«Updated on 28 July 2015 Foreword This document has been produced by the Department for Work and Pensions (DWP) to provide guidance for providers ...»
PIP Assessment Guide
A DWP guidance document for providers carrying out assessments for
Personal Independence Payment
Updated on 28 July 2015
This document has been produced by the Department for Work and Pensions
(DWP) to provide guidance for providers carrying out assessments for
Personal Independence Payment (PIP).
It is intended to supplement the contract documents agreed with providers as
part of the commercial process, providing guidance for health professionals
carrying out assessment activity and for those responsible for putting in place and delivering processes to ensure the quality of assessments.
All Health Professionals (HPs) undertaking assessments on behalf of DWP must be registered practitioners who have also met requirements around training, experience and competence. This document must be read with the understanding that as experienced practitioners and trained disability analysts, HPs will have detailed knowledge of the principles and practice of relevant diagnostic techniques and therefore such information is not contained in this guidance.
In addition, the guidance is not a stand-alone document, and should form only a part of the training and written documentation that HPs receive from providers.
It must be remembered that some of the information may not be readily understood by those who are not trained and experienced HPs. It also focuses specifically on the role of HPs in the assessment and the quality of their work. It is not intended to cover all the requirements placed on providers as part of the PIP assessment contracts; their full business processes; or work carried out by DWP to monitor and manage provider performance.
Office of the DWP Chief Medical Officer Contents Foreword
1.1 About Personal Independence Payment
1.2. The Health Professional role
1.3. The Case Manager role
2. Carrying out PIP assessments
2.1. The PIP assessment process
2.2. Initial reviews
2.3. Further Evidence
2.4. Terminal Illness
2.5. Paper-Based Review
2.6. Face-to-Face Consultation
2.7. Other issues related to face-to-face consultations
2.8. Completing assessment reports
2.10. Review dates
2.11. Identifying claimants with additional support needs
2.12. Requests for Supplementary Advice
2.13. Advice on substantially the same condition
2.14. Consent and Confidentiality
3. The Assessment Criteria
3.1. The assessment approach
3.2. Applying the criteria
3.3 Daily Living Activities
3.4 Mobility activities
4. Health Professional Performance
4.1. Health Professional Competencies
4.2. Training of Health Professionals
4.3 Approval / Revocation of Health Professionals
4.4. Quality Audit
4.5. Quality Audit Criteria
4.7. Assessment quality feedback from Her Majesty’s Courts and Tribunal Service
5.1 Fees for further evidence
5.2. The principles of good report writing
5.3. Sample Quality Audit Proforma
5.4. Audit Quality criteria definitions
1.1 About Personal Independence Payment 1.1.1. Personal Independence Payment (PIP) is a benefit for people with a long-term health condition or impairment, whether physical, sensory, mental, cognitive, intellectual, or any combination of these. It is paid to make a contribution to the extra costs that disabled people may face, to help them lead full, active and independent lives.
1.1.2. The benefit is not means tested and is non-taxable and noncontributory. This means that entitlement to the benefit is not dependent on a person’s financial status or on whether they have paid National Insurance contributions. PIP is not restricted to people who are out of work. It can be paid to those who are in full or parttime work as well.
1.1.3. PIP is replacing Disability Living Allowance (DLA), which has become outdated and unsustainable. The introduction of PIP will ensure the benefit is more fairly targeted at those who face the greatest barriers, by introducing a simpler, fairer, more transparent and more objective assessment, carried out by health professionals.
1.1.4. PIP was introduced in April 2013 for people aged 16 to 64 years making a new claim. The roll-out of PIP to existing DLA claimants commences on a rolling programme from mid 2015. The peak period of reassessment is planned to start in October 2015 and the intention is that by the end of 2018, all eligible DLA claimants aged 16-64 will have been invited to claim PIP. DLA claimants aged under 16 and over 65 will not be affected.
The structure of PIP 1.1.5.
PIP has two components:
1.1.6. Both components are payable at either a standard rate or an enhanced rate, depending on a claimant’s circumstances.
The PIP claimant journey 1.1.7. Entitlement to PIP is determined by a DWP Decision Maker – known as a Case Manager – who acts on behalf of the Secretary of State.
1.1.8. Claims to PIP are made by telephone, although paper forms will be used where claimants find it difficult to claim via this route. Claims will also be made through an e-channel expected in late 2015, designed to eliminate the use of paper where possible. When an individual makes a claim to PIP, DWP gathers basic information about the claimant and their health condition or impairment. A Case Manager then considers whether the claimant meets the basic conditions for entitlement – for example, age and residency requirements.
