Work Capability Assessment

The Work Capability Assessment (WCA) is the medical test used by the British Government's Department for Work and Pensions (DWP) to decide whether jobless welfare claimants are entitled to sickness benefits.[1] The assessment divides claimants into three groups: fit for work; unfit for work but capable of carrying out work-related activity, such as going on a training course; or fit for neither work nor training.

Atos Healthcare conducted the core assessment on behalf of the DWP until the firm prematurely exited the WCA contract in March 2015, at which point the US outsourcing company Maximus took over.

The WCA was designed to play a key part in New Labour's welfare reform policies, which aimed to encourage jobless people of working age to find paid work — especially if they were on Incapacity Benefit or were lone parents.[2] The plan with the WCA was: to make sickness benefits harder to get; to re-evaluate more than two million established recipients; and to put most claimants onto training courses and then into work.

The test went live in 2008, assessing only fresh claims, but the sickness benefit caseload went up — a consequence of the banking crisis and its effect on the economy and on jobs.[3] An overhaul of the test began soon afterwards and the new version was deployed in 2011 by the coalition government led by David Cameron. The WCA then became the fulcrum of a major reassessment programme aimed at people on Incapacity Benefit or Income Support that was supposed to save billions of pounds a year from the welfare budget in a new age of austerity.[4][5]

The reassessment programme was dogged by problems:[6] handling of the contract was criticised by the National Audit Office[7] and by the Public Accounts Committee,[8] which described the DWP's project management style as "complacent";[9] the overhaul of the WCA by medically-qualified civil servants had produced what seemed to be a more stringent version of the test, but outside experts warned it was still flawed; many 'fit for work' decisions were overturned, and the high number of appeals swamped the tribunals service, leading to long delays;[10] accusations of bias, questions about quality and a contractual dispute caused the process to stall completely in 2013; and the DWP's attempts to restart the project in 2015 were hampered by a shortage of healthcare professionals willing and able to carry out the test.

New Labour's welfare reforms of 2008 were championed by the coalition government and supported in principle by Ed Miliband's party in opposition. They were partly responsible for a sharp fall in the number of people claiming Jobseekers Allowance in 2013 — but they failed to shrink the sickness benefit caseload significantly, made no savings from its budget,[11] and led to concerns that wrong 'fit for work' decisions had contributed to the deaths of large numbers of disabled people.[12]

Evolution of the 'fitness for work' test

Before 1995, entitlement to the out-of-work sickness benefit known then as Invalidity Benefit was decided using clinical information provided by the claimant's own doctor.[13]

In 1995, Invalidity Benefit was replaced by Incapacity Benefit (IB) and the Department of Social Security began commissioning its own medical assessments using the All Work Test.

In 2000, the All Work Test was replaced by the Personal Capability Assessment, which was used by government-approved doctors not only to assess new claims but also to reassess some established recipients.[14]

In its last term of office, New Labour introduced Employment and Support Allowance (ESA) as the main out-of-work sickness benefit, with the WCA acting as its gatekeeper. The aims were: to make the test for out-of-work sickness benefits more stringent; to accentuate the positive by "looking at what you can do, not what you can't do"; and to take into account new disability legislation, changes in the workplace and developments in occupational health. Testing capacity was increased by employing nurses and physiotherapists to work alongside doctors, and a semi-structured interview technique based on a computer-generated template was used for the first time.[15]

TIMELINE
Mar 2005: Atos awarded the contract to develop the software for the new test[16]
Jan 2006: White Paper outlines Employment and Support Allowance[17]
Jul 2006: Welfare Reform Bill is introduced to Parliament
May 2007: Welfare Reform Bill receives Royal Assent[18]
Jul 2008: White Paper outlines the Incapacity Benefit reassessment programme[19]
Oct 2008: ESA replaces Incapacity Benefit for new claims
Oct 2008: The Work Capability Assessment is used for the first time
Dec 2008: Planning begins to overhaul and toughen up the WCA[20]

In early 2011, the Conservative-Liberal Democrat coalition government initiated the expansion of the programme to re-evaluate the disability status of more than two million people whom previous governments had judged to be entitled to sickness benefits — mainly, Incapacity Benefit — with around 1.5 million people expected to be assessed in person rather than on paper.[21][22] At the same time the DWP introduced long-planned revisions to the test's eligibility criteria, which became more stringent overall: most notably, the 03/11 version awarded no points when a claimant who had difficulty walking could overcome the disability by using a wheelchair, if reasonably practicable.

Official projections then envisaged most former recipients of Incapacity Benefit moving onto Jobseekers Allowance, or ESA for up to two years, and into a training programme and then into work.[23] As a result, a saving of at least £3 billion annually in the IB/ESA budget was anticipated by the end of the parliament.[24][25]

The assessment process

The process is ultimately a legal one that uses social security legislation as its main reference point (which is why appeals are made to lawyer-led tribunals overseen by the Ministry of Justice). The standard of proof used is 'the balance of probabilities': a claim should be accepted if it is more likely than not that the claimant has a significant disability.

The process starts with an assessment by a healthcare professional, after which an official from the DWP decides on entitlement to Employment and Support Allowance. The process also decides on whether a successful claimant is able to take part in 'work-related activity'. In this way, the process sorts claimants — broadly speaking — into three groups: fit for work; unfit for work but fit for work-related activity (the Work-Related Activity Group); or fit for neither work nor work-related activity (the Support Group). Technically, however, it is more nuanced: the test really tries to establish whether a claimant faces significant extra barriers to work because of their disability; the DWP's position is that the people who face these barriers are entitled to financial support, but some of them — the people in the Work-Related Activity Group — could, over time and with help, probably still find a suitable job.

The strength of a claim is largely determined by comparing the claimant's problem with a framework of set criteria, known as 'descriptors',[26] which are divided into 'functional' and 'non-functional' descriptors.

The healthcare professional's main role is to select the most appropriate descriptor for each activity printed on the ESA claim form that the claimant has marked as being difficult for them in their day-to-day life. To do this, assessors draw on their training in the field of 'functional assessment' — a subspecialty concerned with gauging the practical impact of an impairment on a person's daily life and, in the context of the WCA, on their ability to work.

The healthcare professional also uses their clinical knowledge to:

In principle

Functional descriptors

Each functional descriptor comes with a 'score' of 6, 9 or 15 points that is intended to reflect the relative severity of the disability. A total score of 15 points or more will qualify the claimant for ESA. If the healthcare professional deems that none of the functional descriptors apply, the total score will be zero.

Descriptors are grouped into 17 activities. For example, the activity 'Manual Dexterity' – hand function – comes with the following descriptors for the assessor to choose from:

Only one descriptor may be chosen for each activity, and it should be the highest-scoring option that still accurately describes the loss of function. Someone who can pick up a small object like a coin but cannot use a pen to make a simple mark will score 9 points for that activity.

