«Updated on 28 July 2015 Foreword This document has been produced by the Department for Work and Pensions (DWP) to provide guidance for providers ...»
2.6.39. HPs may wish to examine areas of function relevant to the claimant’s health condition or impairment. Such examinations should be tailored to the individual claimant and will vary depending on the nature of the disabling conditions present. Where there is clear and current evidence of a claimant’s functional examination findings in a particular area, HPs do not need to conduct an examination of that area e.g. if the claimant has a certificate of visual impairment, there will be no need to carry out an eye examination. Functional
examinations may cover one or more of:
• Mental function assessment
• Vision Testing
• Cardiorespiratory system
• Musculoskeletal system.
2.6.40. Before starting an examination, the HP must explain the procedure to the claimant, and obtain explicit verbal consent to continue. The HP must explain to the claimant that he/she is going to carry out a functional examination but that it will be different from the clinical examination they might get at their GP's surgery. This is because the HP is not trying to make a diagnosis of their condition but is interested in how their ability to carry out everyday tasks is affected by it. The HP should note in the report that they have explained the procedure to the claimant and obtained their consent to proceed.
Obtaining consent may need to be repeated as the examination progresses.
2.6.41. Any examination should be carried out in a professional and sensitive manner, aiming to avoid causing the claimant any distress.
Active rather than passive movements should be assessed. The HP should always stress to the claimant that they should not carry out a movement or activity to the point where it causes them discomfort.
2.6.42. The HP will never disturb underwear; never ask the claimant to remove their underwear; and never carry out intimate examinations (breast, rectal or genital examinations).
2.6.43. Some examinations – for example, of the lower limbs – might be carried out with the claimant reclining on an examination couch. If this is not feasible – for example, if the consultation is carried out in the claimant's own home – the HP should make a note of the circumstances and carry out such assessment as he/she can while the claimant is sitting or standing.
2.6.44. Clinical findings from a musculoskeletal examination should be recorded in plain English e.g. ‘able to place hands at the back of the head’, able to reach above the head’ to help the Case Manager understand the details of the examination. However if findings are expressed as a measurement, the HP should put this into context for the Case manager by also describing the range with reference to the normal range of movement e.g. he can turn his head to the right by 40 degrees, which is about half normal movement.
2.6.45. The mental function assessment should be tailored to individual claimants and may include appearance and behaviour, speech, mood, depersonalisation/derealisation, thought, perception, cognitive function, insight and addictions.
2.6.46. If an area of function is examined, the HP must record all findings in the assessment report, even if function is found to be normal.
2.6.47. If any element of function is not examined at the consultation, the HP should record that this area was not examined and not simply leave the section of the report form blank. It would be reasonable, for example, not to examine a claimant’s musculoskeletal function where they are claiming PIP purely because of a mental health condition. Providing justification material can be helpful – such as "Claimant states she has no problems with speech, hearing, or vision".
2.6.48. If the claimant is unaccompanied at a consultation, the HP should consider whether a chaperone would be appropriate during any examination. The presence and name of the chaperone should be recorded in the report.
Concluding the face-to-face consultation 2.6.49. Prior to concluding face-to-face consultations, HPs should give claimants an overview of the findings they have taken from the consultation. Claimants should be invited to clarify any points, ask any questions they have about the assessment procedure and if there is anything else they would like to say before they leave. The HP should answer any issues or concerns they express.
2.6.50. No opinion on entitlement to benefit should be given by the HP.
Claimants who ask should be reminded that it is for the Case Manager to decide entitlement. The report and all other evidence available will be used by the Case Manager who will contact the claimant in due course.
2.6.51. Claimants who request a copy of their report should be advised that HPs are not authorised to give them a copy at the time of the consultation and that the claimant can request a copy of their report from DWP.
2.6.52. HPs should be ready to terminate consultations at any point should they become too stressful for the claimant.
2.7. Other issues related to face-to-face consultations Companions at consultations 2.7.1. Claimants should be encouraged to bring another person with them to consultations where they would find this helpful – for example, to reassure them or to help them during the consultation. The person chosen is at the discretion of the claimant and might be, but is not limited to, a parent, family member, friend, carer or advocate.
2.7.2. Consultations should predominantly be between the HP and the claimant. However, the companions may play an active role in helping claimants answer questions where the claimant or HP wishes them to do so. This may be particularly important where the claimant has a mental, cognitive or intellectual impairment. In such cases the claimant may not be able to give an accurate account of their health condition or impairment, through a lack of insight or unrealistic expectations of their own ability. In such cases it will be essential to get an accurate account from the companion. However, the involvement of companions should be at the discretion of the HP.