1.1.9. If the basic entitlement conditions are met, DWP issues a claimant questionnaire (How your disability affects you) to gather more information about how the individual’s health condition or impairment affects their day-to-day life. This stage is skipped if the individual is claiming under the Special Rules for terminal illness (SRTI), where the case is instead referred directly to the assessment provider (AP) and dealt with as a priority.
1.1.10. At this stage, claimants are encouraged to provide any supporting evidence they already have that they feel should be considered alongside their claim information – for example, evidence from a health or other professional involved in their care or treatment. See paragraph 2.3.11 for further examples of supporting evidence.
1.1.11. Once the claimant questionnaire has been returned to DWP, the case is referred to an AP along with any additional evidence provided. The AP then conducts the assessment, gathering any additional evidence necessary (see section 2 for more information on the assessment), before providing an assessment report to DWP.
1.1.12. If the claimant questionnaire is not returned and the claimant has been identified as having a mental or cognitive impairment, the claim will be referred direct to the AP for assessment. See section 2.10 for more information.
1.1.13. The Case Manager will review the assessment report and all other evidence in the case, before making a decision about benefit entitlement. In all cases the Case Manager will consider the claimant’s own estimation of their needs in the claimant questionnaire and any additional evidence available.
1.1.14. The Case Manager will inform the claimant about their entitlement to the benefit in writing. If the claimant is not satisfied with the decision reached, they can request a reconsideration. This will be conducted by a different Case Manager.
1.1.15. If, following the reconsideration, the claimant is still not satisfied with the decision, they can submit an appeal. A claimant cannot submit an appeal without first requesting a reconsideration.
The PIP assessment 1.1.16. The assessment for PIP looks at an individual’s ability to carry out a series of key everyday activities. The assessment considers the impact of a claimant’s health condition or impairment on their functional ability rather than focusing on a particular diagnosis.
Benefit will not be paid on the basis of having a particular health condition or impairment but on the impact of the health condition or impairment on the claimant’s everyday life.
1.1.17. The activities explored during the PIP assessment are:
1.1.18. Each activity contains a series of descriptors which define increasing levels of difficulty carrying out the activity. A numeric score is allocated to each descriptor. Claimants will be allocated a descriptor (and score) for each activity during the assessment.
1.1.19. The total scores for all of the activities related to each component are added together to determine entitlement for that component. The entitlement threshold for each component is 8 points for the standard rate and 12 points for the enhanced rate. See section 3 for more information on the assessment criteria.
1.2. The Health Professional role 1.2.1. The PIP assessor is a Health Professional (HP) with specialist training in assessing the impact of disability on an individual’s functional ability. The role differs from the therapeutic role of reaching a diagnosis and/or planning treatment. The HP’s role is to assess the functional effects of the claimant’s health condition or impairment on their everyday lives in relation to the assessment criteria. See sections 3.4 – Daily Living Activities and 3.5 – Mobility Activities.
1.2.2. The key elements of the role of the HP in PIP are to:
• Consider information in the claimant questionnaire and any supporting evidence provided along with it
• Determine whether a claim can be assessed on the basis of a paper review and provide appropriate advice
• Determine whether any additional evidence needs to be gathered from health or other professionals supporting the claimant
• Carry out face-to-face consultations as required
• Having considered all the information and evidence of the case, produce a report for DWP containing information on the claimant’s circumstances and recommendations on the assessment criteria that apply to the claimant.
1.2.3. The report to the Department should include:
• A detailed history of the claimant, including information on any health condition or impairment present, their history, functional effects, current medication and treatment
• Advice on the appropriate assessment descriptors for the claimant, based on consideration of the evidence on file and (if appropriate) the evidence that the HP has collected during the face-to-face consultation
• Justification of the advice explaining the evidence used to inform the advice on descriptor choices
• Advice on the likely prognosis of the case (see section 2.9)
• Advice regarding whether if the claimant may need additional support to comply with future claims processes.
1.2.4. The HP may also be asked to provide advice to the Case Manager on a range of other aspects of a claim (see section 2.12).
1.3. The Case Manager role 1.3.1. Case Managers are trained DWP staff who are familiar with the legislation governing PIP, but who do not have a healthcare background. The HP enables Case Managers to make fair and accurate decisions by providing impartial, objective and justified advice.
1.3.2. In the PIP process, the key role of Case Managers is to:
1.3.3. Case Managers are not responsible for liaising directly with providers. This will be done by the Quality Assurance Manager who is knowledgeable in the end-to-end PIP claimant journey and the PIP business process. Part of their responsibility will be to act on behalf
of the Case Manager to:
• Liaise with the HP for additional advice either based on current advice or using further evidence
• Liaise with the HP where there is a discrepancy in descriptor choice or evidence, potentially requesting rework such as reconsidering evidence or requesting missing evidence