If a claimant is capable – in narrow terms – of carry out a particular action but cannot do so reliably, repeatedly, in a timely manner, safely and without significant pain, they should be treated as being incapable of carrying out that action.

The physical functional descriptors cover these activities:

The mental functional descriptors cover:

A 'top score' in one activity will usually qualify the claimant for the Support Group.

Non-functional descriptors

The non-functional descriptors have no points attached but instead have a simple 'yes' or 'no' answer:

Other factors that might be taken into account here include:

Summary
The process uses fixed criteria and a system of points in an attempt to differentiate between people claiming ESA who have no significant disabilities and those who, because of the type and severity of their disability, do face significant barriers to work. Within the latter group, the WCA tries to identify those successful claimants who have one or more severe functional disabilities: they are not required to prepare for future work and will be placed in the Support Group rather than the Work-Related Activity Group (WRAG). A 'yes' answer to a non-functional descriptor question will also effectively qualify the claimant for the Support Group.

The Work-Related Activity Group

This is the cohort of successful ESA claimants whom the DWP thinks are likely to be able to find work in the future after receiving extra help. The WRAG generally contains people with less severe disabilities than those of people in the Support Group. However, the WRAG and the Support Group both contain people whom a disability analyst and the DWP have deemed to face significant extra barriers to work because of their ill-health or disability.

Those in the WRAG are required to take part in 'work-related activity' as a condition of their benefit. The DWP has not defined 'work-related activity' precisely but so far it has not involved applying for jobs, taking part in work placements or undertaking any form of provisional employment. The DWP says: "Claimants identified for this group will take part in work-focused interviews with a personal advisor and have access to a range of support to help them prepare for suitable work" and tells claimants their advisor will "help with things like job goals and improving your skills".[27] Pre-employment training is delivered through the Work Programme, which aims to find people jobs within two years.

Figures released by the DWP in August 2015 showed that people in the WRAG are nearly four times more likely to die than claimants on Jobseekers Allowance, some of whom also have a disability.[28]

In practice

The process starts with a healthcare professional approved by the DWP scrutinizing the ESA claim form and deciding whether to seek further evidence from the claimant's GP or another appropriate source. If the evidence shows that, on balance, and according to the legally-defined criteria of the test, the claimant could not reasonably be expected to work, then a face-to-face assessment is not normally required, the claimant is recommended for the Support Group and the higher rate of ESA is usually granted. Otherwise, the healthcare professional arranges a face-to-face assessment – usually in an examination centre, but occasionally in the claimant's home.

At face-to-face assessments, the assessors – who are nurses, doctors or physiotherapists – are guided and prompted by a computer programme, designed by Atos in conjunction with the DWP, called the 'Logic-integrated Medical Assessment' or 'LiMA'. A large amount of lifestyle data and some clinical information is obtained from the claimant and is entered into the computer by the assessor, mostly by selecting pre-determined 'one click' options from an on-screen menu. As the assessment progresses, LiMA tries to gauge both the impact of the disability on the person's daily life and the person's fitness for work – but while LiMA suggests options to the assessor, it is ultimately the healthcare professional who is responsible for making the recommendations.

As well as taking a clinical history and exploring the claimant's 'Typical Day', the healthcare professional will make general observations of the claimant's hearing, mobility and posture, etc. and there may be a short physical examination. The claimant's mental state will to a large degree become apparent as the interview progresses, but specific questions might be asked in order to elucidate any disordered thinking, abnormalities of perception or cognitive impairment.

During the face-to-face assessment, if it becomes clear that the claimant qualifies for the Support Group on the grounds of severe functional disability, the interview should be brought to an early close and the finding recorded on the claimant's file. If assessors are unsure how to apply the test's criteria in specific cases, telephone advice is available.

After the interview and examination the findings are summarised in free text using Standard English prose, and a report constructed from modifiable LiMA options is sent electronically to the DWP. The whole report attempts to record the findings and to justify the recommendation by comparing and contrasting the disabilities described by the claimant against the criteria – the descriptors – constituting the legal framework of the test[29] (as well as considering the other factors, such as whether there would be a substantial risk if the claimant were declared fit for work). This report normally concludes with the points score together with a statement on whether significant disability is likely or unlikely and a prognosis.

These assessments have been criticised for their repetitive impersonal style and a 'computer says no' attitude to eligibility in the past.

Checks and balances

The recommendation from the outsourcing firm is not the final decision on benefit entitlement. There are a number of what the DWP has called "checks and balances" that can follow the core assessment.[30]

DWP decision-makers

When the assessor's report is sent by the outsourcing firm to the DWP it clearly indicates suitability - or not - for the Support Group, and it contains the assessor's points score and a statement on whether the disability is significant enough for the claimant to qualify for ESA, but it is an official who makes the final decision on which category the claimant falls into and on entitlement to ESA payments. This decision takes into account: the assessor's report; any other available medical evidence; and the aspects of social security legislation pertaining to entitlement to benefits.

Assessors should not supply "prescriptive advice" on benefit entitlement in their reports. However, the structure of the core WCA and the way reports are presented mean that assessors' opinions on fitness for work are obvious to decision-makers. Some claimants are unfit for work but nevertheless ineligible for ESA because they do not meet the non-medical criteria with respect to benefit entitlement.

Reconsideration

If the claimant disagrees with the decision-maker's conclusion, the claimant can ask the DWP to review its decision (in October 2013, the DWP stopped claimants from appealing directly to independent tribunals; claimants must now first ask the DWP to reconsider the case - a process known as 'mandatory reconsideration' - whereas before October 2013, claimants could choose between asking for a reconsideration by the department or going straight to an external appeal).

In early 2014, towards the end of the Incapacity Benefit reassessment process, more than 40% of 'fit for work' decisions undergoing reconsideration were overturned at this stage of the process. By 2015, when very few reassessments were taking place, the overturn rate at this stage had dropped to just over 10%.[31][32]

Independent tribunals

If the result of the reconsideration is unfavourable to the claimant, he or she can then appeal to an independent tribunal – consisting of a judge, a doctor and a layperson – operating under the auspices of the Ministry of Justice. The tribunal takes oral and written evidence from the appellant and observes them during the hearing but the doctor on the panel does not physically examine them; otherwise, the tribunals use the same legal process and the same set of criteria as the DWP and its outsourcing partner.