It is essential that the HP’s advice is based on the claimant’s actual circumstances and not the companion’s views on these. If the presence of a companion becomes disruptive to the consultation, the HP may ask them to leave. However, this should be avoided wherever possible.
2.7.3. HPs should use their judgement about the presence of a third party during any functional examination. Both the claimant and the HP should agree to companions being in the room for an examination.
Companions should take no part in examinations unless the HP asks them, for example, to help the claimant with their garments.
2.7.4. The presence of any companion at a consultation should be recorded in the assessment report.
Audio recording of PIP consultations 2.7.5. The recording of consultations by providers is not currently part of the specification for PIP assessments.
2.7.6. Claimants may use their own equipment to record their face-to-face consultation, should they wish to, subject to any reasonable conditions the Department chooses to impose on such recordings.
These reasonable conditions are:
2.7.7. Providers must publicise these conditions and ideally include them in communications sent to claimants before they attend a face-to-face consultation.
Suitable mediums for recording consultations 2.7.8. To record their consultations, claimants must use appropriate equipment that can provide two copies of the recording in such a way that the provider can be assured that the recording has not been tampered with and is a reliable and accurate record of the consultation. A copy must be given to the provider at the end of the consultation. For this reason certain devices that have the capability of editing, real-time streaming or video recording the session are not approved; such as computing devices (not limited to PCs, tablets, smart phones, MP3 players) or devices that are not capable of providing a verifiable media copy that can be easily verified during the assessment. Media types that are acceptable are standard CD and audio tapes only.
2.7.9. Video recording of assessments is not permitted in order to ensure the safety and privacy of staff and other customers.
Restrictions placed on claimants about the use of recordings 2.7.10. If it is only the claimant’s personal data that is being recorded then there are no restrictions on the use the claimant can make of the recording. However the DWP reserves the right to take appropriate action where the recording is used for unlawful purposes, for example, if it is altered and published for malicious reasons.
Covert recording of consultations
2.7.11. If the HP notices a claimant is covertly recording their consultation, the restrictions relating to the recording of consultations should be explained to the claimant. If the HP is content to be recorded, the claimant is content to sign the agreement form and the claimant’s equipment meets the specified requirements, the consultation can continue. If this is not the case the claimant should be asked to stop recording. If the claimant refuses, the consultation should be terminated and the case should be returned to DWP using the return assessment function with reason failure to participate. The Case Manager will consider whether the claimant has good reason for failing to participate in the consultation. If the only reason for failure to participate is the claimant refused to stop recording their consultation, it is likely the Case Manager will make a negative determination.
Note taking during the consultation
2.7.12. Claimants and companions attending a consultation with the claimant are entitled to take notes for their own purposes. The claimant or companion may keep the notes and does not have to provide a copy to the HP, although the HP may record that notes were taken. The notes are for the claimant or companion’s own purposes and are not an official record of the process. The same approach will apply where the claimant needs notes of their consultation to be taken as a reasonable adjustment, for example using an electronic note taker.
2.7.13. HPs may need to adapt their approach when assessing young people. Care should be taken, as always, to avoid creating stress or anxiety for the claimant. HPs should be mindful that young people are encouraged to be positive about their health condition or impairment and to focus on what they can do, rather than what they cannot. In addition, young people may have limited experience undertaking many activities unsupervised in an independent environment. HPs should ensure that this does not create an unfair perception of the young person’s abilities and the impact of their health condition or impairment.
2.7.14. Young people may attend a face-to-face consultation with a parent.
In these cases, it may be particularly important to distinguish between what a young person can or could do for them self and what the parent does for them as part of their caring role. There may be some activities that have been done for them all of their lives that a young person without a health condition or impairment of the same age may do themselves. There may also be activities that could be carried out by the young person but the parent continues to assume responsibility. It should be emphasised whether the help given is suitable to the role of parent or a carer.
DS1500 presented 2.7.15. If the claimant provides further evidence at a consultation in the form of a DS1500, the HP should consider the evidence presented and provide advice as to whether the claimant is terminally ill. Where the HP considers the claimant terminally ill, they should consider whether it would be appropriate to complete a report for Special Rules for Terminal Illness, rather than a report for a face-to-face consultation. If the claimant is not considered terminally ill, the HP should continue with the consultation and complete a full assessment report, advising on all aspects of the case.