Work Capability Assessment

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The Work Capability Assessment (WCA) is the test designed and used by the Department for Work and Pensions (DWP) in the United Kingdom to determine whether disabled welfare claimants or those suffering from long-term illnesses are entitled to the main out-of-work sickness benefit: Employment and Support Allowance (ESA). The introduction of the WCA as the gatekeeper to ESA was a crucial part of the out-of-work benefit reforms of 2008[1] that the next government continued and developed.

The WCA aims to sort sickness benefit claimants into three groups: fit for work; unfit for work but fit for pre-employment training; or fit for neither work nor training. The DWP views this as the first step in a process that helps some disabled people "off benefits and into work" but the testing procedure has proved highly controversial, with concerns loudly expressed about inaccurate decision-making and the difficulties and delays faced by claimants when they launch an appeal.[2]

Atos Healthcare, part of the UK branch of the Paris-based multinational Atos, conducted the core assessment on behalf of the DWP from October 2008 until 1 March 2015, on which date the American firm Maximus took over.

Labour and the two former coalition parties all support the principle of ESA - to encourage work and thereby reduce welfare spending - but few observers now see the deployment of the WCA as a success, in economic terms or otherwise. Seven years since it was introduced it is still not clear that the test will ever work as intended, and there is persistent criticism of the leadership skills and integrity shown by government ministers and officials during the long attempt to launch what was once a flagship welfare reform.[3][4][5]

Evolution of the test[edit]

Before 1995, entitlement to the welfare payment known as Invalidity Benefit was decided by a government adjudication officer based largely on the opinion of the claimant's general practitioner.

In 1995, the Conservative government replaced Invalidity Benefit with Incapacity Benefit (IB) and the now defunct Department of Social Security began commissioning independent assessments using a test called the Personal Capability Assessment. The change came about partly as a result of the view that a mainly clinical opinion from an individual's doctor might not accurately reflect functional impairment. It has also been noted that some obstacles to work, such as pain and fatigue, can be difficult to gauge using the traditional medical model.

In 2007 the New Labour government passed the Welfare Reform Act[6] which - for fresh claims, initially - would, in the following year, replace Incapacity Benefit with Employment and Support Allowance (ESA) and the Personal Capability Assessment with the new Work Capability Assessment. The aims were to accentuate the positive by "looking at what you can do, not what you can't do"; to make the test for out-of-work sickness benefits more stringent; and to take into account new disability legislation, changes in the workplace and developments in occupational health.

To comply with the terms of the 2007 Act the DWP appointed Professor Malcolm Harrington,[7] an academic with a background in occupational health, to review the WCA system in 2010.[8] In November of that year he published an initial report that included 25 recommendations.[9][10][11] The second year of his review was to include refining the criteria relating to people with mental health problems and conditions that can fluctuate in severity from day to day[12][13] (in 2012, DWP ministers decided to replace Professor Harrington;[14][15] as his successor they appointed Dr Paul Litchfield, a senior figure in the Royal College of Physicians' Faculty of Occupational Medicine).[16][17][18]

In early 2011, the Conservative-Liberal Democrat coalition government brought forward the planned expansion of the programme to assess once again the 2.5 million people whom the DWP had previously judged, before the introduction of ESA and the WCA, to be entitled to Incapacity Benefit.[19][20] At the same time the DWP revised the framework of the test, with the result that the eligibility criteria became even more stringent: most notably, the 03/11 version awarded no points when a claimant who had difficulty walking could overcome the disability by using a wheelchair, if reasonably practicable.

Official projections then envisaged many hundreds of thousands of claimants of Incapacity Benefit moving onto Jobseekers Allowance or into a training programme and then into work.[21] As a result, a saving of £3billion annually in the IB/ESA budget was anticipated by the end of the parliament.[22][23]

The assessment process[edit]

When the New Labour government introduced the 'fit for work' test, it contracted out the core medical component to its existing partner for disability assessments: Atos Healthcare, which was already conducting assessments on people claiming a range of other disability benefits, including Disability Living Allowance and Industrial Injuries Disablement Benefit.[24] On 1 March 2015, the US company Maximus[25] assumed responsibility for carrying out these assessments[26] through its subsidiary, the Centre for Health and Disability Assessments (CHDAUK), also known as the Health Assessment Advisory Service.[27]

The process starts with an assessment by a registered healthcare professional employed by the outsourcing firm, after which an official from the DWP first decides on entitlement to Employment and Support Allowance and then on whether a successful claimant is able to take part in 'work-related activity'. In this way, the process sorts claimants into three groups: fit for work; unfit for work but fit for work-related activity (the Work-Related Activity Group); or fit for neither work nor work-related activity (the Support Group).