Between 2011 and 2013 around 40% of claimants found 'fit for work' appealed to a tribunal and around 40% of those appeals were successful.[33] The number of external appeals dropped markedly over the course of 2013, although most appellants who do reach the tribunal stage now see their 'fit for work' decision overturned.[34][35]

Successful appeals: 50% or 15%?
Critics of the WCA often say that more than 50% of appeals are successful, while the DWP suggests that only 15% of decisions are overturned. Both are technically correct. Independent tribunals do now overturn more than half of the appeals that come before them. However, even in the busy years for tribunals — 2011 to 2013 — this only represented 15% of all the 'fit for work' decisions ultimately made by the DWP. The apparent discrepancy arises because some people don't launch an appeal to a tribunal and because some of those who do appeal are unsuccessful. 
The tribunal is the very end of the process. Some 'fit for work' recommendations are disregarded by the DWP and some initial decisions are overturned on formal reconsideration by the DWP, which leaves a smaller proportion of lingering 'false negatives' to be overturned by independent tribunals.

A 2012 study of 28,000 tribunal hearings analysed the reasons for overturning the DWP's decisions:

Outcomes

During the Incapacity Benefit reassessment programme, a trainer told new assessors:

Good thing for us is, even if you made the wrong decision...you never go to the tribunal. So, sort of, you won't be blamed.[37]

The core WCA generated high volumes of 'fit for work' recommendations from its inception. As the programme went on, the proportion disregarded by decision-makers grew: around 8% of 'fit for work' recommendations were disregarded in 2012, almost doubling to 15% in 2013 and then increasing still further to 20% in 2014.[38]

The results of initial decisions showed a similar trend. At first, when only fresh claims were being assessed, almost two-thirds of claimants were declared 'fit for work' and therefore ineligible for ESA. This dropped to around half once the IB reassessment programme got underway in 2011; by 2013, it was a third; by 2014, only a quarter of claimants were declared 'fit for work' by the DWP at the first stage of the decision-making process.[39]

The DWP overturned a varying percentage of its own decisions at the reconsideration stage, while independent tribunals overturned still more. In this way, the "checks and balances" led to a puzzling discrepancy between the high number of 'fit for work' recommendations generated by the core WCA and the low number of claimants moved off Incapacity Benefit onto Jobseekers Allowance or into work.

Incapacity Benefit reassessment programme

At first, the WCA was only used to gauge fresh applications for ESA. The plan to expand the programme to retest long-term recipients whose sickness benefit claims had begun before 2008 had been a key component of ESA since the design stage.

The Labour Party's manifesto[40] in 2010 declared that if it won:

More people with disabilities and health conditions will be helped to move into work from Incapacity Benefit and Employment and Support Allowance, as we extend the use of our tough-but-fair work capability test. This will help to reduce the benefit bill by £1.5 billion over the next four years. We will reassess the Incapacity Benefit claims of 1.5 million people by 2014, as we move those able to work into jobs.[41]

Professor Harrington

Section 10 of the Welfare Reform Act 2007[42] states that:

The Secretary of State for Work and Pensions shall lay before Parliament an independent report on the operation of the assessments under sections eight and nine [regarding 'limited capability for work' and 'limited capability for work-related activity'] annually for the first five years after those sections come into force.[43]

New Labour submitted no review of the first full year of the WCA's deployment in 2009. In June 2010, the Conservative Secretary of State for Work and Pensions asked Professor Malcolm Harrington, a doctor and an expert in occupational health, to review the performance of the WCA.[44] Professor Harrington was assisted by a small team from the DWP and his work was overseen by an Independent Scrutiny Group that included the National Clinical Adviser to the Care Quality Commission and the chief executive of the mental health charity MIND.

In November of that year he published his first report.[45][46] The Guardian summarised 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".[47] In the executive summary of his report, he wrote:

I found 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...[but] I do not believe the system is broken or beyond repair. I am proposing a substantial series of recommendations to improve the fairness and effectiveness of the WCA. If adopted, I believe these changes can have a positive impact on the process.

He made 25 recommendations. The changes he advised to the core assessment were: 

The evidence-based review of the mental health criteria.
In his first annual review, Professor Harrington asked MIND, Mencap and the National Autistic Society to "provide recommendations on refining the mental, intellectual and cognitive descriptors". Professor Harrington would listen to their ideas and then make recommendations to the DWP, once the recommendations had also been considered by an independent scrutiny group.
The DWP's medical experts were not convinced by the evidence presented: they did not agree that the existing descriptors were not working properly; they saw no evidence that the proposed system would be any better; and they felt that the changes would make the assessment unnecessarily complicated.[48]
The DWP decided to set up an 'evidence-based review' - overseen from start to finish by Professor Harrington and to run in parallel with his annual reports for Parliament - to look at the proposed changes to the mental health criteria used in the WCA. But in his third and final report, Professor Harrington lamented that "the evidence-based review has unfortunately taken longer to develop than is ideal". One reason it had taken longer to develop was that the scope of the review had been broadened to cover the physical descriptors as well, and had mutated into an evaluation of an entirely new assessment.
This 'evidence-based review' did not publish its findings until December 2013 - three years after it had originally been conceived - by which time most of the Incapacity Benefit reassessment programme had been completed.
The review concluded that the proposed alternative assessment was less accurate than the WCA and that "the WCA produced consistent results on the whole, and is an accurate indicator of work capability as compared with expert opinion".[49]

The new version of the WCA

Before Professor Harrington had submitted his first review, the DWP's in-house medical experts were in any case making changes to the physical and mental descriptors - some of which would be to the benefit of future claimants - and toughening up key parts of the test, particularly the mobility descriptors (preparatory work on this major redesign had begun a few months after the test was introduced in 2008, and the changes were approved in principle in the last days of the New Labour administration). The new criteria were piloted in late 2010 under the Coalition and a rolling programme of one-day conversion courses for Atos assessors began soon afterwards.

Pilot studies
Two pilot studies took place, one in Aberdeen and one in Burnley. In total, 1347 people who had been on Incapacity Benefit for more than two years were assessed against the criteria that would be used to gauge the fitness for work of around 1.5 million such people from 2011. The results - before any appeals - suggested that 29% of the people studied would not qualify for ESA, while a similar proportion were found to be so disabled that they would qualify for the Support Group.[50]

The Incapacity Benefit reassessments were expected to begin in 2011 using the new and more stringent version of the test. In February of that year, Professor Paul Gregg, an economist and one of the original architects of ESA, warned that the WCA was "badly malfunctioning" and urged further pilot studies before the new version was used as the default assessment.[51] Three months later, six experts in mental health - including the chief executive of MIND, who was already a senior advisor to the DWP on the WCA - wrote to The Guardian to say that the test was "deeply flawed".[52]

Later, in 2013, after more doubts were expressed about the testing process, The Guardian quoted Professor Harrington as saying: "I would have preferred to do a roll-out [the IB reassessment] in the second year [2012]" and as having told the DWP this before the Incapacity Benefit reassessment programme began. The DWP told the newspaper it had no record of a warning of this kind being given by Professor Harrington and that his "remit was to assess the effectiveness of the Work Capability Assessment, not whether to reassess Incapacity Benefit claimants".[53] Furthermore, the minister who had formally initiated the 'roll out' had said in Parliament that beforehand Professor Harrington had told him: "I believe the system is in sufficient shape for you to proceed with Incapacity Benefit reassessment".[54]

When asked later about this discrepancy, Professor Harrington replied:

Can I clarify this once and for all? In my first year - before the first report, that is - I said to [the minister] that, left to my own devices, I would prefer it if they would postpone the IB migration until I had got at least one review in, so they could just deal with the new claimants and would not be confused by another group of people coming in - a completely different group of people, as you well know. He did not say no; it was just obvious that it was a political done deal and they were going to go ahead and do the IB migration whatever.[55]

2011

Beginning in March 2011, the new version of the WCA was used to carry out face-to-face assessments of more than a million established recipients of ESA's forerunner Incapacity Benefit (IB) and a smaller number of people on Income Support; until that point, none of these recipients had undergone a WCA, although some had undergone a Personal Capability Assessment or an All Work Test between 1995 and 2008, and all had been declared 'unfit for work' by previous governments according to the criteria in use at the time.

