Criticism of the Work Capability Assessment
Criticism of the Work Capability Assessment (WCA), which is used by the Department for Work and Pensions in the United Kingdom to assess and reassess claimants of Employment and Support Allowance, has ranged over concerns about its design, its reliability, its fiscal effectiveness, and its links with the deaths of people with disabilities.
Design
The United Nations Committee on the Rights of Persons with Disabilities published a report on the situation facing disabled people in the United Kingdom. Of the WCA, it said:
A review undertaken by occupational heath expert Professor Malcolm Harrington and a scrutiny group that included the National Clinical Adviser to the Care Quality Commission and the Chief Executive of the mental health charity MIND gave a negative picture of the WCA in 2010, with the The Guardian summarising Professor Harrington's opinion as being that the test was "impersonal", it "lacked empathy" and it was too reliant on "computer systems and drop-down menus". In the executive summary of his report, he wrote that "the WCA is not working as well as it should. There are clear and consistent criticisms of the whole system and much negativity surrounding the process."
When Atos gave its reasons for seeking to exit the contract to carry out the assessment, the firm announced that it had come to the conclusion that "in its current form, the WCA is not working for claimants, for DWP or for Atos Healthcare". Conversely, Dr Paul Litchfield, who advised the DWP on the performance of the WCA in 2013 and 2014, described the test he had helped to design as "by no means perfect" but nevertheless adequate. However, in 2014 he cautioned that: "We have taken the WCA about as far as it can sensibly go in terms of modification and adjustment". Professor Dame Carol Black advised the government on back-to-work policy between 2006 and 2016. She said of the WCA: "I don't think anyone thinks it has been a success", describing it as "badly placed" and too far from when the first sick note or fit-note is penned.
Iain Duncan Smith complained that the system gave doctors a "binary choice", not an opportunity to deliver a more nuanced opinion on claimants' fitness for work. In April 2016, the new Welfare Secretary, Stephen Crabb, said that the WCA had "never worked as intended. The WCA was a mess, it didn't recognise mental health issues and other types of disability". Later the same year, the Shadow Secretary of State for Work and Pensions, Debbie Abrahams, said the test her party had described as "tough but fair" in 2010 had been "discredited". When appearing on Question Time, the president of the Liberal Democrats, Baroness Sal Brinton, described the WCA as "not fit for purpose", adding "this process absolutely fails" and "we need to get rid of it". On the same BBC programme, Kier Starmer QC, a former Director of Public Prosecutions, said: "It is time for a real review of how these assessments are actually working". In September 2016, Damian Green was asked by the BBC's Andrew Marr about the deaths of specific benefit claimants; in reply, the Secretary of State for Work and Pensions acknowledged that "obviously there are individual cases where it looks as though the system is not working".
Reliability
Turnover of decisions
Parliament's Office of Science and Technology has analysed the WCA's performance; it found that "the number of fit-for-work decisions being overturned on appeal has led to questions about the reliability of the assessment process". Between 2011 and 2013, around 40% of claimants found 'fit for work' appealed to a tribunal and around 40% of those appeals were successful.
A 2012 study of 28,000 tribunal hearings analysed the reasons for overturning the DWP's decisions:
* In almost two-thirds of successful appeals, the tribunals found the appellants' descriptions of their difficulties, given in person on the day of the tribunal, sufficiently convincing for them to be awarded the benefit — known as presenting "cogent oral evidence" in legal jargon. By implication, in these cases, the tribunal found the oral evidence more persuasive than had the assessor who had conducted the original face-to-face assessment
* In nearly a quarter of successful appeals, the tribunals agreed with the DWP on the facts of the case but decided that the DWP had come to the wrong conclusion based on those facts
* In 13% of cases, documentary evidence was provided that had not been available at the initial assessment
* In under 1% of cases, the assessment report was found to contain important technical errors.
