Work Capability Assessment

The Work Capability Assessment (WCA) is the test designed and used by the Department for Work and Pensions (DWP) in the United Kingdom to determine whether disabled welfare claimants or those suffering from long-term illnesses are entitled to the main out-of-work sickness benefit: Employment and Support Allowance (ESA). The introduction of the WCA as the gatekeeper to ESA was a crucial part of the out-of-work benefit reforms of 2008^[1] that the next government continued and developed.

The WCA aims to sort sickness benefit claimants into three groups: fit for work; unfit for work but fit for pre-employment training; or fit for neither work nor training. The DWP views this as the first step in a process that helps some disabled people "off benefits and into work" but the testing procedure has proved highly controversial, with concerns loudly expressed about inaccurate decision-making and the difficulties and delays faced by claimants when they launch an appeal.^[2]

Atos Healthcare, part of the UK branch of the Paris-based multinational Atos, conducted the core assessment on behalf of the DWP from October 2008 until 1 March 2015, on which date the American firm Maximus took over.

Labour and the two former coalition parties all support the principle of ESA – to encourage work and thereby reduce welfare spending – but few observers now see the deployment of the WCA as a success, in economic terms or otherwise. More than seven years since it was introduced it is still not clear that the test will ever work as intended, and there is persistent criticism of the leadership skills and integrity shown by government ministers and officials during the long attempt to launch what was once a flagship welfare reform.^[3][4][5]

Evolution of the 'fitness for work' test

Before 1995, entitlement to the payment known as Invalidity Benefit was decided by an Adjudication Officer, based in large part on the opinion of claimants' own doctors.

In 1995, Invalidity Benefit became Incapacity Benefit (IB) and the now defunct Department of Social Security began commissioning its own medical assessments using its new 'All Work Test'.^[6] The change came about partly as a result of the view that a mainly clinical opinion from an individual's doctor might not be an accurate reflection of the barriers to work faced by the claimant (it has also been noted that some symptoms that can have an impact on the ability to work, such as pain and fatigue, can be difficult to gauge using the traditional medical model). From this point on, the testing process looked at the ability of the claimant to do a range of jobs, not just their previous trade.

In 2000, the All Work Test was replaced by the Personal Capability Assessment. Mansel Aylward was at that time Chief Medical Adviser, Medical Director and Chief Scientist of the UK Department for Work and Pensions and was influential in the development of the new process.

In 2007 the New Labour government passed the Welfare Reform Act^[7] which – for fresh claims, initially – would, the following year, introduce Employment and Support Allowance as the main out-of-work sickness benefit, with the new Work Capability Assessment acting as its gatekeeper. The aims were: to accentuate the positive by "looking at what you can do, not what you can't do"; to make the test for out-of-work sickness benefits more stringent; 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.

To comply with the terms of the 2007 Act the DWP appointed Professor Malcolm Harrington,^[8] an academic with a background in occupational health, to review the WCA system in 2010.^[9] In November of that year he published an initial report that included 25 recommendations.^[10][11][12] In his second report he reviewed the test's ability to assess people with mental health problems and conditions that can fluctuate in severity from day to day^[13][14] (in 2012, DWP ministers decided to replace Professor Harrington;^[15][16] as his successor they appointed Dr Paul Litchfield, a senior figure in the Royal College of Physicians' Faculty of Occupational Medicine).^[17][18][19]

In early 2011, the Conservative-Liberal Democrat coalition government brought forward the planned expansion of the programme and reassessed 1.5 million people whom the DWP had previously judged, before the introduction of ESA and the WCA, to be entitled to Incapacity Benefit.^[20][21] At the same time the DWP revised the framework of the test, with the result that the eligibility criteria became even more stringent: 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 either moving onto Jobseekers Allowance or into a training programme and then into work.^[22] As a result, a saving of at least £3billion annually in the IB/ESA budget was anticipated by the end of the parliament.^[23][24]