Although, technically speaking, claimants were now being evaluated for transfer onto a new benefit with different and more stringent eligibility criteria than before, the purpose of the process was not made clear to the people going through it – nor to the wider world, where it was often assumed that when an application for ESA from an established IB claimant was unsuccessful, it meant that there had never been anything really wrong with the claimant in the first place.[56] As a parliamentary report that was compiled at an early stage of the 'migration' of IB claimants onto ESA concluded: "It has caused controversy because some people previously considered disabled and entitled to invalidity benefits are now being found fit-for-work".[57]

To address concerns over the WCA's ability to deal with mental health problems, Atos trained selected assessors to be 'mental function champions' who provided mainly telephone advice to other assessors on mental health issues as they related to the WCA's criteria[58] – a response to one of two key recommendations made by Professor Harrington. The other legacy of his tenure was the introduction of the 'personalised summary statement'. This was intended to be a written explanation to the claimant in plain English of how the assessor's recommendation had been reached, but the DWP decided not to send them to claimants; instead, the department sent a 'decision-makers justification' written by a civil servant.[59] Nevertheless, the DWP insisted that assessors still write summaries, saying that decision-makers found them helpful when trying to understand the main reports. The summarisation process introduced in 2011, although time-consuming for Atos assessors, made little discernible impact on the level of criticism of the WCA.

Professor Harrington declared in November that "The WCA has, in my view, noticeably changed for the better".[60]

The introduction of the new version of the WCA when the year was already two months in, the conversion courses for the new criteria, the subsequent learning curve facing Atos assessors as they got up to speed, and the training and evaluation they had to undergo later in the year in order to write the Harrington summaries, all meant that the full impact of the 03/11 version of the WCA was not felt until the following year.

2012

There were protests outside Atos buildings in London and elsewhere.[61] The test received criticism in Parliament[62] and pressure was applied by many parliamentarians – but particularly by Michael Meacher, Tom Greatrex [63] and Sheila Gilmore – for improvements to the 'fitness to work' assessment.

A parliamentary committee heard evidence from welfare advisors that, in nearly two out of three successful appeals to tribunals against fit-for-work decisions, appellants were seeing their points rise from zero in the original assessments – meaning that the original WCA had detected no relevant disabilities at all – to at least 15 points after the tribunals had independently assessed their claims.[64] Parliament's Office of Science and Technology analysed the WCA's performance and found that "the number of fit-for-work decisions being overturned on appeal has led to questions about the reliability of the assessment process".

Towards the end of 2012, amendments to ESA and the WCA were enacted through the Welfare Reform Act 2012, which would take effect the following year. The result of the main change as far as the WCA was concerned was to broaden the scope for people who were being treated for cancer to be granted ESA.

DWP ministers decided to replace Professor Harrington once he had submitted his final report in 2012, although he maintained an oversight role with the evidence-based review that he had suggested be set up in 2010 and that published its findings at the end of 2013.[65] [66] As his successor they appointed Dr Paul Litchfield, another occupational health specialist and one who had played a key part in designing the WCA's mental and cognitive function descriptors in 2006.[67]

2013

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".[68]

The Public Accounts Committee of MPs chaired by Margaret Hodge heard evidence that over the previous financial year, Atos had been paid £112 million to carry out 738,000 assessments. At that time, 38% of appeals to tribunals were successful and the committee's view was that too many wrong decisions were being made, only for the decisions to be overturned later (while Atos was paid by the DWP, it was the Ministry of Justice that paid for the tribunal appeals, with £500 million being the potential cost of these appeals over ten years).[69] Hodge said that the DWP got "far too many decisions wrong on claimants’ ability to work...at considerable cost to the taxpayer" and added that this can "create misery and hardship to the claimants themselves". She also remarked: "We saw no evidence that the Department was applying sufficient rigour or challenge to Atos given the vulnerability of many of its clients, the size of the contract and its role as a near monopoly supplier. We are concerned that the profitability of the contract may be disproportionate to the limited risks which the contractor bears"[70] and concluded: "The Department's got to get a grip of this contract!".[71]

There was more criticism elsewhere: in Westminster,[72] by the Catholic Church,[73] by the medical profession,[74] by welfare rights advisers,[75] and by disability organisations and protest groups.[76] Concerns were raised about access to assessment centres: a Freedom of Information request revealed that 28 of the 140 assessment centres did not provide wheelchair access and the great majority did not have associated parking.[77]

The DWP's legal position - that the burden of proof lay with the claimant - was challenged under a judicial review. Judges sitting on a higher tier tribunal decided that claimants who had cognitive impairments or learning difficulties were at a significant disadvantage when gathering and presenting evidence in support of their claims.[78] The DWP disagreed.[79]

Supporting evidence
When a claim form is received by the outsourcing company it is scrutinised by a healthcare professional. If it gives a consistent account of a severe disability that is corroborated by attached documentary evidence, ESA will probably be awarded on the basis of the paperwork alone. If a claimant does not write a coherent account of their disability nor provide appropriate written evidence that backs up their claim, the healthcare professional is authorised to request a report from the claimant's GP.
In practice, GPs' reports were infrequently sought by Atos between 2011 and 2013. If claimants sought them instead, then their doctor, often feeling overburdened by these requests, might charge them as much as £130, while some GPs refused to provide claimants with supporting evidence at all[80] (GPs are not contractually obliged to provide these reports to their patients, only to the DWP's outsourcing partner, if it requests one, which must then be provided to the firm free of charge).[81]

Claimants could therefore find themselves in a Catch-22 situation:
1. The DWP said it was for claimants to find and present the medical evidence to back up their claims
2. GPs would refuse to provide this evidence to claimants - though they would give it to Atos if the firm asked for it, but the firm rarely did

A related problem was that Atos assessors only had access to medical information held by the DWP if it was stored electronically on LiMA, the computer system predominantly used after ESA was introduced for new claims in October 2008. The Incapacity Benefit reassessment programme reviewed more than a million claims, all of which, by definition, dated back to the time before ESA began. The original 'basis of claim' was therefore not normally available to assessors, although the DWP's decision-makers could access it at a later stage of the process.