Outcome targets
Professor Malcolm Harrington, the first external reviewer of the operation of the WCA, was asked by a parliamentary committee whether he had ever found any evidence that Atos assessors had been put under pressure to reach targets. He replied:
In 2012, a GP posed as a trainee Atos assessor and recorded undercover video footage that was later broadcast by Channel 4's investigative current affairs programme Dispatches. In the film, trainers warned the NHS doctor that if on average he were to recommend more than one disabled person per day for the Support Group, he would be subject to an increased level of management scrutiny through a mechanism known as "targeted audit". The undercover doctor was told:
An assessor on "targeted audit" would also no longer be allowed to recommend a claimant for the Support Group without asking an authorised colleague for permission to do so. When the doctor asked an experienced assessor where these rules had come from, she replied: "DWP".
Both the DWP and Atos categorically denied ever having had any target for getting claimants off sickness benefits. However, both eventually admitted that Support Group "norms" were being used nationwide, though they both denied that the purpose of "targeted audit" was to limit the number of claimants placed in the Support Group. Atos said that the audit process triggered by the breach of a "norm" was intended to ensure consistency across the firm's UK team: if the assessor's reports met the DWP's expectations, the healthcare professional would not be asked to change their recommendations.
However, in 2012, the Work Programme firms responsible for training people in the Work-Related Activity Group said they had "ongoing concerns about the accuracy of the WCA" and rated earlier improvements to the WCA as only "4 or 5 out of 10". In 2013, the same organisation complained that claimants who were "clearly unfit for any type of work-related activity" were nonetheless being put in the Work-Related Activity Group rather than the Support Group, and that "claimants with terminal cancer, whose life expectancies were shorter than the work-ready prognosis" had been referred to them for pre-employment training.
On the same day, an Atos spokesman made it clear that the training curriculum was set by the DWP and duly followed by Atos, stating: "We do not deviate from government guidelines in our training". The Employment Minister was asked by the BBC about the allegations of bias but he replied with a general explanation of the principles underpinning the Incapacity Benefit reassessment programme. Tom Greatrex MP wrote to the Prime Minister to bring to his attention the whistleblower's allegations that the core assessment was "skewed against the claimant". Downing Street made no reply but simply passed the letter back to the DWP, which issued a non-specific statement.
In July, the former assessor gave an interview to The Guardian. In it, he described how he had first heard trainers advocating the "bogus" interpretations of the test's descriptors in 2011 during a one-day conversion course covering the new version of the WCA and its new criteria. In response to the article's description of auditors instructing assessors — at the point when a report of a face-to-face assessment had been written, but had not yet been sent to the DWP — to alter their reports and reduce the number of points awarded, Atos said:
In August, the whistleblower expanded on his allegations in a first-hand account published by the British Medical Journal. He suggested that the DWP's alleged actions might have been at least partly driven by pressure to "reduce government debt". The DWP's senior doctors made no reply but the clinical director of Atos did respond. In relation to the claim that some Atos assessors had been led to interpret the test's criteria too harshly, she did not deny that the "bogus rules of thumb" had been used in training talks but she said that assessors were expected to follow the written guidance contained in the 255-page instruction manual issued to all assessors:
The foreword to the WCA Handbook states:
On 22 July 2013, the DWP announced that it had recently "directed" Atos to "put in place a quality improvement plan following a DWP audit which identified an unacceptable reduction in the quality of written reports produced following assessments." The DWP said it had carried out an unscheduled and "urgent" audit in "April/May 2013" that looked at reports written over the six months to March, in which time Atos had furnished the DWP with more than 300,000 reports. The DWP said it had found 164 reports that its in-house medical staff had said had scored only a 'C' for quality. However, during the period in question, the 164 reports had been deemed adequate by the department's on-the-ground decision-makers, who had used them to decide on claimants' entitlement to ESA — unacceptable reports are returned to the outsourcer for what the DWP calls "a rework". The department's press release tried to explain the paradox:
Michael O'Sullivan
Michael O'Sullivan suffered from long-term depression and anxiety and was receiving sickness benefit in the form of Income Support until it was stopped by the DWP following a WCA. He committed suicide after being on Jobseekers Allowance for six months. After the inquest, the coroner said: "The intense anxiety that triggered his suicide was caused by his recent assessment...as being fit for work". The assessor — a former orthopaedic surgeon — admitted during the inquest that he had not fully explored the risk of suicide at the face-to-face assessment, despite suicidal ideation being described on the claim form.
