over again: Waddell and Aylward’s biopsychosocial (BPS) model of disability’, Critical Social Policy, 37(1): 22–41.
[2] Patrick, R. (2012) ‘All in it together? Disabled people, the Coalition and welfare to work’, Journal of Poverty and Social Justice, 20(3): 307–322; House of Commons Work and Pensions Committee (2014) Employment and Support Allowance and Work Capability Assessments, First Report of Session 2014–15, HC 302, London: The Stationery Office Limited.
[3] Jnl. Soc. Pol. (2021), 1–18 © The Author(s), 2021. Published by Cambridge University Press
[4] Jnl. Soc. Pol. (2021), 1–18 © The Author(s), 2021. Published by Cambridge University Press
[5] Quadara, A., & Hunter, C. (2016). Principles of Trauma-informed approaches to child sexual abuse: A discussion paper, Sydney: Royal Commission into Institutional Responses to Child Sexual Abuse.
[6] Scullion, LC, Martin, PB , Hynes, CJ and Young, DHJ 2021, 'Social security during Covid-19 : the experiences of military veterans'
[7] https://www.distantwelfare.co.uk/
[8] https://9ec499a2-11fd-40f9-999e-efa4a5fbe856.filesusr.com/ugd/e77e1a_dcbc771bd95e4664924c9cc0adf062e6.pdf