Whistleblowing

In May 2013, a doctor who had resigned from Atos after refusing an instruction from auditors to reduce the number of points he had given to a mentally-ill claimant blew the whistle on biases in the testing process to the BBC and said:

These assessments need to be done independently, impartially, considering all the evidence and with proper use of medical knowledge – and that's just not happening at the moment. Pressure is being put on healthcare professionals in many cases to come up with a particular outcome, really regardless of the facts of the case

He claimed that:

The news report drew attention to misleading interpretations of the eligibility criteria that the former assessor had claimed were being taught as off-the-record rules of thumb during basic training. An Atos executive interviewed by the BBC acknowledged that the guidance referred to "might seem somewhat odd" but said it had been "taken out of context" and was part of a much bigger set of questions considered during assessments.[82]

In a separate interview, the whistleblower was quoted as saying: "The DWP is the real culprit here. It's the government training that makes Atos assessors do this". A spokesperson for Atos said: "We do not deviate from government guidelines in our training".[83]

Official response
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.[84]

In July, the former assessor was interviewed by The Guardian. 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. Atos reiterated that all its training was reviewed and approved by the DWP. On the question of auditors changing the number of points awarded after an assessment, Atos said:

There is no ethical conflict in advising a doctor that aspects of their work require further attention to meet the standards expected[85] 
Atos auditors
Some assessors with several years' experience of carrying out disability assessments were chosen by Atos to audit the work of their colleagues. Their main role was to give feedback to new recruits who had passed their initial classroom training but who had not yet been accredited by the DWP and allowed to 'fly solo'. Auditors would also check the reports of accredited assessors, if the assessors were putting more claimants than expected into the Support Group - a process known as "targeted audit".
Although the whole of a report would be broadly scrutinised, the thrust of an audit was to ensure that the report had been written according to the standards stipulated by the firm's customer - the DWP - and largely focussed on three things:
* The report should include as many examples as possible of activities taken from the claimant's description of their day-to-day life that corroborated the points score awarded by the assessor
* The summary should be an overview of the whole report and should try to explain how the recommendation on fitness for work had been reached
* The assessor's interpretation of the test's criteria should match that taught in training

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 clinical director of Atos responded by saying, with regard to the claim that documentary evidence was frequently missing or never sought prior to an assessment, that the company expected its assessors to gather much of the relevant evidence during the face-to-face assessment. 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 approved by the DWP:

All reports must fully comply with the Department for Work and Pensions guidance contained within the WCA Handbook; all our practitioners are expected to be fully aware of this guidance and are responsible for ensuring that the advice they offer complies with it.[86]

The foreword to the WCA Handbook states:

"This Handbook is not a stand-alone document, and forms only a part of the training and written documentation that a Healthcare Professional receives. As disability assessment is a practical occupation, much of the guidance also involves verbal information and coaching".[87]

The firm's senior medical manager suggested that it was the healthcare professionals working under her direction who were ultimately liable for any shortcomings in the recommendations they made to the DWP: "All practitioners are fully responsible and accountable for the reports they produce". Despite that, she said that Atos auditors might still ask assessors to "consider amending a report" - but only if there was a problem with its "quality".

Retraining of assessors

On 22 July 2013, the DWP announced that it had instructed 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.[30]

The statutory independent report for parliament on the operational performance of the WCA in 2013 dealt with the 'quality improvement plan' in one sentence:

Following a recent audit which showed an unacceptable reduction in the quality of assessment reports, the Department agreed a quality improvement plan with [Atos]...[88] 
The DWP audit
The audit in question covered reports from the six months to May 2013, in which time Atos had furnished the DWP with more than 300,000 reports. The DWP said it had found 164 cases - 0.055% of the total furnished - where the report had scored only a 'C' for quality. The 'C' grade reports had nonetheless been helpful to the DWP in judging entitlement to ESA: inadequate reports are returned to the outsourcer for what the DWP calls "a rework".
Quality of reports
In 2011, Professor Harrington felt that reports did not adequately explain how the recommendation on fitness for work had been reached. This was because the reports were designed to be constructed from preset but editable 'one-click' options. Professor Harrington recommended that reports be summarised in free text using plain English. At the behest of the DWP, Atos trained all its WCA assessors to do this in 2011. At the end of that year, the DWP said the Harrington summaries were proving "particularly useful to Decision Makers" in understanding how Atos's recommendations had been reached.[89]

In 2012, Citizens Advice said that it was the recommendations themselves that were the problem: people were being deemed fit for work when they weren't.[90]

In 2013, the Chartered Society of Physiotherapy found that some reports were "comprehensive" and "easy to read" but others were "poorly drafted" and "contained typing errors", while some were described as "contradictory".[91]

A study of 28,000 tribunal hearings found that technical problems with assessment reports were responsible for less than one percent of successful appeals.[92]

The DWP attempted to explain what it meant by 'quality': "A ‘C’ grade report does not mean the assessment was wrong, and the recommendation given in a ‘C’ grade report may well be correct, but, for example, their reasoning for reaching that recommendation may lack the level of detail demanded by the DWP"[30] - the issue that, in 2011, the DWP had said had been dealt with by the introduction of Professor Harrington's summaries.

The DWP admitted that the 'quality improvement plan' included "retraining and re-evaluating all Atos healthcare professionals".[30] The WCA Handbook was also rewritten and new guidance issued on several aspects of the test, including gauging mobility, mental function and risk. Specific advice was given on how to assess claims from people with motor neurone disease.[93]

The whistleblower described the DWP's audit as a "smokescreen" to cover the real reason for retraining assessors: to root out the "bogus rules of thumb".