The coroner wrote to the DWP in January 2014. She was concerned that neither the Atos doctor nor the DWP decision-maker had sought information from Michael O'Sullivan's own doctors. The DWP wrote back, referring to the guidance issued to the Atos healthcare professionals who, before face-to-face assessments, scrutinised the paperwork submitted by claimants — guidance called the Training and Development ESA Filework Guidelines. The DWP confirmed that suicidal thoughts had been described on Michael O'Sullivan's application form but said "further evidence was not requested in line with the stated policy where the claimant has referred to suicidal ideation". These policy guidelines say: "Where there is evidence of a previous suicide attempt, suicidal ideation, or self-harm expressed in the , the healthcare professional must request further medical evidence".
The DWP said the specific action it would take in response to the coroner's concerns was to issue a reminder to the relevant members of staff. Michael O'Sullivan's daughter's MP said:
The case had many similarities with an earlier death following a WCA, where a coroner had also written to the DWP about the lack of an attempt to contact the psychiatrist who had been treating a person with mental health problems who went on to commit suicide.
David Barr
David Barr suffered from paranoid delusions and had a history of self-harm. He was taking anti-psychotic medication prescribed by his psychiatrist. He jumped from a bridge to his death after a risk assessment — by a physiotherapist — that led the DWP to deny his claim for ESA. The department later admitted that its decision was wrong; it said he should have been categorised as being at substantial risk of harm.
Epidemiology
A study published in the Journal of Epidemiology and Community Health in November 2015 found an independent correlation between the deployment of the Incapacity Benefit reassessment programme in England and an increase in reported mental health problems, higher levels of antidepressant prescribing and 590 additional suicides. The DWP responded by pointing out that association does not imply causation: the rise in mental health issues when the WCA was deployed after 2010 could have been caused by something else entirely and the temporal association with the reassessment programme could just have been a coincidence. The researchers said they had found no other explanation for the rise.
Deaths after WCAs
In response to a campaign using the Freedom of Information Act, the Information Commissioner ordered the DWP to disclose the number of people who had died in the 12 months after their WCA since May 2010 - the DWP had sought to withhold this information, arguing variously that it was too time-consuming, the department was about to publish it anyway or it would not be in the public interest because the data might be misinterpreted. But in August 2015, the DWP was forced to reveal that between December 2011 and February 2014, 2,380 claimants had died after being declared fit for work. However, as Dr Ben Goldacre has explained, an imprecise question in the original FOI request and an unhelpful DWP response — which Goldacre characterised as "essentially a PDF and an excel spreadsheet full of red herrings" — meant that no firm conclusion could be drawn from these figures alone about whether the death rate of people found fit for work is any higher or lower than expected.
Deaths and claims ending
DWP figures show that, between January and November 2011, 10,600 sick and disabled people died within six weeks of their benefit claim ending; many disability campaigners believe that these deaths occurred after — and even because — the claimants were declared fit for work. The Daily Telegraph has questioned this: it posits that the 10,600 deaths include people who happened to die from natural causes, after which their benefit payments ceased. The newspaper said that when the DWP states "within six weeks", this "does not mean 'within the following six weeks': it means 'within six weeks either side'. What that means is that the large, presumably overwhelming, majority of those 10,600 people died, and then their claims ended because they were dead."
United Nations report
In November 2016, the United Nations Committee on the Rights of Persons with Disabilities published its report on the situation facing disabled people in the United Kingdom. Of deaths after WCAs, it said:
The DWP responded by confirming that it did not systematically monitor or investigate deaths following WCAs. It admitted that it had reviewed the deaths of at least 49 claimants, but said it only did this a): when formally notified of a death by "a family member or solicitor", and b): where a link between the death and the DWP's actions has been alleged by the family member or their legal advocate. The department said that an internal review might "make recommendations for possible improvements" but would not "seek out or apportion blame" (internal reviews have though been used by the DWP to deny any culpability for deaths following WCAs).
