«Updated on 28 July 2015 Foreword This document has been produced by the Department for Work and Pensions (DWP) to provide guidance for providers ...»
In the case of an appeal, the claimant, his/her representative and members of the tribunal will see a copy of the report.
Harmful Information 2.8.23. In all cases and on all forms the HP completes when giving advice, the HP should check their advice and the evidence upon which it is based for any information which could be seriously harmful to the claimant’s health if it were disclosed – for example, a poor prognosis that is unknown to the claimant or a diagnosis of a psychotic illness in a claimant who lacks insight into their condition. This is known as “Harmful Information”. In law, this is the only information that can be withheld from a claimant.
2.8.24. No Harmful Information should be included in the assessment reports to the Department and HPs will be expected to verify that this is the case.
2.8.25. Should Harmful Information be present – either contained in supporting evidence or identified at a face-to-face consultation - this should be recorded separately on the Harmful Information note (PA7) or within the Harmful Information screens in the PIP Assessment Tool and clearly marked as “harmful”. The HP should indicate where any Harmful Information is contained in supporting evidence – for example: “Part X of the GP Factual Report dated XXXX contains harmful information.” 2.8.26. Any further evidence that has been requested and received subsequent to the initial claim should be reviewed to identify any information which could be harmful. The HP should indicate on the PA7 or the relevant screen within the PIP Assessment Tool where any Harmful Information is contained in supporting evidence 2.8.27. In relation to Terminal Illness claims:
2.9. Prognosis 2.9.1. As part of the assessment for entitlement to PIP, HPs are asked to give advice to Case Managers on the probable timescales over which a health condition or impairment is likely to affect a claimant’s function and if/when it would be sensible to review the claimant’s circumstances. To formulate this opinion the HP should use their knowledge and experience and the consensus of medical opinion, taking into account the specific details relating to the case under consideration.
2.9.2. Entitlement to PIP is dependent on the functional effects of a health condition or impairment having been determined as likely to have been present at the required level for at least three months and being expected to last for at least a further nine months. These periods are known respectively as the Qualifying Period and Prospective Test. Case Managers will decide whether these conditions are met but need advice from the HP on the duration of any health condition(s) or impairment(s) to help inform this.
2.9.3. The Case Manager also needs advice to help inform decisions on when claims should be reviewed, taking into account issues such as the likely progression of the condition and whether it is likely to improve, stay the same or worsen. For example, if the claimant has corrective surgery planned for the near future which would be expected to significantly impact their level of ability, a review at a point following the surgery might be appropriate. Other conditions are likely to deteriorate over time, so a review may be appropriate to see whether the claimant is now entitled to a higher rate of PIP.
Other conditions might be unlikely to see significant changes in impact, which might suggest a longer period between reviews.
Advising on prognosis
2.9.4. Advising on prognosis is not an exact science. However, the HP is expected to offer advice in keeping with the balance of probability, using their knowledge of health conditions or impairments; their effects and likely course; the results of treatment and adaptation;
and the evidence provided in the case.
2.9.5. Advice must be current, logical, take into account recent advances in medical care and in keeping with the consensus of medical opinion.
2.9.6. The advice should consider if improvement in the condition or its functional effects can be expected as a result of factors such as, but
not limited to:
2.9.7. The advice should consider if deterioration in the condition or its functional effects can be expected as a result of factors such as, but
not limited to:
2.9.8. The advice should take into consideration that even though in some conditions there may be no expectation of improvement of the underlying condition, it may be possible for the person to adapt given sufficient time or with appropriate treatment and/or support, thereby reducing the effects on functional ability. HPs should consider whether there is evidence that such an adaptation or adjustment has taken place.
2.9.9. If there is more than one relevant functional condition, the prognosis should take account of the effects of all conditions and the added impairment resulting from any interactions that may occur, and thus based on the overall functional prognosis.
2.9.10. Each case should be considered on its own merits. The same health condition may have different prognoses.
2.9.11. Age is not a medical cause of incapacity but it can be an indicator of disease progression. The functional effects of a health condition or impairment may be worse in an older person. For example, it might be reasonably expected that a 25-year-old man who is otherwise healthy but has lost his lower leg in an accident might adapt well to the loss. However, a sixty year old with multiple other pathologies who loses the lower leg because of complications due to diabetes is more likely to struggle.
2.9.12. Prognosis advice must be fully explained and comprehensively justified. Where the HP’s opinion differs from other opinions on file – for example in further medical evidence or a previous HP’s advice – then a full explanation of the reasons for the difference of opinion should be given.