The WCA in theory[edit]

The assessment process is ultimately a legal one that uses social security legislation as its main reference point (which is why appeals are made to lawyer-led tribunals overseen by the Ministry of Justice). The standard of proof used is 'the balance of probabilities': a claim should be accepted if it is more likely than not that the claimant has a significant disability.

The strength of a claim is largely determined by comparing the claimant's problem with a framework of set criteria, known as 'descriptors', in a procedure that draws on occupational health theory, broad clinical knowledge, and the field of 'functional assessment' - a subspecialty concerned with gauging and validating the practical impact of a physical or mental impairment on a person's daily life and, in the context of the WCA, on their ability to work.

The descriptors are split into 'functional' and 'non-functional' descriptors. The functional descriptors are then subdivided, depending on whether physical or mental function is affected. Each functional descriptor comes with a 'score' of 6, 9 or 15 points that is intended to reflect the relative severity of the impairment; the assessor's core role is to select the most appropriate descriptor for each activity printed on the ESA claim form that the claimant has marked as being difficult for them in their day-to-day life. A successful claimant will normally 'score' at least 15 points in total.

For example, the activity 'Manual Dexterity' - hand function - comes with the following descriptors for the assessor to choose from:

  • The claimant cannot use a computer keyboard or mouse (9 points)
  • The claimant cannot use a pen (9 points)
  • The claimant cannot pick up a small object (15 points)
  • The claimant cannot press a button or turn a page (15 points and a place in the Support Group)

Only one descriptor may be chosen for each activity, and it should be the highest-scoring option that still accurately describes the loss of function. Someone who can pick up a small object like a coin but cannot use a pen to make a simple mark will score 9 points for that activity.

If a claimant is capable - in narrow terms - of carry out a particular action but cannot do so reliably, repeatedly, in a timely manner, safely and without significant pain, they should be treated as being incapable of carrying out that action.

The physical functional descriptors cover these activities:

  • Mobilising
  • Standing and sitting
  • Reaching
  • Picking up and moving an object
  • Manual dexterity
  • Making yourself understood
  • Understanding others
  • Finding your way around
  • Continence
  • Consciousness

The mental functional descriptors cover:

  • Learning tasks
  • Hazard awareness
  • Planning and problem-solving
  • Coping with change
  • Getting about
  • Coping with other people
  • Behaviour

The non-functional descriptors - which have no points attached but instead have a simple 'yes' or 'no' answer - apply when:

  • The claimant cannot eat or drink
  • The medical condition is life-threatening and uncontrollable
  • The claimant will probably die within 6 months
  • The claimant's health would be at real risk if they were found fit for work

Other factors that might be taken into account include:

  • The claimant is pregnant
  • There is a risk to others
  • Intravenous therapy is being administered
  • The claimant has cancer

A score of 15 for one activity or a 'yes' answer to a non-functional descriptor question will usually qualify the claimant for the Support Group.

The process also usually gathers a large amount of information about the claimant's day-to-day life, to build up a picture of what is officially termed their 'Typical Day'.

An often-heard criticism of the WCA is that there is nothing built into the core assessment to draw a distinction between disabilities that will never change and conditions that are expected to improve - or worsen - over time: the picture is only a 'snapshot' taken at the time of the assessment (although a prognosis is usually given after the main assessment, its accuracy will depend on the medical knowledge of the assessor, which varies according to their professional background and clinical experience).

In summary, the process uses fixed criteria and a system of points in an attempt to:

  • Identify those claiming ESA who have disabilities that, in a legal sense, are not significant - and identify those who have no disability at all.
  • Identify those claiming ESA who, because of the nature of their disability, face significant barriers to work.
  • Identify those claiming ESA who have one or more severe functional disabilities; they are usually then deemed to be incapable of participation in work-related activity.