The DWP drew the committee's attention to the role of the coroner in England and Wales.<ref name="auto12"/>
Design
The United Nations Committee on the Rights of Persons with Disabilities published a report on the situation facing disabled people in the United Kingdom. Of the WCA, it said:
A review undertaken by occupational heath expert Professor Malcolm Harrington and a scrutiny group that included the National Clinical Adviser to the Care Quality Commission and the Chief Executive of the mental health charity MIND gave a negative picture of the WCA in 2010, with the The Guardian summarising Professor Harrington's opinion as being that the test was "impersonal", it "lacked empathy" and it was too reliant on "computer systems and drop-down menus". In the executive summary of his report, he wrote that "the WCA is not working as well as it should. There are clear and consistent criticisms of the whole system and much negativity surrounding the process."
When Atos gave its reasons for seeking to exit the contract to carry out the assessment, the firm announced that it had come to the conclusion that "in its current form, the WCA is not working for claimants, for DWP or for Atos Healthcare". Conversely, Dr Paul Litchfield, who advised the DWP on the performance of the WCA in 2013 and 2014, described the test he had helped to design as "by no means perfect" but nevertheless adequate. However, in 2014 he cautioned that: "We have taken the WCA about as far as it can sensibly go in terms of modification and adjustment". Professor Dame Carol Black advised the government on back-to-work policy between 2006 and 2016. She said of the WCA: "I don't think anyone thinks it has been a success", describing it as "badly placed" and too far from when the first sick note or fit-note is penned.
Iain Duncan Smith complained that the system gave doctors a "binary choice", not an opportunity to deliver a more nuanced opinion on claimants' fitness for work. In April 2016, the new Welfare Secretary, Stephen Crabb, said that the WCA had "never worked as intended. The WCA was a mess, it didn't recognise mental health issues and other types of disability". Later the same year, the Shadow Secretary of State for Work and Pensions, Debbie Abrahams, said the test her party had described as "tough but fair" in 2010 had been "discredited". When appearing on Question Time, the president of the Liberal Democrats, Baroness Sal Brinton, described the WCA as "not fit for purpose", adding "this process absolutely fails" and "we need to get rid of it". On the same BBC programme, Kier Starmer QC, a former Director of Public Prosecutions, said: "It is time for a real review of how these assessments are actually working". In September 2016, Damian Green was asked by the BBC's Andrew Marr about the deaths of specific benefit claimants; in reply, the Secretary of State for Work and Pensions acknowledged that "obviously there are individual cases where it looks as though the system is not working".
Reliability
Turnover of decisions
Parliament's Office of Science and Technology has analysed the WCA's performance; it found that "the number of fit-for-work decisions being overturned on appeal has led to questions about the reliability of the assessment process". Between 2011 and 2013, around 40% of claimants found 'fit for work' appealed to a tribunal and around 40% of those appeals were successful.
A 2012 study of 28,000 tribunal hearings analysed the reasons for overturning the DWP's decisions:
* In almost two-thirds of successful appeals, the tribunals found the appellants' descriptions of their difficulties, given in person on the day of the tribunal, sufficiently convincing for them to be awarded the benefit — known as presenting "cogent oral evidence" in legal jargon. By implication, in these cases, the tribunal found the oral evidence more persuasive than had the assessor who had conducted the original face-to-face assessment
* In nearly a quarter of successful appeals, the tribunals agreed with the DWP on the facts of the case but decided that the DWP had come to the wrong conclusion based on those facts
* In 13% of cases, documentary evidence was provided that had not been available at the initial assessment
* In under 1% of cases, the assessment report was found to contain important technical errors.
