«Updated on 28 July 2015 Foreword This document has been produced by the Department for Work and Pensions (DWP) to provide guidance for providers ...»
2.3.13. Where necessary, HPs may also seek evidence from professionals by telephone. Such telephone calls should be made by approved HPs not by clerical staff.
2.3.14. A written record should be taken of any telephone discussions seeking further information and the content included in the assessment report provided to the Department or via the PIP Assessment Tool. The HP should inform the professional being contacted that this record is being produced and that this may be made available to the claimant and/or their representative.
2.3.15. The HP should also clarify whether any information provided by the professional is Harmful or Confidential (See paragraphs 2.8.23 and 2.14.36).
2.3.16. Claimants will be asked during the initial claim stage to give consent to contact third parties. See section 2.14 for further information on consent.
Seeking further information from the claimant 2.3.17. Where necessary, providers may seek further information from claimants by telephone. Such telephone calls should be made by approved HPs, not by clerical staff.
2.3.18. HPs should identify who they are and the purpose of the call. A written record should be taken of any telephone discussions seeking further information, using the claimant’s own words as precisely as possible. This information should be included in the assessment report provided to the Department or via the PIP Assessment Tool.
The HP should always ask if there is anything else that the claimant wishes to say before concluding the call. The call should conclude by reading back what has been documented and advising the claimant that this information will be added as evidence to the file.
Paying for further evidence 2.3.19.
The Department currently pays for two specific forms of evidence:
factual reports from GPs; and GP and Consultant completed DS1500s.
2.3.20. Providers are responsible for making payments for GP Factual Reports (GPFRs) where they have sought them, with DWP reimbursing them the fees paid. DS1500s will be sought and paid for by DWP.
2.3.21. More information on the fees payable for further evidence is included in the Appendices at 5.1, including the circumstances when fees may not be paid – for example, due to the inadequacy of the reports.
Late return of Further Evidence 2.3.22. Where further evidence is received after the assessment has been completed and returned to DWP, the evidence will be sent to the Case Manager for consideration. If evidence is returned to the provider in error, it should be forwarded to DWP for scanning.
2.3.23. If the evidence is received after the claimant has been scheduled for a face-to-face consultation, the case should be reviewed and the evidence scrutinised to decide whether advice can be given on the basis of a paper-based review or a face-to-face consultation. If advice can be given on the basis of a paper-based review, the consultation should be cancelled.
2.4. Terminal Illness 2.4.1. Individuals who identify themselves as terminally ill can seek to claim PIP under the ‘Special Rules for Terminal Illness’ (SRTI). Such cases will be flagged to the provider at the point of referral. HPs will be required to advise on whether the claimant satisfies the SRTI provisions (see below), and provide advice with appropriate justification to DWP.
2.4.2. The criteria for SRTI claims set out in legislation are that the claimant: “is suffering from a progressive disease and death in consequence of that disease can reasonably be expected within six months.” 2.4.3. If the claimant meets the SRTI provisions, they automatically receive the enhanced rate of the Daily Living component. The claimant does not automatically receive the Mobility component and entitlement for this component will need to be assessed. Information will be available to the provider on the initial claim form.
2.4.4. Individuals claiming under the SRTI provisions do not need to satisfy the three-month required period nor the nine-month prospective period to qualify for either the Daily Living or Mobility Component.
Referral procedure 2.4.5. If the claimant states that they are terminally ill when applying for PIP, they are advised to obtain form DS1500 from their GP, consultant or specialist nurse. DWP will wait 7 working days for the DS1500 to be returned before making a referral to the Provider.
2.4.6. The referral sent to the provider via the PIP Computer System will include the initial claim details together with the DS1500 if it has been submitted by the claimant. Some claimants will have sought a DS1500 before contacting DWP.
2.4.7. SRTI referrals will not contain the claimant questionnaire “How your disability affects you” due to the need to process claims quickly.
However, some relevant information about the claimant’s circumstances will be gathered during the initial claim stage and supplied to providers. This will include details of the claimant’s key supporting health professional and basic information about their mobility.
2.4.8. All SRTI claims will be clearly flagged. SRTI referrals must be completed and returned to DWP within two working days.
2.4.9. Face-to-face consultations are not required where a claim has been referred under the SRTI provisions.
HP advice in SRTI claims 2.4.10.
In SRTI claims, HPs are required to advise on:
• Whether they consider, on balance, the claimant is or is not terminally ill under the prescribed definition
• If so, which of the descriptors in the mobility activities set out in the assessment criteria are likely to be relevant to the claimant (see sections 2.8 and 3).
2.4.11. The HP must provide a summary justification to support the advice and provide the reasons for the advice. Failure to provide this may result in the advice being returned for clarification or rework. See section 2.8 for further advice for the completion of the summary justification.
