«Updated on 28 July 2015 Foreword This document has been produced by the Department for Work and Pensions (DWP) to provide guidance for providers ...»
2.7.16. Very rarely during the consultation, the HP may identify that the claimant appears to have a significant undiagnosed medical condition - for example an apparently unrecognised depressive illness. If the HP identifies such a condition, they have a responsibility as a health professional to take appropriate action, by notifying a suitable person involved in the claimant's care. This will usually be their General Practitioner.
2.7.17. The HP also has a duty to protect the confidentiality of the information obtained during the consultation. Therefore consent to inform the GP of the unexpected finding should be obtained from the claimant. The HP should explain what information will be shared and why. If the claimant agrees, the HP should complete and send the relevant referral form to the claimant’s GP, and give the claimant a copy.
2.7.18. The HP should ensure the referral form is sent to the claimant’s GP within 24 hours. If the unexpected finding is of a life-threatening nature, he/she should seek the claimant's consent to telephone the GP and advise the claimant to see their GP as soon as they can.
Such a telephone call should be followed up with a written notification to the GP. It is strongly recommended that the HP seek the claimant’s consent to telephone their GP and inform them of the finding as soon as possible in all cases.
2.7.19. If the claimant declines to give consent for the HP to contact their GP, the HP should make a judgement as to whether the situation is sufficiently serious that it warrants breaking confidentiality by telling the GP even without the claimant's consent. Both the General Medical Council and the Nursing and Midwifery Council provide guidance on medical ethics and when it is acceptable to break medical confidentiality. If the HP acts within the guidelines, and is able to justify his/her actions, they should have no need to fear being sanctioned. Procedures to follow and sources of support and guidance should be covered in HP training.
2.7.20. Consultations may potentially be carried out at a variety of locations but some will need to be carried out at the claimant’s home.
Providers may also decide to carry out a home consultation for business reasons or simply to give claimants choice. As a minimum they should consider whether a home consultation is necessary where a claimant indicates that they are unfit to travel to a consultation in a location other than their home or where travel would require high levels of support.
2.7.21. When considering a request for a home consultation, providers
2.7.22. The request for a home consultation may come from a GP or other healthcare professional involved in the claimant’s care. When
assessing such requests, providers should consider issues such as:
2.7.23. In each case the evidence should be reviewed. At times it may be necessary to seek further clarification from the author of the report to clarify the medical facts.
2.7.24. Information that may help support a home consultation request may
2.7.25. Providers may also consider whether other options may be acceptable - for example if travelling on public transport is the issue, could a taxi be considered?
Home consultations and further evidence 2.7.26. If, during a home consultation, the claimant provides further evidence that they want to be considered, HPs should inform the claimant that this will need to be taken away and used to inform advice to the Department but will be returned back to them once used.
2.7.27. If claimants refuse to allow the evidence to be removed from their presence, the HP should take sufficient details of the evidence that will allow them to use it when providing advice to the Department.
This should be recorded in the assessment report or via the PIP Assessment Tool.
Uncooperative claimants 2.7.28. If the claimant is uncooperative during a face-to-face consultation, the HP may terminate the consultation where they have gathered sufficient evidence to complete the assessment report and provide advice for the Case Manager. If the claimant is persistently uncooperative – for example, if they are under the influence of alcohol or drugs – the consultation should be terminated and the case returned to the Department, along with an explanation of why the consultation had to be terminated.
2.7.29. The provider should not send incomplete reports to the Department.
2.8. Completing assessment reports 2.8.1. Once HPs have completed assessment activity, they will need to complete a report containing advice for the Department.
2.8.2. The assessment report with the HP’s advice is sent electronically through the PIP Assessment Tool or clerically, where appropriate
using the following clerical forms:
2.8.3. Copies of all the forms are provided separately.
2.8.4. The nature of the information required in reports varies depending on the nature of the activity. Reports produced further to face-to-face consultations require the most content, as HPs will need to record the discussion, observed findings and conclusions from the consultation.
2.8.5. Section 5.2 provides more information on the principles of giving advice and effective report writing.
Choosing descriptors 2.8.6. The most important areas of advice in relation to benefit entitlement are the assessment criteria themselves. For each activity area, the HP should use evidence to choose the descriptor that is the one which best reflects the claimant's ability to carry out an activity, taking into account whether they need to use aids or appliances and whether they need help from another person or an assistance dog.
