Written evidence submitted by the Department for Work and Pensions (SPR0035)

1.     The Department welcomes the opportunity to provide evidence to this Inquiry, which is an important step in addressing and combatting the rising suicide rates, amongst both men and women, in recent years. This is an issue that this Department takes extremely seriously.

2.     We are aware that some external commentators have drawn a link between the Work Capability Assessment (WCA) and suicides – a link which we do not accept.  The purpose of this evidence is, therefore, primarily to set out the details of the Department’s approach to vulnerability, and what safeguards it has in place – within the WCA process and more generally – to protect users of its services who are most at risk of suicide.

3.     Separately, officials in this Department are supporting the Department of Health in reviewing Preventing Suicide in England: A cross-governmental outcomes strategy to save lives, which highlights some of the positive work that the Department for Work and Pensions and the Department of Health have been undertaking to enhance support for individuals with mental health conditions. Through the Work and Health Unit the Government is investing £43 million to develop a series of trials with the aim of building an evidence base around what works for individuals with mental health conditions, trialling different approaches to combined health and employment support, which might also benefit those at risk of suicide.

The Department’s approach to vulnerability and vulnerable people

4.     This Department is reforming the welfare system so that the greatest number of people possible have the opportunity to lead a full and fulfilling life in work, rather than being parked for a lifetime on benefits. We are doing this whilst also protecting the most vulnerable people in our society; no other government department connects with as many people to support them at so many different and important moments in their lives.

5.     The Department’s approach to vulnerability is to ensure that we have in place the steps to identify those individuals with complex needs and those who require additional support in order that they can receive the help they need to enable them to access benefits and use the Department’s services. The Department achieves this through an agreed definition of vulnerability which provides both consistency and continuity in the delivery of its services.

6.     The Department defines a vulnerable individual as someone “who is identified as having complex needs and/or requires additional support to enable them to access DWP benefits and use our services”. Its definition of complex needs is someone who is experiencing “difficult personal circumstances and/or life events that affect the ability of the individual to access DWP benefits and use our services”. Such life events include a declared intention of suicide and/or self-harm. Staff in the Department are equipped with instructions and learning to recognise vulnerability in its many forms, so as to tailor the services offered accordingly.

Employment and Support Allowance

7.     Since 2008 Employment and Support Allowance (ESA) has been the main out-of-work benefit for people who have limited capability for work because they are disabled or have a health condition. There are around 2.5 million people receiving ESA, at a cost to the Exchequer of around £14 billion a year.

8.     The Work Capability Assessment (WCA) is the process for determining whether an individual’s capability for work is limited by their physical or mental health condition or disability, for the purposes of determining entitlement to ESA. It is a functional assessment, which was developed in consultation with medical and other experts, including representative groups, to ensure it is appropriate for all health conditions. Since 2008 over 6 million WCAs have been carried out. Once it has been determined that a claimant has limited capability for work and is eligible for ESA they may be required to have further assessments from time to time to ensure that they are still entitled to ESA and getting the correct rate of benefit; the effect of their health condition might have improved or worsened over time.

Allegations of a direct causal link between the WCA and suicide / premature death

9.     Since the introduction of the WCA there have been a number of tragic, high profile cases of individuals having gone through a WCA subsequently taking their own life.

10. While these cases are small in number they have, understandably, attracted considerable, political, media and stakeholder attention. There is understandably seldom any coverage of the many occasions when the Department’s staff recognise a person’s extreme vulnerability, and successfully work with police and others to prevent them harming themselves.

11. Any suicide is a tragedy and the reasons for them are complex, however it would be inaccurate and misleading to link it solely to a person’s benefit claim. Given the tragedy that any suicide represents, the Department’s continuing focus has been on ensuring that the WCA works as effectively as possible for vulnerable claimants.

12. In August 2015 the Department published statistics on the mortality rate for people who have died, of any cause, while claiming an out-of-work benefit, which showed that between 2003 and 2013 the rate fell in line with the decrease in mortality rate for the general population[1].

13. They showed that for people claiming ESA the mortality rate for those in the Work-Related Activity Group (WRAG) is about three times lower than for those in the Support Group[2]; this is to be expected and demonstrates that accurate assessments are being made of those who are severely sick or disabled. In this publication the Department made clear that any attempt to extrapolate any link beyond these figures in relation to the WCA is inappropriate.

Safeguards for people using the Department’s services

14. The Department takes the issue of suicide and self-harm extremely seriously, and has a number of safeguards in place to support as best we can those individuals who state an intention to attempt suicide and self-harm.

15. The Department maintains a set of Vulnerability instructions, which is a resource for staff to access information and guidance about how to support vulnerable individuals.

16. One of the uses of these Vulnerability instructions is to signpost staff to specific guidance on managing individuals’ declared intentions to attempt suicide or self-harm. This includes the Six Point Plan framework.