The statutory review for parliament concluded its single-sentence analysis by saying that the 'quality improvement plan' had "...addressed the quality issues and this report will not comment on that matter further". Separately, the government called in PricewaterhouseCoopers to investigate problems with the quality of the WCA where Atos and the DWP meshed. The report remains classified.[30][94]

Board level talks

At some point between May and July 2013, Atos decided to stop carrying out the WCA on the Isle of Man, despite having performed the assessments there to the satisfaction of the Manx government since 2012.[95][96]

In the October reshuffle, the Employment Minister, who had borne ministerial responsibility for the WCA since September 2012, returned to the backbenches.[97] In December, the Minister for Disabled People — to whose portfolio the WCA had been transferred — told a parliamentary committee that top level talks were taking place with Atos, but he couldn't say what they were about:

I can't go into too much detail [but] there are global contract negotiations going on with Atos to do with their contract...Certainly, the conversations I've had at board level with Atos, we've taken it to a level where they had to realise just how bad this [the disputed events of May, June and July] was for their reputation in the UK - with other contracts and with other departments as well[98]

2014

Atos to exit the contract

In February, The Guardian was sent a document that purported to outline the future of the DWP's relationship with Atos. The newspaper described the document in terms that suggested that ministers were preparing to "oust" Atos from the WCA contract. In response to this apparent leaking of confidential information to the press, Atos told the newspaper that the contract wasn't working for either party and complained that the "constant flow of criticism" endured by the company "inevitably has an impact on our staff, who diligently endeavour to carry out assessments as laid out in DWP guidelines".[99]

A few days later, as disabled people staged protests outside Atos assessment centres nationwide, the French contractor told The Financial Times that it had been trying to get out of the WCA contract since 2013. The firm said: "For several months now, we have been endeavouring to agree an early exit from the work capability assessment contract".[100] The BBC said its Whitehall sources were "furious" that the company had unilaterally announced its intention to end the contract.[101]

The following month, the Disabilities Minister confirmed in Parliament that the contract with Atos was in the process of being brought to a premature close, with Atos paying a "substantial financial settlement" to the DWP as part of a mutual agreement to terminate the WCA contract early.[102] The DWP continued to employ the French firm to assess most claims for the Personal Independence Payment and Atos IT staff continued to run the computer system used in the WCA.[103] The Veterans Agency had voiced no concerns about the quality of reports written by Atos doctors in the assessment of claims for War Pensions made by former members of the UK's Armed Forces.

The number of appeals falls

Retrospective data from the DWP showed that the total number of appeals had dropped dramatically over the course of 2013. This was the result of fewer assessments taking place overall, better outcomes for claimants after their initial assessments, and, in October 2013, the introduction of Mandatory Reconsideration.[104]

Backlogs appear

In early 2014, the DWP stopped reassessing people who had already 'passed' a WCA.[105] In the summer, the BBC reported a backlog of more than half a million new ESA claims. Both phenomena were the result of a bottleneck caused by longer, more detailed, assessments and the loss through resignation of hundreds of Atos assessors — consequences of the 'quality improvement plan' and the events leading up to it the previous year.[106]

Economic effectiveness

The National Institute of Economic and Social Research analysed the effect of the IB reassessment programme on the combined Incapacity Benefit (IB)/Employment and Support Allowance (ESA) caseload:[107] the trend in the number of people receiving these benefits had already peaked in 2004; it then fell slowly until 2008, went up a little after the financial crisis, then began to fall again; the falling trend accelerated in 2011, only to abruptly reverse in the second half of 2013.[108]

The caseload continued to rise until early 2015.

The Office for Budget Responsibility found that between 2010 and 2014 no savings at all had been made in the IB/ESA budget, which remained at more than £13 billion a year.[109] The government's fiscal watchdog then raised its forecast for spending on IB/ESA by a further one billion pounds a year, because more claimants than previously expected were being placed in the Support Group.[110]

Jonathan Portes, a former Chief Economist at the DWP, has described the botched IB reassessment programme as "the biggest single social policy failure of the last fifteen years".[108]

Maximus takes on the WCA

Maximus Inc. took over a revised version of the WCA contract - referred to by the company in its internal communications as the 'HAAS contract' - on 1 March 2015.[111][112]

The DWP hoped that a new contract and a new outsourcing partner would mean the start of a new chapter for the assessment. However, executives from Atos had complained that their firm had been lambasted for doing nothing other than "applying the legislation the government had laid out", adding that it was "massively over-simplistic" to think that choosing a different outsourcer would, in itself, deal with the flaws in the WCA process.[113][114]

Maximus said it would improve evidence-gathering prior to a face-to-face assessment, introduce specialist assessors for particular types of disability and communicate more effectively with claimants.[115][116] The firm acknowledged that hundreds more healthcare professionals would have to be recruited in order to clear the backlog of ESA claims and hit the contract's new target.[117]

Volume targets

Within six months of taking over the contract, the DWP expected Maximus to have the capacity to carry out one million assessments a year[118] - 250,000 more than Atos had achieved at its peak. This was intended to clear the backlog and then allow the department to order hundreds of thousands of reassessments of people who had already been granted ESA, in the belief that many would have recovered from their illness and so could be taken off benefits. Repeated assessments were one of four key tenets of ESA from the very beginning, but the programme had to be put on hold in early 2014.

At the end of October 2015, the DWP's director-general of finance was bullish about hitting this higher target when he appeared before a parliamentary committee, saying: "We are confident that [Maximus] will over-achieve the amounts of work over and above the forecast that was set".[119]

But at the start of November, Maximus's senior management team warned[120] its shareholders that:

On the same day, the price of shares in the company fell sharply, losing more than 20% of their value.[121]

National Audit Office

In January 2016, the National Audit Office (NAO) published its evaluation of the DWP's health and disability assessment contracts.[122] It said the cost of each WCA had risen from £115 under Atos to £190 under Maximus.[123]

The report went on to say that Maximus was facing "significant challenges with staff failing to complete training requirements" and revealed that in July 2015 - less than six months into the new contract - the DWP had been obliged to draw up a 'performance improvement plan' with Maximus because "volume targets were not being met".

The NAO also declared that the DWP had "allowed bidders to make assumptions about staff training that it knew were overly optimistic and difficult to achieve" and implied that the target set by the DWP of one million assessments a year was too ambitious, saying: "One experienced bidder withdrew from the process because it could not meet the required number of assessments". The next month, the most senior official in the DWP told a parliamentary committee that of all the bidders for the WCA contract, only Maximus and one other unnamed firm had submitted bids that anticipated hitting the DWP's ambitious new target.

Response from Maximus

In early February 2016, the senior executive in charge of the WCA contract at Maximus told Parliament's Public Accounts Committee:[124]

Press coverage

As the backlog shrank towards zero and the programme to reassess established ESA claimants got going again, the WCA process attracted more negative headlines in February 2016 after the DWP initiated reassessment proceedings against a military veteran in the advanced stages of Alzheimer's disease[125] and the most injured survivor of the London terrorist bombings of 2005.[126]

In May 2016, a man missing much of his brain was declared fit for work, despite cognitive impairment and problems with mobility.[127]

New volume targets

In March 2016, Iain Duncan Smith resigned as Secretary of State for Work and Pensions. In his resignation letter, he complained that his plans were not being adequately funded, saying that there was "not enough awareness from the Treasury, in particular, that the Government's vision of a new welfare-to-work system could not be repeatedly salami-sliced". Shortly afterwards, sources close to the new Welfare Secretary, Stephen Crabb, told The Sunday Times that a contract with Maximus was "under scrutiny", which the newspaper implied was the WCA contract.[128]

In early May, Maximus senior executives admitted that the target of one million WCAs a year had been "very, very challenging" then revealed that government planners had lowered their expectations after a spending review. The executives said:

The contract was modified to put a greater emphasis on carrying out face-to-face assessments at a reduced level. This will achieve DWP's service goals, while at the same time delivering greater value for money overall.