Outcome targets
Professor Malcolm Harrington, the first external reviewer of the operation of the WCA, was asked by a parliamentary committee whether he had ever found any evidence that Atos assessors had been put under pressure to reach targets. He replied:
In 2012, a GP posed as a trainee Atos assessor and recorded undercover video footage that was later broadcast by Channel 4's investigative current affairs programme Dispatches. In the film, trainers warned the NHS doctor that if on average he were to recommend more than one disabled person per day for the Support Group, he would be subject to an increased level of management scrutiny through a mechanism known as "targeted audit". The undercover doctor was told:
An assessor on "targeted audit" would also no longer be allowed to recommend a claimant for the Support Group without asking an authorised colleague for permission to do so. When the doctor asked an experienced assessor where these rules had come from, she replied: "DWP".
Both the DWP and Atos categorically denied ever having had any target for getting claimants off sickness benefits. However, both eventually admitted that Support Group "norms" were being used nationwide, though they both denied that the purpose of "targeted audit" was to limit the number of claimants placed in the Support Group. Atos said that the audit process triggered by the breach of a "norm" was intended to ensure consistency across the firm's UK team: if the assessor's reports met the DWP's expectations, the healthcare professional would not be asked to change their recommendations.
However, in 2012, the Work Programme firms responsible for training people in the Work-Related Activity Group said they had "ongoing concerns about the accuracy of the WCA" and rated earlier improvements to the WCA as only "4 or 5 out of 10". In 2013, the same organisation complained that claimants who were "clearly unfit for any type of work-related activity" were nonetheless being put in the Work-Related Activity Group rather than the Support Group, and that "claimants with terminal cancer, whose life expectancies were shorter than the work-ready prognosis" had been referred to them for pre-employment training.
On the same day, an Atos spokesman made it clear that the training curriculum was set by the DWP and duly followed by Atos, stating: "We do not deviate from government guidelines in our training". The Employment Minister was asked by the BBC about the allegations of bias but he replied with a general explanation of the principles underpinning the Incapacity Benefit reassessment programme. Tom Greatrex MP wrote to the Prime Minister to bring to his attention the whistleblower's allegations that the core assessment was "skewed against the claimant". Downing Street made no reply but simply passed the letter back to the DWP, which issued a non-specific statement.
In July, the former assessor gave an interview to The Guardian. In it, he described how he had first heard trainers advocating the "bogus" interpretations of the test's descriptors in 2011 during a one-day conversion course covering the new version of the WCA and its new criteria. In response to the article's description of auditors instructing assessors — at the point when a report of a face-to-face assessment had been written, but had not yet been sent to the DWP — to alter their reports and reduce the number of points awarded, Atos said:
In August, the whistleblower expanded on his allegations in a first-hand account published by the British Medical Journal. He suggested that the DWP's alleged actions might have been at least partly driven by pressure to "reduce government debt". The DWP's senior doctors made no reply but the clinical director of Atos did respond. In relation to the claim that some Atos assessors had been led to interpret the test's criteria too harshly, she did not deny that the "bogus rules of thumb" had been used in training talks but she said that assessors were expected to follow the written guidance contained in the 255-page instruction manual issued to all assessors:
The foreword to the WCA Handbook states:
On 22 July 2013, the DWP announced that it had recently "directed" Atos to "put in place a quality improvement plan following a DWP audit which identified an unacceptable reduction in the quality of written reports produced following assessments." The DWP said it had carried out an unscheduled and "urgent" audit in "April/May 2013" that looked at reports written over the six months to March, in which time Atos had furnished the DWP with more than 300,000 reports. The DWP said it had found 164 reports that its in-house medical staff had said had scored only a 'C' for quality. However, during the period in question, the 164 reports had been deemed adequate by the department's on-the-ground decision-makers, who had used them to decide on claimants' entitlement to ESA — unacceptable reports are returned to the outsourcer for what the DWP calls "a rework". The department's press release tried to explain the paradox:
Michael O'Sullivan
Michael O'Sullivan suffered from long-term depression and anxiety and was receiving sickness benefit in the form of Income Support until it was stopped by the DWP following a WCA. He committed suicide after being on Jobseekers Allowance for six months. After the inquest, the coroner said: "The intense anxiety that triggered his suicide was caused by his recent assessment...as being fit for work". The assessor — a former orthopaedic surgeon — admitted during the inquest that he had not fully explored the risk of suicide at the face-to-face assessment, despite suicidal ideation being described on the claim form.