The healthcare professional:

  • Answers factual questions that have a bearing on eligibility, such as: "Is the claimant an expectant mother?" or "Is the claimant being treated with radiotherapy"?
  • Delivers clinical judgements, such as on whether the claimant is at substantial risk or terminally ill.
  • Supplies a prognosis based on medical knowledge.

And a face-to-face assessment will gather detailed information about the claimant's day-to-day life.

The WCA in practice[edit]

The process starts with a healthcare professional approved by the DWP scrutinizing the ESA claim form and deciding whether to seek further evidence from the claimant's GP or another appropriate source. If the evidence shows that a claimant probably has both limited capability for work and limited capability for work-related activity then a face-to-face assessment is not normally required, the claimant is recommended for the Support Group and the higher rate of ESA is usually granted. Otherwise, the healthcare professional arranges a face-to-face assessment - usually in an examination centre, but occasionally in the claimant's home.

At face-to-face assessments, the assessors - who are nurses, doctors, physiotherapists or occupational therapists - are guided and prompted by a computer programme, designed by Atos in conjunction with the DWP, called the 'Logic-integrated Medical Assessment' or 'LiMA' (despite no longer carrying out WCAs directly, Atos is still paid by the DWP to operate LiMA because Atos owns the software, although the DWP owns the intellectual property rights). A large amount of lifestyle data and some clinical information is obtained from the claimant and is entered into the computer by the assessor. As the assessment progresses, LiMA tries to gauge both the impact of the disability on the person's daily life and the person's fitness for work - but while LiMA suggests options to the assessor, it is ultimately the healthcare professional who is responsible for making the recommendations.

As well as taking a clinical history and exploring the claimant's 'Typical Day', the healthcare professional will make general observations of the claimant's hearing, mobility and posture, etc. and there may be a short physical examination. The claimant's mental state will to a large degree become apparent as the interview progresses, but specific questions might be asked in order to elucidate any disordered thinking, abnormalities of perception or cognitive impairment.

During the face-to-face assessment, if it becomes clear that the claimant qualifies for the Support Group, the interview should be brought to an early close and the finding recorded on the claimant's file.

After the interview and examination the findings are summarised in free text using Standard English prose, and a typed report - largely, apart from the summary, constructed from modified pre-set LiMA options - is sent electronically to the DWP. This report attempts to describe the claimant's 'Typical Day' and to justify the recommendation by comparing and contrasting the disabilities described by the claimant against the criteria - the descriptors - constituting the legal framework of the test[28][29] (as well as considering the other factors, such as whether there would be a substantial risk if the claimant were declared fit for work). This report normally concludes with the points score intended to reflect the level of disability together with a final recommendation on fitness for work and a work-related prognosis. If the assessment is carried out in the claimant's home, the report is usually written by hand and is substantially shorter (normally, only doctors are authorised to write reports by hand, i.e. without using LiMA).

If assessors encounter practical difficulties or are unsure how to apply the test's criteria in specific cases, telephone advice is available.

These assessments[30] have been criticised for their repetitive impersonal style, while the reports have been criticised for several aspects of their overall quality and for the accuracy of their recommendations.[31][32] Poor evidence-gathering before an assessment and a perceived reluctance to recommend claimants for the Support Group are specific and longstanding criticisms. The reliability of LiMA in gauging disability has never been independently demonstrated.

The decision-maker[edit]

The task of the DWP official is to establish from the evidence whether or not the claimant has 'Limited Capability for Work' i.e. whether they are entitled to ESA at all; if they are, officials then have to to decide on whether the disabled person has 'Limited Capability for Work-Related Activity' i.e. whether they are capable of taking part in 'work-related activity' (usually interpreted to mean pre-employment training). If the person qualifies for ESA but is deemed not to have limited capability for work-related activity, they will be placed in the Work-Related Activity Group (WRAG) and will take part in mandatory training; they will also receive less money than those selected for the other category - the Support Group - where training is not compulsory (in the July 2015 Budget, it was announced that new claimants put into the WRAG after April 2017 will receive no more money than if they were on Jobseekers Allowance).[33]

People in the Support Group usually, but not invariably, have more severe disabilities than those in the WRAG: a score of 15 for one functional activity or the application of a non-functional descriptor is almost always the reason why a claimant is put in the Support Group (but someone with multiple problems who scores 9 for several activities would not normally qualify for the Support Group; on the other hand, someone with little apparent disability in their day-to-day life will normally go into the Support Group if their health would be at risk if they were declared fit for work).