There has also been speculation within the investment community that the contract was under review for cancellation or significant changes. I want to dispel that myth today...We've had personal reassurances from DWP that the Secretary of State has not expressed concern over the continuity of the contract. Further, there's no current plan on making substantial changes or terminating the contract.[129]

Policy overhaul

At the beginning of October 2016, the recently-appointed Work and Pensions Secretary, Damian Green, said it was "pointless" to reassess claimants if it was clear that their clinical condition had no realistic prospect of improvement or would only get worse.[130]

He said:

If someone has a disease that can only get worse then it doesn't make sense to ask them to turn up for repeated appointments. If their condition is not going to improve, it is not right to ask them to turn up time after time. So we will stop it.[131]

In a later statement, he revealed that the policy change would not be formalised before the end of 2017. Medical and operational factors had not been worked out and the "IT changes needed" prevented it from happening sooner - although Green did say: "In the meantime, we will be working to ensure that people with these conditions are not reassessed unnecessarily".[132]

Green was asked by the Scottish Parliament's Social Security Committee if there was a list of conditions that would be exempt from reassessment by WCA. He replied:

It's not the condition. Well, I mean, we know which conditions degenerate or which conditions don't improve. I think the - but the key is, it's got to be individualised. It all fits in with that pattern: that there will be people who, at some stages of having, say, multiple sclerosis can work and at some stage it may get to the point where they can't work. What I'm saying is that, If they've got to the point where they've been assessed as being unable to work, then with a condition like that, there is no point calling them back in two years time saying we're going to reassess you because we know it won't have got better.[133]

At the end of October 2016, the government published a Green Paper outlining its plans for ESA, which included the possibility of another "overhaul" of the WCA in the future.[134][135]

Credibility of the test

Apart from questions arising from the substantial proportion of 'fit for work' recommendations that are disregarded by decision-makers or overturned by tribunals or by the DWP itself, concerns about the reliability of the WCA as an indicator of fitness for work have arisen from a number of other sources.

Outcome targets

Professor 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:

They say not, and whenever I have gone anywhere, they say not. This is purely anecdotal, but there was one Atos assessment centre I went to where the bosses walked out and I was left with a couple of assessors having a cup of coffee at the end of the session, and they told me they were under pressure.[55]

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".[37] The undercover doctor was told:

If it's more than I think 12% or 13%, you will be fed back 'your rate is too high'

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 deny having had any target for getting claimants off sickness benefits. However, both have admitted that Support Group 'norms' were in use nationwide,[136] though they 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.[137]

In the phase from the inception of the WCA in October 2008 to November 2010, only new claims for ESA were assessed. Figures obtained by the Daily Mail in July 2011 showed that in this period, the percentage of claimants placed in the Support Group after undergoing a WCA was 11%.[138]
Soon afterwards, a 'norm' of 1 in 8 or 12.5% was in use as the benchmark for targeted audit during the Incapacity Benefit reassessment programme, suggesting that the DWP was expecting a very similar proportion of claimants to be recommended for the Support Group overall.
However, Professor Harrington has described the set of people making fresh claims as "a completely different group of people" from long-term recipients, who generally have a significantly higher level of disability than new claimants. Moreover, studies of long-term Incapacity Benefit recipients carried out by the DWP before the 'roll out' of the Incapacity Benefit reassessment programme suggested that 31% of established recipients - almost 1 in 3 - would be suitable for the Support Group.[139] Despite this, the 'norm' does not appear to have been adjusted upwards to reflect the more severe disabilities experienced by the people being tested from 2011 onwards.

In 2013, the Work Programme's training providers - outsourcing companies who coach and train people put into the Work-Related Activity Group after their WCA - 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.[140]

Much later, a Green Paper provided more evidence that a de facto outcome target had been in use. In 2016 the government conceded that:

At the time Employment and Support Allowance was implemented in 2008 it was assumed that less than 10% of those having a Work Capability Assessment would go into the Support Group and that, as a result of [the extra help to find work given to people in the Work-Related Activity Group], there was an aspiration that one million fewer people would be on incapacity benefits by 2015. In practice, over the last 12 months, we have seen on average 50% of people going into the Support Group.[141]

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 the WCA, it said:

Evidence indicates several flaws in the processes related to the Employment and Support Allowance. In particular, the Committee notes that, despite several adjustments made to the Work Capability Assessment, the assessment has continued to be focused on a functional evaluation of skills and capabilities, and puts aside personal circumstances and needs, and barriers faced by persons with disabilities to return to employment, particularly those of persons with intellectual and/or psychosocial disabilities.[142]

The DWP responded by saying that promoting and enabling work for persons with disabilities was a high priority and it described the various ways it was trying to bring this about. The department emphasised its hopes for the future, especially the aspirations outlined in its recent Green Paper.[143]

Expert opinion

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".[144]

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".[145]

Professor Dame Carol Black advised the government on back-to-work policy between 2006 and 2016; in that time, she reviewed the role of the WCA as part of a formal report to government submitted in 2011. More recently, in October 2016, she said of the test: "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.[146]

Politicians' assessments

In October 2015, the minister who had been the Work and Pensions Secretary since 2010 said the WCA had been "unbelievably harsh" when it was first introduced.[147] Iain Duncan Smith also 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".[148]

Later the same year, the Shadow Secretary of State for Work and Pensions, Debbie Abrahams, said the test her party had described in 2010 as "tough but fair" was now "discredited"; she said her party would "scrap" it.[149]

In late October 2016, 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.[150]

In September 2016, Damian Green, the latest Welfare Secretary, was asked by the BBC's Andrew Marr about the deaths of specific benefit claimants:[151]

You know these cases, they must be on your desk, you've been [at the DWP] over the summer, when you look at them, are you completely satisfied yourself that the government has done this right in the past? Do you want to look again at any of these cases and think again about the way disabled people are assessed for work?

In reply, the Secretary of State acknowledged that "obviously there are individual cases where it looks as though the system is not working". Marr asked once more: "Are you going to look again at the way people have been assessed generally to see if it has been as fair and humane as [...] you would like it to be?" Green replied:

I am permanently looking at all these systems. And of course, there are tens of thousands of these assessments going on all the time. There will, I dare say, be individual cases that are wrong and as they are brought to the attention of ministers we look at them.

Fitness for work, risk, and avoidable deaths

The DWP accepts that being found fit for work and ineligible for sickness benefit can, in some circumstances, harm a recipient's physical or mental health. For this reason, one of the WCA's eligibility criteria - the non-functional descriptor Substantial Risk - applies where there is, on balance, more than a small risk of harm if the claimant were to be declared 'fit for work'. In these circumstances, the at-risk person should be given the benefit.