2.8.7. Before selecting a descriptor, the HP must consider whether the claimant can reliably complete the activity in the manner described in
the descriptor, taking into account where they can do so:
2.8.8. The HP must also take into account that most health conditions or impairments can fluctuate over time. The HP should consider ability over a 12 month period as this helps to iron out fluctuations and presents a more coherent picture. For some conditions different time periods will need to be considered, such as the potential impact of different times of the day. If a claimant is unable to complete an activity or needs support to do so at a point in the day when you would reasonably expect them to complete it, the need should be treated as existing for the whole of the day, even if it does not exist at other points in the day.
2.8.9. For a scoring descriptor to apply, the claimant’s health condition or impairment must affect their ability to complete the activity on more than 50 per cent of days in the 12 month period. Where one single descriptor in an activity is likely to not be satisfied on more than 50 per cent of days, but a number of different scoring descriptors in that activity together are likely to be satisfied on more than 50 per cent of days, the descriptor likely to be satisfied for the highest proportion of the time should be selected.
2.8.10. See section 3 for more comprehensive guidance on the assessment criteria, including notes on interpretation of the descriptors, the interpretation of issues of reliability and the assessment of fluctuating conditions.
Evaluation and analysis of evidence 2.8.11. It is essential that the Case Manager is made aware of the evidence the HP has used to complete the assessment report. The HP must acknowledge that they have considered all the available evidence when formulating their advice.
2.8.12. All evidence must be interpreted and clearly evaluated using medical reasoning and considering the circumstances of the case and the expected impact on the claimant’s daily living and/or mobility. When weighing up the evidence, it is important to highlight any contradictions and any evidence that does not sufficiently reflect the claimant’s health condition or impairment or the effect on their daily life.
2.8.13. The HP’s advice and justification must provide a clear explanation as to why more reliance has been placed on some evidence and not others. The age of the evidence should also be considered in deciding whether it is relevant to the claim. However, the HP should bear in mind that for claimants with stable long-term conditions, the
Summary justification 2.8.14. Report forms should contain where appropriate an overall "summary justification" or an individual justification for each descriptor choice providing a succinct summary for the Case Manager of the evidence obtained and used in the HP’s consideration and the reasons for descriptor choice.
2.8.15. The advice must be able to stand up to challenge and the HP should draw out key evidence in support of their choice of descriptors in the report, drawing fact-based findings and/or well supported opinion from all of the evidence.
2.8.16. If the HP’s opinion on descriptor choice differs from information provided by the claimant, the HP should refer to evidence to fully justify their advice. Where relevant, HPs should justify descriptor choices by reference to objective evidence in the file.
2.8.17. When the HP evaluates the opinion of a third party who provides evidence – for example, a carer or health professional – the HP should evaluate the strength of the opinion being expressed. The HP’s evaluation should include the level of expertise of the individual offering the opinion; their direct knowledge of the claimant’s health condition or impairment; and whether it is medically reasonable. The HP should also consider whether the third party is acting impartially, or as the claimant's advocate. Consideration should also be given to whether, as a result of the claimant’s health condition or impairment, the claimant’s companion or advocate may be better placed to describe their needs. For example, some claimants with mental, intellectual, cognitive or developmental impairments may lack insight into their condition.
2.8.18. If there are discrepancies in the evidence about the claimant’s ability to carry out an activity, the HP should draw attention to the discrepancies when justifying his/her choice of descriptors, for example “He claims his right hand is too weak for him to be able to grip anything. However, on examination I found no evidence of muscle wasting or reduced strength in the right upper limb; and I observed him gripping his walking stick when walking across the room”.
2.8.19. In some health conditions, the level of disability varies over time.
These conditions are characterised by periods of remission and relapse or ‘good’ days and ‘bad’, during which the level of functional impairment can change e.g. multiple sclerosis or chronic fatigue syndrome. When advising on descriptors and justifying advice, the HP should consider the functional effects of the claimant’s health on the majority of days.
2.8.20. Advice about variability should be clarified by looking at the effects of the health condition or impairment on daily living and/or mobility on good, bad and average days and not on how the claimant was on the day of assessment. The HP must quantify the proportion of “good” days to “bad”, for example if the claimant has epilepsy it is a question of the type, frequency and after effects of the seizures. It is essential to describe the claimant’s function as described both on “bad” days and on “good” days for the Case Manager to understand the claimant’s circumstances and the consequences of their health condition or impairment. The advice should allow the Case Manager to understand whether the described variability is in keeping with the nature of the health condition or impairment applies for the ‘majority of days’.
Requirements of a justified report 2.8.21.
A properly justified report should contain the following:
Who will see the report?
2.8.22. The consultation report is primarily for Case Managers but the claimant has a right to see it and can request a copy from the DWP.