There is little in the core test that separates disabled people who are likely to be able to work at some point in the future from those who are not: people in the Support Group can and do apply for, and get, full-time jobs.[34] Furthermore, the claimant's ability to cope with work-related activity is not specifically evaluated on an individual basis within the core assessment: the architects of the WCA took the view that a severe problem in one functional area - such as being unable to point a finger under 'Manual Dexterity' - would make employment-related training too difficult, whereas a less severe problem in the same functional area - such as being unable to form a pinch grip with the index finger and thumb - would not.

For these reasons, the assertion that there is a clear distinction between the two categories of ESA claimant is difficult to sustain.

In practice, when the assessor's report is sent by the outsourcing firm to the DWP it already contains the assessor's opinion on fitness to work and on suitability for the Support Group, but it is an official that makes the final decision. This decision takes into account: the assessor's recommendation; any other available medical evidence, e.g., a sick-note or another DWP report, for example one from a previous Disability Living Allowance assessment; and the legal aspects of social security legislation pertaining to entitlement to benefits.

In 2014, 20% of fit-for-work recommendations from assessing healthcare professionals were overruled by a DWP decision-maker[35] (up from 8% in early 2013).

If the claimant disagrees with the decision, he or she is entitled to ask the DWP to formally reconsider, though the onus is on the claimant to initiate this. If the result of this formal review is unfavourable to the claimant, he or she can then appeal to an independent tribunal - consisting of a judge, a doctor and a layperson - operating under the auspices of the Ministry of Justice. The tribunals take evidence from appellants and observe them during the hearing but the medical member of the panel does not physically examine them; otherwise, the tribunals use the same legal process and the same set of criteria as the DWP and its outsourcing partner, but they do not use LiMA nor set out to delineate the claimant's 'Typical Day'.

At the reconsideration stage 20-25% of initial fit-for-work decisions are reversed and a further 15% are reversed by tribunals (or to look at it another way: historically, as many as 40% of appellants who have got as far as a tribunal have seen the DWP's decision overturned).[36][37]

The work-related activity group[edit]

The Work-Related Activity Group (WRAG) contains people whom a disability analyst has deemed to face significant barriers to work because of ill-health or disability. They have been accepted by the DWP as being entitled to ESA, though they are required to take part in 'work-related activity' as a condition of their benefit. The DWP has not defined 'work-related activity' precisely but so far it has not involved applying for jobs, taking part in work placements or undertaking any form of provisional employment. The DWP says: "Claimants identified for this group will take part in work-focused interviews with a personal advisor and have access to a range of support to help them prepare for suitable work".[38]

The WRAG usually contains people with less severe disabilities than those in the Support Group but the clinical prognosis has no bearing on whether the claimant is placed in the WRAG or the Support Group, except when the claimant is terminally ill. At the end of a WCA, the assessor does give an estimate of the timescale for return to work. However, this prediction is not developed by the internal workings of the WCA but is instead added on at the end by the assessor, based on their knowledge and experience as a healthcare professional - and as with the clinical prognosis, the work-related prognosis normally has no bearing on whether the claimant goes into the Support Group or the WRAG (it is used by the DWP to decide on how soon to bring the claimant back for another WCA, in the hope that their level of disability will have improved).

Historically, the DWP expected the two categories of ESA to contain people with few differences in their levels of disability or their natural prognoses. In the first years of ESA, the DWP's intention was to use the WCA to identify claimants who could move closer to being ready for work through some of the following: active therapeutic rehabilitation, e.g. speech therapy; an aid, such as a wheelchair; or an adaptation, such as a bespoke computer for work, built around the disability. But in early 2011, the nature of the intervention shifted towards largely generic activities and training, based on the Work Programme.