Post-mortem case reviews

The DWP has looked into the deaths of at least 49 benefit claimants. Most died after undergoing a WCA. The department was compelled to publish their findings in May 2016 after a campaign by Disability News Service.[152][153] The conclusions of the heavily redacted reports included:

  1. A "persistent area of possible concern" was "a dislocation between policy intent and what actually happens to claimants who may be vulnerable"
  2. The Incapacity Benefit reassessment programme lacked a clear system for identifying vulnerable recipients
  3. DWP staff did not always check the DWP's database for indicators that claimants were at risk
  4. The WCA's medical criteria for identifying risk were not properly applied
  5. Claimants with cognitive problems were not filling in their claim forms in the manner that the DWP had envisaged (or at all)
  6. Requests by claimants for a reconsideration of the department's initial decision - while waiting for which, the claimant receives no sickness benefit - were not prioritised in a "common sense" way
  7. Appeal dates for tribunals took too long
  8. The failure to apply the department's Six Point Plan for dealing with people with suicidal ideas was "a recurring theme"

Inquests and media reports

There have been several media reports of unexpected deaths after assessments where the claimants seem to have been at risk of harm if found fit for work.

TIMESCALE
The most widely reported deaths followed assessments that took place in the seven months from December 2012 to June 2013. The deaths themselves were clustered around the summer of 2013:
Tim Salter (assessed December 2012; deceased September 2013)
Linda Wootton (assessed February 2013; deceased April 2013)
Mark Wood (assessed March 2013; deceased August 2013)
Michael O'Sullivan (assessed March 2013; deceased September 2013)
David Barr (assessed June 2013; deceased August 2013)

Tim Salter

Tim Salter was visually impaired as a result of brain damage from a previous suicide attempt. He killed himself after being found fit for work. At his inquest, the coroner said: “A major factor in his death was that his state benefits had been greatly reduced, leaving him almost destitute and with threatened repossession of his home”.[154][155]

Linda Wootton

Linda Wootton had undergone two heart-and-lung transplants and was left with a weakened immune system caused by the immunosuppressant therapy she was taking to prevent her body rejecting the transplanted organs. She died days after the DWP upheld its decision to declare her 'fit for work' (neither the assessor, the first decision-maker nor the second official who reviewed her case had deemed her to be at substantial risk of harm).[156][157]

Mark Wood

Mark Wood was receiving Incapacity Benefit and Disability Living Allowance because of long-term mental health problems, including a "phobia" of some types of food and overvalued concerns about his food's freedom from contamination. He had been losing weight for many months before his WCA. He died, weighing 35 kg, after he was declared fit for work and his Incapacity Benefit and Housing Benefit were stopped (the DWP continued to pay him Disability Living Allowance). His family believes that the stress of his forthcoming WCA and then afterwards the loss of the bulk of his income damaged his already fragile mental state, worsened what the DWP called his "eating disorder" and so contributed to his death.

The Oxfordshire Coroner delivered a narrative verdict in which he said the final pathological event was "unascertained", but he saw no significant evidence of neglect or self-neglect (neglect has a very precise legal definition), suicide, or unlawful killing (for which a high evidence threshold must be crossed before a coroner can deliver it as a verdict).

The DWP carried out a post-mortem case review then admitted that the decision to declare him fit for work had been wrong, but the department denied that its decision had contributed to his death.[158]

In response to the case, Tom Pollard of the mental health charity Mind said:

Unfortunately this tragic case is not an isolated incident. We hear too often how changes to benefits are negatively impacting vulnerable individuals, who struggle to navigate a complex, and increasingly punitive, system. We know the assessment process for those applying for employment and support allowance is very stressful, and too crude to accurately assess the impact a mental health problem has on someone's ability to work. This leads to people not getting the right support and being put under excessive pressure which can make their health worse and push them further from the workplace. We urgently need to see a complete overhaul of the system, to ensure nobody else falls through the cracks.[159]

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.[160]

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 [in the Training and Development ESA Filework Guidelines] 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 [information on the claim form], the healthcare professional must request further medical evidence".[161]

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 coroner said there was a causal link between his intense anxiety, the assessment and the consequences. His daughter has been asking for answers to how that happened, what went wrong...and she hasn't got answers for three years...it really deserves to be looked at.[162]

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.[163]

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 after a risk assessment - by a physiotherapist - that led the DWP to deny his claim for ESA.[164] The department later admitted that its decision was wrong; it said he should have been categorised as being at substantial risk of harm.[165][166]

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.[167] 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[168] – 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.[12][169][170][171]

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;[172] 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."[173]

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] initially stated that it did not monitor deaths that occurred after assessments. Evidence gathered during the inquiry indicated that, in 2012 and 2015, such information was released by the Department for Work and Pensions following freedom of information requests. Additionally, information originated from official sources indicated that 33 deaths of claimants who died after being assessed were examined. The [DWP] claims there is no causal link. The Committee is not aware of any attempts at objective, thorough, open and impartial investigation regarding those deaths by an independent body.[174]

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.[175]

Other out-of-work welfare reforms

After the General Election in May 2015, the new Conservative government declared that welfare reform was ultimately about creating "a complete shift in the welfare culture"[176] and pointed to the large number of jobless people who had found work during the economic recovery that had begun in 2013. As part of this trend, the number of people claiming Jobseekers Allowance (JSA) fell back dramatically to prerecession levels[177] and a saving of up to one billion pounds a year was hoped for in JSA costs.[178]

In January 2016, overall unemployment fell to its lowest level since 2005.[179] New data showed that the IB/ESA caseload had fallen by 12,000 in one month, although the total number of sickness benefit recipients was little different from what it was in 2011 when the IB reassessment programme was launched.

I, Daniel Blake

In October 2016 the film drama 'I, Daniel Blake' was released, directed by Ken Loach. The eponymous character, a man in late middle-age who has worked all his adult life, has recently had a heart attack. As the film begins, his recovery is incomplete and his cardiologist is concerned that Daniel's heart might begin to beat in an abnormal way, putting him in danger of developing a life-threatening arrhythmia.

Daniel has fair day-to-day function - he can shop, do DIY and generally look after himself - yet manages to score 12 points at his WCA. However, the points tally is below the threshold of 15 needed to qualify for ESA on points alone. For reasons the film does not explicitly state, the non-points-based criterion covering people at risk - which would in theory have qualified him for ESA - is neither recommended by the assessor nor applied by the DWP decision-maker. He is then declared 'fit for work'.

Daniel is now caught in a dilemma from which there is no obvious escape: if he works - against the advice of his medical specialists - he risks sudden death from his heart condition; if he doesn't work, he will receive no social security benefits and so be left destitute. His only hope is a favourable outcome from the appeal tribunal.

The film won the Palme d'Or at Cannes.[180]

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