The coroner wrote to the DWP in January 2014. She was concerned that neither the Atos doctor nor the DWP decision-maker had sought information from Michael O'Sullivan's own doctors. The DWP wrote back, referring to the guidance issued to the Atos healthcare professionals who, before face-to-face assessments, scrutinised the paperwork submitted by claimants — guidance called the Training and Development ESA Filework Guidelines. The DWP confirmed that suicidal thoughts had been described on Michael O'Sullivan's application form but said "further evidence was not requested in line with the stated policy where the claimant has referred to suicidal ideation". These policy guidelines say: "Where there is evidence of a previous suicide attempt, suicidal ideation, or self-harm expressed in the , the healthcare professional must request further medical evidence".
The DWP said the specific action it would take in response to the coroner's concerns was to issue a reminder to the relevant members of staff. Michael O'Sullivan's daughter's MP said:
The case had many similarities with an earlier death following a WCA, where a coroner had also written to the DWP about the lack of an attempt to contact the psychiatrist who had been treating a person with mental health problems who went on to commit suicide.
David Barr
David Barr suffered from paranoid delusions and had a history of self-harm. He was taking anti-psychotic medication prescribed by his psychiatrist. He jumped from a bridge to his death after a risk assessment — by a physiotherapist — that led the DWP to deny his claim for ESA. The department later admitted that its decision was wrong; it said he should have been categorised as being at substantial risk of harm.
Epidemiology
A study published in the Journal of Epidemiology and Community Health in November 2015 found an independent correlation between the deployment of the Incapacity Benefit reassessment programme in England and an increase in reported mental health problems, higher levels of antidepressant prescribing and 590 additional suicides. The DWP responded by pointing out that association does not imply causation: the rise in mental health issues when the WCA was deployed after 2010 could have been caused by something else entirely and the temporal association with the reassessment programme could just have been a coincidence. The researchers said they had found no other explanation for the rise.
Deaths after WCAs
In response to a campaign using the Freedom of Information Act, the Information Commissioner ordered the DWP to disclose the number of people who had died in the 12 months after their WCA since May 2010 - the DWP had sought to withhold this information, arguing variously that it was too time-consuming, the department was about to publish it anyway or it would not be in the public interest because the data might be misinterpreted. But in August 2015, the DWP was forced to reveal that between December 2011 and February 2014, 2,380 claimants had died after being declared fit for work. However, as Dr Ben Goldacre has explained, an imprecise question in the original FOI request and an unhelpful DWP response — which Goldacre characterised as "essentially a PDF and an excel spreadsheet full of red herrings" — meant that no firm conclusion could be drawn from these figures alone about whether the death rate of people found fit for work is any higher or lower than expected.
Deaths and claims ending
DWP figures show that, between January and November 2011, 10,600 sick and disabled people died within six weeks of their benefit claim ending; many disability campaigners believe that these deaths occurred after — and even because — the claimants were declared fit for work. The Daily Telegraph has questioned this: it posits that the 10,600 deaths include people who happened to die from natural causes, after which their benefit payments ceased. The newspaper said that when the DWP states "within six weeks", this "does not mean 'within the following six weeks': it means 'within six weeks either side'. What that means is that the large, presumably overwhelming, majority of those 10,600 people died, and then their claims ended because they were dead."
United Nations report
In November 2016, the United Nations Committee on the Rights of Persons with Disabilities published its report on the situation facing disabled people in the United Kingdom. Of deaths after WCAs, it said:
The DWP responded by confirming that it did not systematically monitor or investigate deaths following WCAs. It admitted that it had reviewed the deaths of at least 49 claimants, but said it only did this a): when formally notified of a death by "a family member or solicitor", and b): where a link between the death and the DWP's actions has been alleged by the family member or their legal advocate. The department said that an internal review might "make recommendations for possible improvements" but would not "seek out or apportion blame" (internal reviews have though been used by the DWP to deny any culpability for deaths following WCAs).
The DWP drew the committee's attention to the role of the coroner in England and Wales.<ref name="auto12"/>
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