London Journal of Primary Care 2012;4:154–6
# 2012 Royal College of General Practitioners
London Landscape
General practitioners and fitness for work Deborah Padfield Benefits Adviser, Cambridge Citizens Advice Bureau, UK
General practitioners (GPs) along with other health and support workers have been assigned an ambiguous, but often crucial, role in decision-making for Employment and Support Allowance (ESA), the replacement for Incapacity Benefit (IB). It is important that GPs understand how ESA works and the help claimant–patients may need.
Eligibility In the past, long-term sick or disabled people received either IB, if they had paid sufficient National Insurance (NI) contributions, or Income Support (IS), if they had low savings and income. Many people remained on these for many years, with little or no encouragement to return to work. In 2008, IB and IS were replaced for new claimants by ESA. Only parents of children under 7 and carers are now placed on IS. Early this year, Job Centre Plus (JCPlus) started assessing existing IB/IS claimants for ESA. People found to be fit for work are expected to claim Job Seekers Allowance (JSA). They can alternatively appeal the ESA decision. Both ESA and JSA can be awarded either on the basis of NI contributions or income/savings. People receiving ESA are reviewed at intervals between 6 months and 3 years, depending on JCPlus’s estimate of their level of fitness. For those found eligible for ESA, there is currently no time limit to entitlement. From spring 2012, it is likely that people receiving contribution-based ESA will receive it only for 12 months. Payments to those who have been on contribution-based ESA for 12 months will stop immediately. Letters are now going out warning claimants of this probable coming change. If people in this situation are below the income/ savings threshold for income-based ESA, they will continue to receive payments at the same rate. Otherwise, they will be expected to live on their funds unless or until these fall below the threshold.
Contribution-based JSA is already limited to 6 months, with the possibility of income-based JSA for those eligible.
A gradation of benefits The stated purpose of JSA and, for most people, of ESA, is to move people back to work. This replaces the old approach of defining people as permanently unemployable. There is a gradation of benefits and levels of support. For people who are: .
.
.
.
. . .
.
.
Unemployed and able-bodied: JSA with stringent conditions, sanctions and limited support. Longterm unemployed move into the Work Programme, with further training and conditions. Unemployed and disabled: JSA with modified conditions and the support of JCPlus Disability Advisers, but the same sanctions regime. Long-term unemployed move into the Work Programme. Unemployed and more seriously disabled: ESA work-related activity group, involving less-rigorous conditions but strict sanctions; eligibility reviewed at intervals of 6 months to 3 years. Individuals have ‘prognosis’ date by which they are expected to be fit for work; 3 months earlier, they must participate in the Work Programme, but can opt in earlier. Too disabled for work-related activity: ESA support group, involving no conditions or sanctions; reviewed at intervals set by JCPlus. People can opt into Work Programme activities, but will then join the work-related activity group. The benefit rates are also graded: JSA, £67.50pw for a single person over 25; ESA assessment rate, paid once claim and Med3 are registered, £67.50pw; same rate is paid during an appeal; ESA work-related activity group, paid once eligibility is confirmed, 13 weeks after initial claim, £94.25pw; ESA support group, paid once eligibility is confirmed, 13 weeks after initial claim, £99.85pw.
GPs and fitness for work
These differentials will widen under Universal Credit (from 2013), with relatively few people assessed as seriously disabled receiving significantly higher rates than others. People on any of these benefits, or in work, may be eligible for Disability Living Allowance.
155
Attendance at a pain clinic is stronger evidence than a patient’s self-description or a prescription list.
Being awarded the ‘right’ benefit, with appropriate levels of support and demands, is critical for claimants’ wellbeing. The criteria for ESA, always tighter than those for IB/IS, were further narrowed in April 2011. They permit people with significant disabilities to be found fit for work. In practice, Atos Healthcare’s assessments lead many who fulfil the criteria to be turned down or put inappropriately in the work-related activity group. Some fall between stools, being turned down for ESA then being told at Job Seekers’ interviews that they are not fit for work. Providing the right evidence of disability at the right time can be crucial. It is possible to appeal the refusal of ESA and allocation to the work-related activity group. Evidence from doctors or other health or support workers can be provided either during the initial assessment or at the appeal stage.