Therefore it would be inaccurate to suggest that people in the WRAG are fit to work, or that their functional problems will improve any more rapidly than will those that qualify claimants for the Support Group, or that the barriers they face are largely a lack of work experience or a need for advice on how to apply for a job.[39]

2011-2013: a barrage of criticism[edit]

The first 'fit to work' assessments using the WCA format took place in October 2008, but the test only came to the attention of the general public after March 2011 when the DWP began to reassess welfare recipients it had previously judged to be too ill to work. Although, technically-speaking, claimants were simply being evaluated for transfer onto a new benefit with more stringent eligibility criteria than before, the purpose of the process was not made clear to the claimants going through it - nor to the wider world, where it was often assumed that when an application for ESA from an established IB claimant was unsuccessful, it meant that there had never been anything really wrong with the claimant in the first place.[40] As a parliamentary report that was compiled at an early stage of the 'migration' of IB claimants onto ESA concluded: "It has caused controversy because some people previously considered disabled and entitled to invalidity benefits are now being found fit-for-work".[41]

The WCA was then loudly criticised: in the media,[42][43][44] in Parliament,[45] by the Church,[46] by the medical profession,[47] and by protest groups.[48][49][50] In 2012, Parliament's Office of Science and Technology analysed the WCA's performance and found that "the number of fit-for-work decisions being overturned on appeal has led to questions about the reliability of the assessment process"; in the same year, MPs first debated the WCA and Atos Healthcare.[51] Since then there has been considerable pressure applied by parliamentarians of all parties - but particularly by Michael Meacher,[52] Tom Greatrex [53][54] and Sheila Gilmore - for improvements to the 'fitness to work' assessment. Greatrex also wrote to the Prime Minister to bring to his attention allegations made by a whistleblower that the core assessment was "skewed" against the claimant. Downing Street made no reply but simply passed the letter back to the DWP, which issued a non-specific statement;[55] Greatrex described the response as "woefully inadequate".

Controversially, patients with serious conditions such as brain damage,[56] terminal cancer, severe multiple sclerosis, and Parkinson's Disease have been found fit for work.[57] On 24 April 2013, a woman who was a double heart and lung transplant patient died in her hospital bed only days after she was told that her Incapacity Benefit was being stopped and that she was fit for work.[58][59]

Criticism has been directed at the test over its ability to deal with mental health problems and with other conditions where symptoms vary over time.[60] Atos Healthcare did train selected assessors to be 'mental function champions' who provided mainly telephone advice to other assessors on mental health issues as they related to the WCA's criteria[61] - a response to one of two key recommendations made by Professor Harrington. The other legacy of his tenure was the introduction in 2011 of the 'personalised summary statement'. This was intended to be a written explanation to the claimant in plain English of how the assessor's recommendation had been reached, but the DWP decided not to send them to claimants; instead, the department sent a 'decision-makers justification' written by a civil servant.[62] Nevertheless, the DWP insisted that assessors still write summaries, saying that decision-makers found them helpful when trying to understand the main reports. This summarisation, though time-consuming for Atos assessors, made little discernible impact on the level of criticism of the WCA.

At a meeting in June 2012 British Medical Association doctors voted that the WCA should be ended ‘with immediate effect and be replaced with a rigorous and safe system that does not cause unavoidable [sic] harm to some of the weakest and vulnerable in society’.[63]

In 2013 the Public Accounts Committee made up of MPs and chaired by Margaret Hodge heard that in 2011/12 Atos was paid £112.4 million to carry out 738,000 assessments. 38% of appeals to tribunals were successful and the Committee took the view that the WCA resulted in too many wrong decisions being overturned. Whilst Atos was paid to do the assessments, it is the government that pays for the tribunal appeals, with £500 million being the potential cost to the taxpayer for these appeals over ten years.[64] "The Department's got to get a grip of this contract." concluded Margaret Hodge, adding[65] "We saw no evidence that the Department was applying sufficient rigour or challenge to Atos given the vulnerability of many of its clients, the size of the contracts and its role as a near monopoly supplier. We are concerned that the profitability of the contract may be disproportionate to the limited risks which the contractor bears."[66]

Also in 2013, the UK Statistics Authority disproved a claim by the Conservative Party chairman that 878,300 benefit claimants dropped their claims rather than be assessed by Atos. Andrew Dilnot, chairman of UKSA, found that the figure appears to "conflate" new claims, where the claimant might simply have recovered, with established claimants coming up for reassessment.[67][68]