The work capability assessment process

When the New Labour government introduced the 'fit for work' test, it contracted out the core medical component to its existing partner for disability assessments: Atos Healthcare, which was already conducting assessments on people claiming a range of other disability benefits, including Disability Living Allowance and Industrial Injuries Disablement Benefit.^[25] On 1 March 2015, the US company Maximus^[26] assumed responsibility for carrying out these assessments^[27] through its subsidiary, the Centre for Health and Disability Assessments (CHDAUK), also known as the Health Assessment Advisory Service.^[28]

The process starts with an assessment by a registered healthcare professional employed by the outsourcing firm, after which an official from the DWP first decides on entitlement to Employment and Support Allowance and then 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. In this way, someone can be classed as 'unfit for work' but still apply for jobs and get them without penalty.

The WCA in theory

The assessment process^[29] 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 strength of a claim is largely determined by comparing the claimant's problem with a framework of set criteria, known as 'descriptors', in a procedure that draws on occupational health theory, broad clinical knowledge, and the field of 'functional assessment' – a subspecialty concerned with gauging and validating the practical impact of a physical or mental impairment on a person's daily life and, in the context of the WCA, on their ability to work.

The descriptors^[30] are split into 'functional' and 'non-functional' descriptors. The functional descriptors are then subdivided, depending on whether physical or mental function is affected. Each functional descriptor comes with a 'score' of 6, 9 or 15 points that is intended to reflect the relative severity of the impairment; the assessor's core 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. If the assessor deems that none of the functional descriptors apply – despite what the claimant might have said on the claim form – the total score will be zero. A successful claimant will normally score at least 15 points in total.

For example, the activity 'Manual Dexterity' – hand function – comes with the following descriptors for the assessor to choose from:

• The claimant cannot use a computer keyboard or mouse (9 points)
• The claimant cannot use a pen (9 points)
• The claimant cannot pick up a small object (15 points)
• The claimant cannot press a button or turn a page (15 points and a place in the Support Group)

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:

• Mobilising
• Standing and sitting
• Reaching
• Picking up and moving an object
• Manual dexterity
• Making yourself understood
• Understanding others
• Finding your way around
• Continence
• Consciousness

The mental functional descriptors cover:

• Learning tasks
• Hazard awareness
• Planning and problem-solving
• Coping with change
• Getting about
• Coping with other people
• Behaviour

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

• The claimant cannot eat or drink
• The medical condition is life-threatening and uncontrollable
• The claimant will probably die within 6 months
• The claimant's health would be at real risk if they were found fit for work

Other factors that might be taken into account include:

• The claimant is pregnant
• There is a risk to others
• Intravenous therapy is being administered
• The claimant has cancer

A 'yes' answer to a non-functional descriptor question or – for most but not all activities – a 'top score' in one area will usually qualify the claimant for the Support Group (but several scores of 9, for instance, will not).

The process also usually gathers a large amount of information about the claimant's day-to-day life, to build up a picture of what is officially termed their 'Typical Day'.

One criticism of the WCA is that there is nothing built into the core assessment to draw a distinction between disabilities that will never change and conditions that are known to change over time: the picture is only a 'snapshot' taken at the time of the assessment (although a prognosis is usually given after the main assessment, its accuracy will depend on the medical knowledge of the assessor, which varies according to their professional background and clinical experience).

In summary, the process uses fixed criteria and a system of points in an attempt to:

• Identify those claiming ESA who have no disabilities or disabilities that, in a legal sense, are not significant.
• Identify those claiming ESA who, because of the nature of their disability, face significant barriers to work.
• Identify those claiming ESA who have one or more severe functional disabilities; they are usually then deemed to be incapable of participation in work-related activity.

The healthcare professional:

• Answers factual questions that have a bearing on eligibility, such as: "Is the claimant an expectant mother?" or "Is the claimant being treated with radiotherapy?".
• Delivers clinical judgements, such as on whether the claimant is at substantial risk or terminally ill.
• Supplies a prognosis based on their medical knowledge.

And a face-to-face assessment will gather detailed information about the claimant's day-to-day life.