The diagnosis is secondary: this is a functional test of the person’s ability to cope with specific activities. There is sense in this. While one person who is blind or has bipolar affective disorder will be significantly disabled, another will become home secretary or a TV star. This functionality creates a double-bind. According to the Department for Work and Pensions (DWP) and Atos, supporting letters from clinicians are encouraged (although this is not made very clear to claimants). Clinical evidence is, however, potentially devalued because doctors, unlike Atos professionals, are not seen as ‘disability analysts’. So it is crucial for patients that evidence be tied as tightly as possible to the ESA descriptors. A simplified version of these is given below. The full version, with an outline of the system, is at http://www.direct.gov.uk/prod_consum_dg/groups/ dg_digitalassets/@dg/@en/@disabled/documents/ digitalasset/dg_177366.pdf, on pages 17 et seq. Apart from these descriptors, the only grounds on which people can claim ESA are ‘exceptional circumstances’ relating to an uncontrollable or uncontrolled life-threatening illness; or where there is a disease or disablement resulting in ‘a substantial risk to the mental or physical health of any person’ if the claimant were found fit for work.
Assessment and evidence
Onus on claimant
Evidence comes in several forms:
For ESA, as increasingly throughout the benefit system, the emphasis is on individual responsibility. Claimants are expected to prove their own incapacity, on paper and in person at the medical examination, irrespective of the nature or degree of their problems. Atos Healthcare provides evidence and a recommendation to JCPlus, the decision-making body. It has no contractual incentive to ensure that its report gives a full picture of claimants’ disabilities. Unlike the Disability Living Allowance (DLA) process, Atos very seldom contacts claimants’ GPs for evidence, so payment is rarely available. As for DLA, payment is never available at appeal stage. Should the evidence from Atos prove inadequate or misleading, leading to a wrong decision, claimants must appeal. This involves first an internal reconsideration by JCPlus then, if necessary, a tribunal hearing. Because of the backlog of cases, appeals take several months.
The ‘right’ rate
.
.
.
.
.
Med3, needed throughout the assessment or appeal stage, a basic requirement rather than substantive evidence of entitlement ESA50 medical questionnaire, sent by Atos Healthcare to the claimant early in the claim, a demanding form with which many people need help medical assessment by Atos Healthcare professionals (doctors, nurses) following return of the ESA50, vulnerable claimants should if possible take support workers or friends with them supporting letters by clinicians or other health or support workers, these are not required but can be crucial, reducing the likelihood of having to go to appeal. Particularly where disability is hard to prove – including mental health conditions, fatigue and chronic pain – assessors look for ‘objective’ evidence.
156
D Padfield
The clinician’s role It is not part of the clinician’s role to specialise in welfare benefits or disability analysis. Nor can doctors write letters for all long-term sick patients. Unfortunately, unless they can where necessary provide relevant evidence, vulnerable people will be wrongly deprived of ESA. When people are at risk of being inappropriately turned down, particularly where problems of mental health, chronic pain or fluctuating conditions are involved, we at Cambridge Citizens Advice Bureau
encourage them to discuss the descriptors with their doctors. Where possible we suggest asking for a letter relating directly to the descriptors, which can be sent to Atos Healthcare before the medical assessment. The Atos address is given on letters sent to the claimant. Alternatively, doctors can be asked for evidence at the appeal stage. ESA aims to re-open closed doors and enable people to return to employment. But it has a history of blindness to the reality of complex or chronic problems. That is where the clinician can help.
Box 1 Physical health problems The ESA tests the activities relevant to the physical assessment ability to: . . . . . . . . . .
Mobilise (walk with or without crutches/mobilise unassisted with a wheelchair/go unassisted up or down two steps) Stand or sit without exhaustion for 30 minutes/1 hour Raise either arm (problem with one arm is insufficient) Pick up and move objects with one or other hand (problem with one hand is insufficient) Use fingers, e.g. to write, pick up coin, use keyboard with one or other hand Make self understood by speaking, writing, typing or other means Understand by hearing, lip-reading, reading 16-point print ‘Navigate’ safely unassisted, with or without a guide dog Control bowels and/or bladder Maintain consciousness: involuntary episodes of lost or altered consciousness resulting in significantly disrupted awareness or concentration
Box 2 Mental health problems/learning difficulties . . . . . .
Inability to learn new tasks, e.g. to operate alarm clock or washing machine, because of learning difficulty or mental health condition Unawareness of everyday hazards (e.g. boiling water) causing significant risk of injury or damage to person or property Inability to organise/plan/motivate self to initiate and/or carry out sequential activities Inability to cope with planned or unplanned change to routine, making day-to-day life seriously difficult Inability to get to familiar or unfamiliar places unaccompanied Inability to take part in social activities for most or all of the time
ADDRESS FOR CORRESPONDENCE
Deborah Padfield Email: [email protected]
These are my personal views and not representative of the Citizens Advice Bureau.