On 22 May 2013, a decision in a judicial review brought by two individuals with mental health problems ruled that the WCA process was not fair to people with cognitive impairments and other mental health issues, because the upper tier tribunal felt that these claimants were at a disadvantage when attempting to gather and present evidence to support their own claims.[69] The DWP disagreed.[70]

In the same month, a Freedom of Information request by Reading councillor and Chair of Reading Borough Council’s Access & Disabilities Working Group, Pete Ruhemann, revealed that: "28 of the 140 medical assessment centres, or 20 percent, do not provide wheelchair access," and, "[m]any, including the larger centres, are on the second or third floor". Furthermore, the "great majority do not have associated parking".[71] The councillor characterised this national situation as, "a disgrace".[71] It has been revealed that Atos has already made an out-of-court settlement with one user, "for disability discrimination […] over access."

Also in May, a doctor who had resigned from Atos after refusing to downgrade his rating of the disability of a mentally ill claimant blew the whistle on biases in the testing process to the BBC and said: "These assessments need to be done independently, impartially, considering all the evidence and with proper use of medical knowledge - and that's just not happening at the moment. Pressure is being put on healthcare professionals in many cases to come up with a particular outcome, really regardless of the facts of the case" and accused the DWP of "pulling strings behind the scenes" to boost the number of fit-for-work recommendations being made by the outsourcing firm. The subsequent news report drew particular attention to widespread and unduly harsh misinterpretations of the assessment's system for awarding points, on key abilities such as mobility and mental concentration, that the former assessor had claimed were being promulgated through the training programme[72][73] for new WCA assessors[74][75] – to which Atos replied that it was the DWP that was responsible for setting the curriculum for new assessors, not Atos.[76]

Atos ends the contract early[edit]

On 22 July 2013, the barrage of criticism of the Work Capability Assessment appeared to be vindicated when the DWP announced that in June it had directed Atos to put in place a 'quality improvement plan' - as part of which, all WCA assessors would be obliged to undergo retraining - and said it would be bringing in new providers to carry out assessments, at this point supposedly in addition to Atos. The move ostensibly followed an audit of reports produced in the six months to April 2013 (when Atos furnished more than 300,000 recommendations on fitness for work) in which the DWP claimed that it had found 164 that were unsatisfactory - yet the DWP went on to suggest that these "unsatisfactory" reports had nonetheless come up with the correct recommendation on fitness to work! [77]

At the same time, the Coalition's attitude towards the WCA underwent a sea-change. PricewaterhouseCoopers were called in to audit 'quality issues'[78] and in the autumn reshuffle the Prime Minister ordered the incumbent of the ministerial post with responsibility for the WCA to return to the backbenches.[79] In December, in a statement to the Work and Pensions Committee, the new Disabilities Minister criticised the test and blamed the Labour government which introduced it, describing the assessment process as a "mess" that the Coalition had been obliged to pick up when it came to power.[80]

Meanwhile, Atos abruptly backtracked on a promising arrangement to carry out fitness-for-work assessments on the Isle of Man and began to secretly negotiate an early exit from its £500m WCA contract with the DWP in Great Britain (but not in Northern Ireland, where the contract with the devolved Department for Social Development remained intact).[81][82]

In February 2014 the French firm went public, citing death threats to its staff, criticism from Labour MPs and its own opinion that the WCA was "not working" as the reasons why it wanted to quit.[83] At the same time, the company removed the 'Atos Healthcare' branding from its occupational health division and rebadged it as 'OH Assist'.[84]

In March 2014, when responding to Dr Paul Litchfield's review of the WCA's performance for the DWP published the previous year,[85] the Disabilities Minister poured more scorn on the WCA process and once again blamed the previous Labour government. The minister said: "...the system we inherited from the previous administration was not fit for purpose. The process was riddled with problems..." and declared that as well as extending the testing process to the 2.5 million people already on Incapacity Benefit, ministers and officials had been trying to fix the problems since coming to power.[86] At the same time, the minister told Parliament that the contract with Atos was in the process of being brought to a premature close, with Atos paying a "substantial financial settlement" to the DWP as part of a mutual agreement to terminate the WCA contract early (but which was erroneously represented by some media organisations as Atos being 'sacked').[87][88]

Nevertheless, the DWP continued to employ the French firm to assess most new claims for the Personal Independence Payment (PIP)[89] (from October 2015, Atos Healthcare will reassess most existing claimants of Disability Living Allowance for suitability for transfer to PIP - the disability benefit that is replacing DLA). The Veterans Agency voiced no concerns over the work of Atos doctors in the assessment of claims for War Pensions made by former members of UK Armed Forces.