17. When a claimant, or another user of the Department’s services, states that they intend to attempt suicide or self-harm, the six point plan states that staff should:

• take the declaration seriously and remain calm and listen carefully;
• ask a colleague to act as a support partner;
• gather information to assess the level of risk;
• provide referral advice if the situation is considered non-urgent (general distress but no immediate plans or the means to attempt suicide or self-harm);
• get emergency help if claimant is extremely distressed and is considered to be at serious risk or in immediate danger; and
• review and discuss the incident with line manager and record for future use by staff.

18. Detailed guidance and underpinning learning is available to staff and managers to support the application of the six point plan, including resources for staff to direct the vulnerable individual to follow-up support services. A six point plan template, as used by the Department’s sites across the country, can be found at Annex A.

19. A number of safeguards to protect vulnerable people have been built into the ESA process – some since its inception, and others subsequently (some as a result of recommendations made in the independent reviews of the WCA, 2010-2014[3]).

20. DWP Visiting Officers can be sent to visit individuals in their own homes, at any stage in the process, if concerns have been raised about their vulnerability. As well as helping them to complete benefit claims, they can providing full explanations of any requirements placed on claimants at different stages of their claim, and the consequences of not doing so without good reason. They can also relay concerns back to the Department if they are particularly concerned about an individual’s welfare. This could result in a decision maker (DM) contacting the claimant’s GP, social services department or, for example, their community mental health nurse if they have one.

Initial benefit claim stage

21. Most claimants telephone the Department to claim ESA, and are asked to state their primary and secondary disability or health condition. These details are recorded on the relevant Departmental IT systems. Where a mental health condition is reported a mental health flag is placed on the system. Additionally when the claim is in writing the claimant’s disability or health condition is identified on the claim form and recorded on the relevant systems. Later in the claim process this allows certain modifications of the claim process to be made for these claimants.

22. Shortly afterwards claimants are sent a questionnaire to complete (the ESA50), where they are asked to detail how their health condition or disability affects their day-to-day life. If claimants need help to complete their questionnaire, as well as asking a friend, family member or carer to help them, they can contact Jobcentre Plus who will direct them to the Centre for Health and Disability Assessments (CHDA) – the assessment provider – who will help complete the form with them on the telephone, and send them a copy to sign.

23. Claimants must return their questionnaire within four weeks. If they do not do so, and they do not have good reason for not doing so, their claim is closed.

24. However, if a claimant who is ‘flagged’ as having a mental health condition does not return their questionnaire within the four week period, their benefit does not end; instead the healthcare professional (HCP), who carries out the WCA, either requests further evidence from the claimant’s GP or other professional involved in their care, to see if they can provide advice to the Department’s DM based on paper evidence, or they ask the claimant to attend a face-to-face assessment. This is a safeguard to protect vulnerable individuals who may find it difficult to engage with the process.

Healthcare professionals

25. All HCPs carrying out assessments on behalf of CHDA must be registered doctors, nurses or physiotherapists who are required to have a minimum level of previous clinical experience, and have to be approved by this Department’s Chief Medical Adviser

26. They all have training in Disability Assessment Medicine and must demonstrate an up to date knowledge of relevant clinical subjects. They are given specific training in assessing individuals with mental health conditions and receive continuing professional education in order to remain up to speed with developments in the field.

27. Following a recommendation made by Professor Malcolm Harrington in the first independent review of the WCA[4], mental function champions were introduced in July 2011, to spread best practice amongst HCPs in mental health, learning difficulties and cognitive impairment, and to support other HCPs carrying out assessments.

28. Since March 2015 CHDA has:

• increased  the number of mental function champions;
• introduced claimant champions among customer facing staff who will assist claimants on the day of their assessment, understanding their needs and handling any difficult or distressing situations; and
• introduced a telephone support service to help claimants complete their questionnaire about the impact of their condition, including advising about the types of further evidence required.

Assessment stage

29. Claimants are encouraged to provide all evidence that will be relevant to their claim, including medical evidence supplied by their GP or other professionals involved in their care, such as consultants, support workers, carers and community nurses.

30. HCPs are expected to seek further evidence where it would help them provide advice to the DM (who makes the decision on the benefit claim) without calling a claimant for a face-to-face assessment, which some claimants can find to be a stressful experience.

31. However, they must seek further evidence from the claimant’s GP or other professional involved in their care in all cases where there is evidence in the claimant’s questionnaire of a previous suicide attempt, suicidal ideation or self-harm.

32. If the HCP cannot provide advice to the DM based on the paper evidence alone, they will ask the claimant to attend a face-to-face assessment. If a claimant does not attend their assessment they are given the opportunity to explain why they did not attend. A DM will then decide if they had a good enough reason, and if they decide that they did not, the claim is closed.

33. However, additional safeguards are in place in cases where somebody with a mental health condition does not attend an assessment. Benefit continues in payment and attempts will be made to contact them by telephone and, if appropriate, to arrange a safeguarding home visit before a decision on entitlement is made.

34. Regulations 29(2)(b) and 35(2) of the Employment and Support Allowance Regulations 2008 provide that claimants may be treated as having limited capability for work or limited capability for work-related activity respectively in circumstances where there may be a substantial risk to the mental or physical health of the claimant or any other person if the claimant was not found to have limited capability for work or work related activity.