# 2012 Royal College of General Practitioners
London Landscape
General practitioners and fitness for work Deborah Padfield Benefits Adviser, Cambridge Citizens Advice Bureau, UK
General practitioners (GPs) along with other health and support workers have been assigned an ambiguous, but often crucial, role in decision-making for Employment and Support Allowance (ESA), the replacement for Incapacity Benefit (IB). It is important that GPs understand how ESA works and the help claimant–patients may need.
Eligibility In the past, long-term sick or disabled people received either IB, if they had paid sufficient National Insurance (NI) contributions, or Income Support (IS), if they had low savings and income. Many people remained on these for many years, with little or no encouragement to return to work. In 2008, IB and IS were replaced for new claimants by ESA. Only parents of children under 7 and carers are now placed on IS. Early this year, Job Centre Plus (JCPlus) started assessing existing IB/IS claimants for ESA. People found to be fit for work are expected to claim Job Seekers Allowance (JSA). They can alternatively appeal the ESA decision. Both ESA and JSA can be awarded either on the basis of NI contributions or income/savings. People receiving ESA are reviewed at intervals between 6 months and 3 years, depending on JCPlus’s estimate of their level of fitness. For those found eligible for ESA, there is currently no time limit to entitlement. From spring 2012, it is likely that people receiving contribution-based ESA will receive it only for 12 months. Payments to those who have been on contribution-based ESA for 12 months will stop immediately. Letters are now going out warning claimants of this probable coming change. If people in this situation are below the income/ savings threshold for income-based ESA, they will continue to receive payments at the same rate. Otherwise, they will be expected to live on their funds unless or until these fall below the threshold.
Contribution-based JSA is already limited to 6 months, with the possibility of income-based JSA for those eligible.
A gradation of benefits The stated purpose of JSA and, for most people, of ESA, is to move people back to work. This replaces the old approach of defining people as permanently unemployable. There is a gradation of benefits and levels of support. For people who are: .
.
.
.
. . .
.
.
Unemployed and able-bodied: JSA with stringent conditions, sanctions and limited support. Longterm unemployed move into the Work Programme, with further training and conditions. Unemployed and disabled: JSA with modified conditions and the support of JCPlus Disability Advisers, but the same sanctions regime. Long-term unemployed move into the Work Programme. Unemployed and more seriously disabled: ESA work-related activity group, involving less-rigorous conditions but strict sanctions; eligibility reviewed at intervals of 6 months to 3 years. Individuals have ‘prognosis’ date by which they are expected to be fit for work; 3 months earlier, they must participate in the Work Programme, but can opt in earlier. Too disabled for work-related activity: ESA support group, involving no conditions or sanctions; reviewed at intervals set by JCPlus. People can opt into Work Programme activities, but will then join the work-related activity group. The benefit rates are also graded: JSA, £67.50pw for a single person over 25; ESA assessment rate, paid once claim and Med3 are registered, £67.50pw; same rate is paid during an appeal; ESA work-related activity group, paid once eligibility is confirmed, 13 weeks after initial claim, £94.25pw; ESA support group, paid once eligibility is confirmed, 13 weeks after initial claim, £99.85pw.
GPs and fitness for work
These differentials will widen under Universal Credit (from 2013), with relatively few people assessed as seriously disabled receiving significantly higher rates than others. People on any of these benefits, or in work, may be eligible for Disability Living Allowance.
155
Attendance at a pain clinic is stronger evidence than a patient’s self-description or a prescription list.
Being awarded the ‘right’ benefit, with appropriate levels of support and demands, is critical for claimants’ wellbeing. The criteria for ESA, always tighter than those for IB/IS, were further narrowed in April 2011. They permit people with significant disabilities to be found fit for work. In practice, Atos Healthcare’s assessments lead many who fulfil the criteria to be turned down or put inappropriately in the work-related activity group. Some fall between stools, being turned down for ESA then being told at Job Seekers’ interviews that they are not fit for work. Providing the right evidence of disability at the right time can be crucial. It is possible to appeal the refusal of ESA and allocation to the work-related activity group. Evidence from doctors or other health or support workers can be provided either during the initial assessment or at the appeal stage.
