Medical Assessments PIP & ESA

1. Medical Assessments PIP& ESA Mutual Support

2. PIP & ESA – The Similarities • Medical assessments to determine eligibility, with regular review (very few get 10 year reviews). • Face to face assessments, carried out by a private company (ATOS or Capita) on behalf of DWP. Usually an appointment at an assessment centre, although there may the possibility of a home visit • Some cases may be assessed on papers only, if the written evidence (including claim form) is strong enough and properly supported. • The assessment report is passed to a DWP decision maker (DM). • You may receive a phone call from DWP before final decision is made

3. When Might You Have To Attend A PIP/ESA Medical Assessment • You have made a new claim for PIP or for ESA • You are receiving PIP or ESA and you are called for a review • You have received Incapacity Benefit, Income Support, or Severe Disablement Allowance since before 2008, and you are called for a WCA to be transferred to ESA • You have been receiving Disability Living Allowance, but you now have to make a new claim for PIP instead • your fixed term award of DLA expires • you notify DWP that there has been a change in your care or mobility needs • You turn 16 years of age

4. ESA Entitlement Conditions ESA • A person is entitled to ESA if they have limited capability for work A person has limited capability for work if— (a) his capability for work is limited by his physical or mental condition, and (b) the limitation is such that it is not reasonable to require him to work • A person will be placed in the support group if they have limited capability for work-related activity A person has limited capability for work-related activity if— (a) his capability for work-related activity is limited by his physical or mental condition, and (b) the limitation is such that it is not reasonable to require him to undertake such activity. The detail is in regulations

5. Incontinence Treated Differently in LCW and LCWRA • Within LCW – Absence or loss of controlleading to extensive evacuation of the bowel and/or bladder, other than enuresis (bed-wetting), despite the wearing or use of any aids or adaptations which are normally, or could reasonably be, worn or used • Within LCWRA – Absence or loss of control over extensive evacuation of the bowel and/or bladder, other than enuresis (bed-wetting) despite the presence of any aids or adaptations normally used. At least once a week experiences loss of control leading to extensive evacuation of the bowel and/or voiding of the bladder.

6. ESA – Exceptional Circumstances Exceptional circumstances • LCW – Because of your physical or mental health condition or learning disability, there would be a substantial risk to the mental or physical health of any person, including you, if you were found not to have limited capability for work. And the risk could not be reduced by a significant amount by reasonable adjustments being made in your workplace or by your taking medication to manage your condition that has been prescribed by a registered medical practitioner who is treating you. • LCW – Because of your physical or mental health condition or learning disability, there would be a substantial risk to the mental or physical health of any person, including you, if you were found not to have limited capability for work-related activity.

7. MS And PIP • PIP has no equivalent of the requirement for ‘continual supervision’ that existed in Disability Living Allowance (DLA) • The PIP supervision test is very a high hurdle to jump, but it might mean, for example, that a person with a history of status epilepticus may get the high rate care (even if their fits were comparatively rare – not assured) • In practice the supervision requirement may depend on an assessment of whether the person dealing with particular aspect of MS is capable of recognising the symptoms early enough to take pre-emptive action.

8. PIP – A DWP Case Study Pete is 19 and lives with his family. He works from home in the family business as he is not allowed to drive. He is unable to take part in sport as he is worried about having a fit. These have been more frequent since puberty and his neurologist keeps his treatment under constant review to try to reduce his fit frequency; he is currently having a mix of either grand-mal or petit-mal fits most days and sometimes more than once a day. He is occasionally incontinent during a grand-mal fit and falls asleep for a while afterwards. Between fits he is fairly independent although he only takes a shower if a family member is in the house and he never cooks when alone – in the past he has suffered injuries including scalds and burns in the kitchen. He has little or no warning of a fit and previously he has received cuts and bruising from fits while outdoors. He never goes out unaccompanied because of the risk and danger from traffic or from members of the public. • What level of PIP could Pete expect ?

9. PIP – DWP Case Study – Result 1 Likely descriptor choices – Daily Living 1 Needs supervision to either prepare or cook a simple meal 4 2 Can take nutrition unaided 0 3 Can manage medication, therapy and monitor a health condition unaided, or with the use of an aid or appliance 0 4 Needs supervision or prompting to bathe 2 5 Can manage toilet needs or incontinence unaided 0 6 Can dress and undress unaided 0 7 Can communicate unaided and access written information unaided, or using spectacles or contact lenses 0 8 Can engage socially unaided 0 9 Can manage complex financial decisions unaided 0 Mobility 10 Needs supervision, prompting or a support dog to follow a journey to a familiar destination 15

10. PIP – DWP Case Study – Result 2 Total points Daily living activities = 6 (no daily living component entitlement) Mobility activities = 15 (enhanced rate mobility component) Explanation Daily living Although Pete has fits on most days, which are unpredictable with minimal warning, he is independent in all daily living activities other than cooking and bathing, where having a seizure would result in significant risk. He therefore only requires supervision for these activities. Mobility He requires supervision whenever he goes out, because of the significant risk of injury.

11. Be Very Careful at the Medical • The Health Care Professional (HCP) may appear to be friendly and ask you your favourite TV program. If you say East Enders, for example, they will ask whether you watched a recent episode. - If the answer is ‘yes’, they will conclude that you can sit in a chair without falling out or without suffering any discomfort and you can concentrate for at least 30 minutes. Also your memory is OK.

12. Be Very Careful at the Medical • Don’t walk across the car-park, someone may well be watching; • Ask for a disabled car-parking space. • Ask if they have a lift, DON’T walk up stairs. • Ask for a home visit; • Don’t answer the door yourself; • Don’t offer the HCP tea and biscuits, they are not on your side.

13. Be Very Careful at the Medical • You should be accompanied and supported at all times; • Ask for and insist upon a recording of the meeting with the HCP – it is your right. • If, and ATOS may well do so, insist and say that you are unable to continue with the medical assessment unless you have a recording of the meeting. • Have copies of all your PIP/ESA paperwork with you – the HCP may not have everything.

14. Links Up-to-date information can be found here: Individuals:https://www.gov.uk/pip Advisers: https://www.gov.uk/government/publications/the-personal-independence-payment-toolkit-for-partners/the-personal-independence-payment-pip-toolkit-for-partners