2.4.12. If the claimant is already in receipt of PIP and the case has been referred for SRTI as a change of circumstances, the HP must include an indication of when the claimant first became terminally ill.
Failure to provide this information may result in the advice being returned for rework.
2.4.13. Advice must be evidence based on the balance of probability. HPs should remember that prognosis can be uncertain and if in their opinion life expectancy is, on balance, likely to be less than six months, they should advise accordingly.
2.4.14. The HP is required to advise DWP on the descriptors in the mobility activities that are most appropriate to the claimant. Although the claimant will have not completed the full claimant questionnaire, there will be information in the initial claim and it should be possible to give this advice in most cases in which the person is terminally ill.
The terminal illness itself, or the treatment being given, could impede mobility due to malaise, weakness, fatigue or another factor. The evidence must support the advice that the mobility needs indicated by the descriptors recommended are, on balance, either currently present or are likely to be present in the foreseeable future as a result of treatment or of a deterioration of their health condition. For example, if further evidence is required from the claimant’s own health professional, the HP should consider asking for that person’s knowledge of any cognitive and/or physical restrictions that impact on the claimant’s mobility.
2.4.15. The HP is required to advise whether the claimant has additional support needs.
2.4.16. The relevant information required when offering advice on SRTI claims is set out in the PIP Assessment Tool or clerical form PA2.
See section 2.8 regarding completing assessment reports.
DS1500 2.4.17. This form is completed by a health professional involved in the care of a claimant who is suffering from an illness which is likely to result in their death. The professional might be the claimant’s GP, a hospital consultant or a specialist nurse.
2.4.18. The DS1500 does not offer a prognosis but gives factual information about the claimant’s condition, any treatment received and any further treatment planned.
Further evidence in SRTI claims 2.4.19. If there is insufficient information in the claim file to confirm terminal illness and consent is clearly indicated on the file (see section 2.14 on Consent and Confidentiality), the HP should telephone the health professional such as a GP or hospital specialist identified by the claimant detailed in their initial claim. When making telephone contact with a GP or other specialist, the HP should also endeavour to determine whether the claimant is aware of their illness or prognosis and consider whether the information they have obtained may be potentially harmful (see paragraphs 2.8.23 - 2.8.27 on Harmful Information).
2.4.20. If no DS1500 has been provided and there is no additional medical evidence, a telephone call to the relevant clinician will always be required. If a DS1500 or additional medical evidence has been provided it may still be necessary to phone the relevant clinician if further information is required in order to give advice.
2.4.21. If the HP is unable to contact a clinician then they should try to contact another relevant clinician involved in the patient’s care. On rare occasions, it may not be possible to contact the GP or other relevant clinician to obtain advice. In such cases the HP may need to seek advice from another person, for example (this list is not
2.4.22. In all cases, the HP must ensure that they have consent to contact the person they phone. It is particularly important to remember that GPs and specialists are responsible for any information divulged by the administrative staff so HPs must ensure that the person they speak to has the authority to provide the information. The HP must record the telephone conversation in their notes, indicating who has given that person the authority to speak on their behalf.
2.4.23. Any telephone conversations with clinicians should be recorded and include all relevant clinical information required by the HP to support their advice. The information gathered forms part of the suite of evidence and should be included in the assessment report provided to the Department and discussed in the summary justification.
Contacting claimants in SRTI claims
2.4.24. Every effort should be made to provide advice in SRTI cases. If the HP cannot obtain further evidence from the GP or other health professional, the HP should by exception consider contacting the claimant or the person claiming on their behalf. Where the claim has been made by a third party, the HP should contact the third party, rather than the claimant as the claimant may not be aware of their prognosis. The claimant or their representative may be able to provide updated information on where they are having their treatment and who is treating them. This may be enough to enable the HP to gather further medical evidence or advise whether the claimant satisfies the criteria for SRTI. The claimant or their representative may also be able to provide updated information on treatment received or planned. HPs are expected to use their professional knowledge, skills and judgement to determine what questions are appropriate to ask about treatment.
2.4.25. Should the HP fail to obtain an unequivocal answer to whether the claimant is terminally ill or their prognosis, their advice to the case manager must be founded on the balance of medical probability, which should if possible be evidence based. In exceptional circumstances a written request for further evidence can be issued.
Referrals of claimants already in receipt of benefits for terminal illness 2.4.26. In SRTI referrals DWP will check for an Employment and Support Allowance (ESA) claim under special rules. If the information is available, the Case Manager will transcribe the decision and any justification, word for word, into the medical evidence screen of the PIP Computer System.
2.4.27. The HP will be asked to consider the ESA evidence when providing advice to the DWP.
2.4.28. Where it is felt that this is still insufficient, the HP would be asked to contact the healthcare professional the claimant has identified on the claim form, to obtain information in order to advise DWP.