35. The Department has developed guidance for HCPs on the assessment of claimants who might be at substantial risk of harm. It makes clear that if they feel requiring the claimant to participate in reasonable, tailored work-related activity would put them at substantial risk of harm – including by suicide or self-harm – then they should advise the DM that the claimant should be placed in the Support Group, where no such requirements would be placed on them. From 2008 up to September 2015, almost 400,000 people were placed in the Support Group due to substantial risk of harm.[5]

36. If a claimant mentions suicidal thoughts / ideation at assessment the HCP is expected to:

• explore current suicidal  thoughts  and any previous episodes of self-harm;
• perform a mental state assessment;
• assess the  level of suicidal intent by, for example, consideration of factors associated with a high risk of suicide and evaluation of additional evidence;
• decide whether the risk of suicide or self- harm would be triggered if the claimant were found to be fit for work or work related activity, and advise the DM accordingly.
• if the HCP considers that the claimant is at significant risk of suicide they must, taking into account guidance from their professional organisation (e.g. GMC), either:
• advise the claimant’s GP (if they are not already aware) by telephone, followed up by written confirmation (form UE1); or
• ensure immediate clinical care is arranged for the person.

37. The HCP provides advice to the Department’s DM, who uses all of the available evidence to make a decision on the benefit claim. DMs can seek further advice or clarification from the HCP, and can request further evidence if they need it to make their decision.

38. Keeping safe training (part of the six point plan) is mandatory for all public facing staff, including DMs, and provides support on mental health and suicide awareness. This computer-based training has been developed by the Department of Health and, depending on local availability, can be enhanced by face-to-face sessions delivered by such organisations as Mind and the Samaritans.

Post-decision stage

39. In cases where the DM is likely to disallow a claim for ESA, they contact the claimant by telephone to review the information already held, and to request any additional information that they could consider before making their decision. If they do then decide to disallow the claim, they explain to the claimant that their ESA award will stop, and advises them which benefits they could apply for. The DM makes two separate attempts to contact the claimant; in cases where the claimant is vulnerable and cannot be contacted they will arrange a safeguarding home visit to the claimant.

40. There are a number of further safeguards, which apply to all claimants, if they are not satisfied with the decision on their claim:

• they can ask for a mandatory reconsideration. This is when all of the evidence is looked at again by a different DM to the one that made the original decision. As part of this process the claimant will be asked if there is any other evidence or information that they would like to be considered;
• if, following a mandatory reconsideration, the claimant is still not satisfied with the decision they have the right to lodge an appeal at the First-tier Tribunal.

41. Claimants who are found fit for work and claim Jobseeker’s Allowance are only asked to meet reasonable requirements tailored to take account of their circumstances and capability, including any physical or mental health condition. Safeguards are in place to ensure that claimants that are considered vulnerable understand what they are expected to do, and the consequences of not doing so without good reason.

42. Those in the ESA WRAG are provided with support to overcome the barriers to employment that they face. Work coaches/advisers have discretion to set work-related activity, in consultation with the claimant, while giving full consideration to their individual circumstances, including the nature and severity of their health condition.

43. Work-related activity is personal for each individual and must be appropriate and reasonable, taking into account their individual circumstances, including their physical and mental health. It could include such activities as attending courses and group sessions, but for some people activities such as preparing a CV or keeping a diary of daily activities would be more appropriate. Claimants cannot be asked to undertake anything that is unrealistic or could put their health at risk.

44. If somebody is not happy with their work-related activity, and this cannot be resolved by discussing it with their work coach/adviser, they have the right to have this formally reconsidered.

Further safeguards

45. Since 2012 Departmental guidance has provided that it is mandatory to carry out an internal process review of a case where the Department is notified that a claimant has died by suicide and there is an allegation that Departmental activity may have contributed. Internal Process Reviews are a tool for staff to look at the handling of a specific case. The purpose is to scrutinise the Department’s handling of particular cases to identify whether processes have been properly followed and, if appropriate, identify recommendations for changes to the process. It is not a mechanism to be used to seek out or apportion blame, and policy is outside the scope.

Conclusion 

46. The Department appreciates that suicide is a complex and multi-factorial issue, the fallout of which is a tragedy for all involved. It has been the Department’s intention that by contributing to this Inquiry, we have been able to demonstrate that we treat this issue with the utmost importance, and have processes in place to ensure as far as possible that people who use our services and are at risk of suicide are protected, and that we wish to continue improving how we support individuals who find themselves in these distressing circumstances.

September 2016

Annex A: Outline Local Six Point Plan for Handling Customers Declarations of Intention to Attempt Suicide or Self Harm

Six Point Plan for [Name of site]

At all times consider your own safety.

Managing the conversation with the customer

You are not expected to counsel the customer. The purpose of your conversation with the customer is to identify their needs and encourage or help them to seek appropriate support

DWP policy and guidance for Managing Customer Declarations of Intention to Attempt Suicide or and Self Harm.