The diagnosis is secondary: this is a functional test of the person’s ability to cope with specific activities. There is sense in this. While one person who is blind or has bipolar affective disorder will be significantly disabled, another will become home secretary or a TV star. This functionality creates a double-bind. According to the Department for Work and Pensions (DWP) and Atos, supporting letters from clinicians are encouraged (although this is not made very clear to claimants). Clinical evidence is, however, potentially devalued because doctors, unlike Atos professionals, are not seen as ‘disability analysts’. So it is crucial for patients that evidence be tied as tightly as possible to the ESA descriptors. A simplified version of these is given below. The full version, with an outline of the system, is at http://www.direct.gov.uk/prod_consum_dg/groups/ dg_digitalassets/@dg/@en/@disabled/documents/ digitalasset/dg_177366.pdf, on pages 17 et seq. Apart from these descriptors, the only grounds on which people can claim ESA are ‘exceptional circumstances’ relating to an uncontrollable or uncontrolled life-threatening illness; or where there is a disease or disablement resulting in ‘a substantial risk to the mental or physical health of any person’ if the claimant were found fit for work.
Assessment and evidence
Onus on claimant
Evidence comes in several forms:
For ESA, as increasingly throughout the benefit system, the emphasis is on individual responsibility. Claimants are expected to prove their own incapacity, on paper and in person at the medical examination, irrespective of the nature or degree of their problems. Atos Healthcare provides evidence and a recommendation to JCPlus, the decision-making body. It has no contractual incentive to ensure that its report gives a full picture of claimants’ disabilities. Unlike the Disability Living Allowance (DLA) process, Atos very seldom contacts claimants’ GPs for evidence, so payment is rarely available. As for DLA, payment is never available at appeal stage. Should the evidence from Atos prove inadequate or misleading, leading to a wrong decision, claimants must appeal. This involves first an internal reconsideration by JCPlus then, if necessary, a tribunal hearing. Because of the backlog of cases, appeals take several months.
The ‘right’ rate
.
.
.
.
.
Med3, needed throughout the assessment or appeal stage, a basic requirement rather than substantive evidence of entitlement ESA50 medical questionnaire, sent by Atos Healthcare to the claimant early in the claim, a demanding form with which many people need help medical assessment by Atos Healthcare professionals (doctors, nurses) following return of the ESA50, vulnerable claimants should if possible take support workers or friends with them supporting letters by clinicians or other health or support workers, these are not required but can be crucial, reducing the likelihood of having to go to appeal. Particularly where disability is hard to prove – including mental health conditions, fatigue and chronic pain – assessors look for ‘objective’ evidence.
156
D Padfield
The clinician’s role It is not part of the clinician’s role to specialise in welfare benefits or disability analysis. Nor can doctors write letters for all long-term sick patients. Unfortunately, unless they can where necessary provide relevant evidence, vulnerable people will be wrongly deprived of ESA. When people are at risk of being inappropriately turned down, particularly where problems of mental health, chronic pain or fluctuating conditions are involved, we at Cambridge Citizens Advice Bureau
encourage them to discuss the descriptors with their doctors. Where possible we suggest asking for a letter relating directly to the descriptors, which can be sent to Atos Healthcare before the medical assessment. The Atos address is given on letters sent to the claimant. Alternatively, doctors can be asked for evidence at the appeal stage. ESA aims to re-open closed doors and enable people to return to employment. But it has a history of blindness to the reality of complex or chronic problems. That is where the clinician can help.
Box 1 Physical health problems The ESA tests the activities relevant to the physical assessment ability to: . . . . . . . . . .
Mobilise (walk with or without crutches/mobilise unassisted with a wheelchair/go unassisted up or down two steps) Stand or sit without exhaustion for 30 minutes/1 hour Raise either arm (problem with one arm is insufficient) Pick up and move objects with one or other hand (problem with one hand is insufficient) Use fingers, e.g. to write, pick up coin, use keyboard with one or other hand Make self understood by speaking, writing, typing or other means Understand by hearing, lip-reading, reading 16-point print ‘Navigate’ safely unassisted, with or without a guide dog Control bowels and/or bladder Maintain consciousness: involuntary episodes of lost or altered consciousness resulting in significantly disrupted awareness or concentration
Box 2 Mental health problems/learning difficulties . . . . . .
Inability to learn new tasks, e.g. to operate alarm clock or washing machine, because of learning difficulty or mental health condition Unawareness of everyday hazards (e.g. boiling water) causing significant risk of injury or damage to person or property Inability to organise/plan/motivate self to initiate and/or carry out sequential activities Inability to cope with planned or unplanned change to routine, making day-to-day life seriously difficult Inability to get to familiar or unfamiliar places unaccompanied Inability to take part in social activities for most or all of the time
ADDRESS FOR CORRESPONDENCE
Deborah Padfield Email: [email protected]
These are my personal views and not representative of the Citizens Advice Bureau.