Over the summer of 2014 it emerged that there was a backlog of more than half a million ESA claims caused by longer assessments and a dearth of assessors - unintended consequences of the 'quality improvement plan' begun the previous year.[90]

Maximus wins the contract[edit]

At the end of October 2014, the DWP announced that the US firm Maximus - trading as the Health Assessment Advisory Service[91] - would take over the WCA contract from Atos in March 2015, only five months short of the natural end date of the five year Atos contract.[92][93] Maximus would be paid £595m to carry out the work capability assessments over a three-year period. On signing the contract, Maximus said that it would improve evidence-gathering prior to a face-to-face assessment, introduce specialist assessors for particular types of disability and communicate more effectively with claimants.[94] However, concerns were expressed about whether this was truly the start of a new chapter when it emerged that, because it was the DWP that owned or leased most of the real estate, the assessments would continue to take place in buildings that were often difficult for disabled people to access. Some activists were alarmed to discover that key former senior staff from both the DWP and Atos, along with - in an act of apparent defiance of the "death threats" to its staff that Atos gave as a reason for wanting to leave - most of the assessors, were transferring to the new provider.[95]

The president of the new outsourcer's health services division acknowledged that hundreds more healthcare professionals would have to be recruited in order to clear the backlog of 500,000-600,000 ESA claims and boost capacity in the future.[96]

Economic effectiveness[edit]

A government follow-up study of 1100 former incapacity benefits claimants who had been declared fit for work - the results of which were obtained through a Freedom of Information Act request in 2012 - found that more than half of the people in the study reported being without a job and without any income of their own; nearly a third were on Jobseekers Allowance or a similar benefit and only one in eight had found work.[97]

More recently, the National Institute of Economic and Social Research analysed the effectiveness of the WCA process in reducing the IB/ESA claimant count.[98] It found that the broad downward trend since 2004 in the number of people claiming out-of-work sickness benefits accelerated in 2011, only for the trend to abruptly reverse in the second half of 2013.[99]

In October 2014, the government's fiscal watchdog found that between 2010 and 2014 no savings at all were made in the IB/ESA budget, which remained at more than £13billion a year.[100] Six months later, the Office for Budget Responsibility raised its forecast for spending on IB/ESA by a further one billion pounds a year, because more claimants than before were being placed in the Support Group.[101]

Jonathan Portes, former Chief Economist at the DWP, has described the botched IB reassessment programme as "the biggest single social policy failure of the last fifteen years".[99]

But after the General Election in May 2015, the new Conservative government declared that welfare reform was actually about creating "a complete shift in the welfare culture"[102] and pointed to the large number of jobless people who had found work during the economic recovery that began in 2013 - a trend which brought unemployment down to a level not seen since the early phase of the 2008 recession; as part of this trend, the number of people claiming Jobseekers Allowance (JSA) fell back dramatically to prerecession levels[103] and a saving of one billion pounds a year was hoped for in JSA costs[104] - although the 500,000-600,000 jobless claimants on the WCA waiting list, which Maximus was brought in to reduce, were not counted in the official JSA claimant count.

In July 2015, the JSA claimant count began to rise again.

Credibility of the test[edit]

In 2011, between January and November, the DWP's own figures show that 10,600 sick and disabled people died within six weeks of their benefit claim ending;[105] it is widely believed that these deaths occurred after - and even because - the claimants were declared fit for work. The Daily Telegraph has questioned this: it posits that the 10,600 deaths include some people who happened to die from natural causes, after which their benefit payments ceased.[106] Nevertheless, there have been numerous media reports of unexpected deaths after assessments where the claimant seems to have been at risk: a vulnerable man who starved to death;[107] a woman with a weakened immune system dying days after the DWP denied her appeal;[108] a paranoid man jumping from a bridge;[109] and a man with brain damage from a previous suicide attempt killing himself after being found fit for work.[110] In response to a campaign using the Freedom of Information Act, the Information Commissioner has ordered the DWP to disclose the number of people that have died within a year of a WCA since May 2010;[111] the DWP has sought to withhold this information, arguing variously that it was too time-consuming, the department was about to publish it anyway or it would not be in the public interest because the data might be misinterpreted.