Completing the prognosis advice on the assessment report 2.9.13. After the Case Manager has decided on their chosen descriptors and determined entitlement, they must select the most appropriate award type and duration. The advice given by the HP on prognosis will help the Case Manager decide on the type of award.
2.10. Review dates 2.10.1. The HP will be asked to provide advice on when it would be appropriate to review the claimant’s functional ability in line with their claim to PIP, i.e. where their functional ability may have increased or decreased which may trigger a review of the level of their award.
The HP should use the text free box to clearly describe to the CM why they have selected the relevant review point and the potential change to the claimant’s level of functional ability that may lead to a review being necessary. The HP should use the following guide
when considering review points:
No Review Required 2.10.2. It would be appropriate for the HP to select the “no review required”
option in the following circumstances:
impairment”; or “the claimant’s level of functional ability is stable and is unlikely to change in the long term”; or “the claimant is due to undergo surgery within the next 12 months, after which an 8 week recovery period is anticipated. It is likely that the claimant will not experience their current functional limitations post recovery period”.
Specification of a Review Period
2.10.4. Where the HP considers that the claimant’s level of functional ability will change (either increase or decrease), they should advise on an appropriate review point for an assessment of the level of entitlement to PIP, unless this change is within a 2 year period, in which case the HP should advise that no review is required as per the above guidance.
2.10.5. The following scenarios are examples of review periods which may
be appropriate, including no review necessary:
2.10.6. The HP is asked to confirm whether the functional restriction is likely to be present at the recommended point of review.
2.10.7. Selecting the ‘Yes’ box will indicate that the claimant’s functional restriction is likely to still be present at the recommended point of review, regardless of whether it is likely to improve, remain the same or deteriorate. It indicates to the Case Manager that the case will need to be reviewed to determine the correct level of any on-going entitlement. In these cases, the Case Manager is likely to arrange for a review before the end of the claim.
2.10.8. It is expected that the ‘Yes’ box will be ticked in most cases.
2.10.9. The HP should select the ‘No’ box if they consider it likely that the claimant’s health condition is likely to improve – or that they will adapt – to the point that there will be no or a very low level of functional restriction – for example, in the case of a broken limb where a full recovery is likely in a relatively short period of time. In these cases, the Case Manager is likely to make a fixed term award of benefit.
2.10.10. The ‘Not applicable’ box should be selected where the HP considers that there is no health condition or impairment affecting function present at the point of the consultation.
2.11. Identifying claimants with additional support needs 2.11.1. It is recognised in PIP that claimants who have a mental health or behavioural condition, learning difficulty, developmental disorder or memory problems may not comply fully with the claims process due to a lack of mental capacity or insight – for example, not understanding or caring about the consequences of not returning a claim form. In PIP, these claimants are stated as having “additional support needs”. Elements of the PIP claims process have been adapted to provide further support for this group.
2.11.2. In relation to the assessment, claimants identified as having additional support needs and who do not return the claimant questionnaire will not automatically be disallowed the benefit but will be referred to APs.
2.11.3. Many claimants with mental, intellectual or cognitive impairments will have no problems returning the questionnaire. Others will have support from a family member, carer, Community Psychiatric Nurse or other person who will usually ensure that the questionnaire is returned. However, this will not always be the case and this process ensures that such claimants are not unfairly penalised because of the impact of their impairment.
2.11.4. During the gathering of initial claim information, questions will be asked by DWP in order to identify claimants who potentially have additional support needs. This will be flagged on their case file on the PIP Computer System. Providers need to consider the most appropriate approach to completing the assessment, be that paper based review or face-to-face consultation.
2.11.5. During all face-to-face consultations HPs should consider whether claimants have a mental, intellectual or cognitive impairment that would create additional support needs in relation to future activity.
They should do so even where the claimant has not been previously flagged as having additional support needs. This is because the HP should be able to make a more sensitive and specific assessment of the presence or absence of additional support needs as a result of a mental, intellectual or cognitive impairment, considering the claimant’s mental capacity and insight. The HP should use their knowledge, training and experience, along with any evidence received or findings reached during a consultation – such as whether the claimant needed support from another person at the consultation – to inform their advice.
2.11.6. It is expected that the HP should identify if a claimant has additional support needs even if the claimant themselves has not identified such a need.
2.11.7. Examples of health conditions that may affect mental capacity and potentially lead to additional support needs include (but are not
2.11.8. The HP’s opinion on additional support needs should be indicated in the advice given to DWP.