In 2012, The Independent reported that 43 complaints against Atos doctors and nurses were being investigated by the General Medical Council or the Nursing and Midwifery Council[112] but Atos has countered that the number of formal complaints is small in comparison to the total number of assessments. Also in that year the Public Accounts Committee heard that Ministry of Justice tribunals were seeing, in nearly two out of three successful appeals, claimants' points scores rising from zero in the original assessments - meaning that the assessors had detected no disabilities whatsoever - to at least 15 points after the tribunals had considered the cases and awarded the claimants the ESA to which they were entitled.[113] In the same year, a GP posed as a trainee Atos assessor and recorded undercover video footage that was later broadcast by Channel 4's investigative current affairs programme Dispatches. In the film, trainers warned the NHS doctor that if he recommended more than 1 in every 8 claimants for the higher category of support he would be subjected to an increased level of management scrutiny through a mechanism known as "targeted audit".[114] Both the DWP and Atos later admitted using "norms"[115] to set the rate at which they expected assessors to recommend that claimants be put in the Support Group but they denied that "targeted audit" meant that there was a target for getting people off benefits, or that the norms artificially suppressed the number of claimants ultimately placed in the Support Group; Atos explained that the process merely detected outliers and was intended to ensure consistency across the firm's nationwide team of assessors: if an audit showed no cause for concern, no action would be taken against the healthcare professional.[116]

In 2013, government figures were cited in Parliament to show that in the first year of the Incapacity Benefit reassessment programme, 1300 claimants put into the 'Work Related Activity Group' died within six weeks;[117] meanwhile, the Work Programme's training providers - themselves, like Atos, outsourcing companies - were complaining about the WCA to Parliament: the firms had "ongoing concerns about the accuracy of the WCA"; they rated earlier improvements to the WCA as only "4 or 5 out of 10"; claimants who were "clearly unfit for any type of work-related activity" were nonetheless being put in the Work-Related Activity Group; and even "claimants with terminal cancer, whose life expectancies were shorter than the work-ready prognosis" had been referred to them for pre-employment training.[118] Medical charities have perennial questions about the wisdom of trying to rehabilitate people who suffer from diseases that are only going to get worse; the DWP has acknowledged the problem but has not come up with a satisfactory answer.[119][120]

In 2014, an MP asked the UK Statistics Authority to analyse the high overturn rate of fit-for-work decisions by independent tribunals, as well as by the DWP itself at the pre-tribunal 'Reconsideration' stage.[121] The query was passed back to the DWP, after which nothing more was heard. The DWP has elsewhere[122] suggested that this high overturn rate demonstrates the effectiveness of the system's checks and balances; critics say that it demonstrates the unreliability of the core assessment. When, in early 2014, Atos gave its reasons for seeking to exit the contract to carry out the core assessment, the firm announced that it had come to the conclusion that "in its current form, the WCA is not working for claimants, for DWP or for Atos Healthcare".[123] But at the end of 2014 the DWP-appointed reviewer of the WCA - who viewed the test as "by no means perfect" but nevertheless adequate - declared that "we have taken the WCA about as far as it can sensibly go in terms of modification and adjustment" and warned that "there is no better replacement that can be pulled off the shelf".[124]

In February 2015 during the 'long campaign' to fight the General Election in May, the Prime Minister proposed using WCA findings to earmark people suffering from conditions that might respond to further intervention and then require them to undergo treatment or lose their entitlement to social security benefits.[125][126] The Conservative MP Sarah Wollaston - a former GP and the chair of Parliament's select committee on health - described the plan as "unworkable" and "illegal".[127] It soon emerged that such ideas had been considered and rejected by the DWP before;[128][129][130] no more was heard of the Prime Minister's proposal[131] until the story resurfaced five months later, unworked on in the interim.[132][133] Professor Dame Carol Black will now consider the proposal and report back by the end of 2015.

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