The WCA 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 a claimant probably has both limited capability for work and limited capability for work-related activity (in other words: the claimant would be likely to get a 'top score' for certain functional activities, or a non-functional descriptor would probably apply) 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, physiotherapists or occupational therapists – are guided and prompted by a computer programme, designed by Atos in conjunction with the DWP, called the 'Logic-integrated Medical Assessment' or 'LiMA' (despite no longer carrying out WCAs directly, Atos is still paid by the DWP to operate LiMA because Atos owns the software, although the DWP owns the intellectual property rights). A large amount of lifestyle data and some clinical information is obtained from the claimant and is entered into the computer by the assessor. 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.

After the interview and examination the findings are summarised in free text using Standard English prose, and a typed report – largely, apart from the summary, constructed from modified pre-set LiMA options – is sent electronically to the DWP. This report attempts to describe the claimant's 'Typical Day' 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^[31] (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 intended to reflect the level of disability together with a final recommendation on fitness for work and a work-related prognosis. If the assessment is carried out in the claimant's home, the report is usually written by hand and is substantially shorter (normally, only doctors are authorised to write reports by hand, i.e. without using LiMA).

If assessors encounter practical difficulties or are unsure how to apply the test's criteria in specific cases, telephone advice is available.

These assessments^[29] have been criticised for their repetitive impersonal style, while the reports have been criticised for several aspects of their overall quality as well as for the accuracy of their recommendations.^[32][33] Poor evidence-gathering before an assessment, a 'computer says no' attitude to eligibility, and a reluctance to recommend successful claimants for the Support Group are perceived as historic faults in the system. The reliability of LiMA in gauging disability has never been independently demonstrated.

The decision-maker

The task of the DWP official is to establish from the evidence whether or not the claimant has 'Limited Capability for Work' i.e. whether they are entitled to ESA at all; if they are, officials then have to to decide on whether the disabled person has 'Limited Capability for Work-Related Activity' i.e. whether they are capable of taking part in 'work-related activity' (usually interpreted to mean pre-employment training). If the person qualifies for ESA but is deemed not to have limited capability for work-related activity, they will be placed in the Work-Related Activity Group (WRAG) and will take part in mandatory training; they will also receive less money than those selected for the other category – the Support Group – where training is not compulsory (in the July 2015 Budget, it was announced that new claimants put into the WRAG after April 2017 will receive no more money than if they were on Jobseekers Allowance).^[34]

People in the Support Group usually, but not invariably, have more severe disabilities than those in the WRAG: a 'top score' for one functional activity or the application of a non-functional descriptor is almost always the reason why a claimant is put in the Support Group (but someone with multiple problems who scores 9 for several activities would not normally qualify for the Support Group; on the other hand, someone with little apparent disability in their day-to-day life will normally go into the Support Group if their health would be at risk if they were declared fit for work).

There is little in the core test that separates disabled people who are likely to be able to work at some point in the future from those who are not: people in the Support Group can and do apply for, and get, full-time jobs.^[35] Furthermore, the claimant's ability to cope with work-related activity is not specifically evaluated on an individual basis within the core assessment: the architects of the WCA took the view that a severe problem in one functional area – such as being unable to point a finger under 'Manual Dexterity' – would make employment-related training too difficult, whereas a less severe problem in the same functional area – such as being unable to form a pinch grip with the index finger and thumb – would not.

For these reasons, the assertion that there is a clear distinction between the two categories of ESA claimant is difficult to sustain.

In practice, when the assessor's report is sent by the outsourcing firm to the DWP it already contains the assessor's opinion on fitness to work and on suitability for the Support Group, but it is an official that makes the final decision. This decision takes into account: the assessor's recommendation; any other available medical evidence, e.g., a sick-note or another DWP report, for example one from a previous Disability Living Allowance assessment; and the legal aspects of social security regulations pertaining to entitlement to benefits.

In 2014, 20% of fit-for-work recommendations from assessing healthcare professionals were overruled by a DWP decision-maker^[36] (up from 8% in early 2013).

The independent tribunal

If the claimant disagrees with the decision, he or she is entitled to ask the DWP to formally reconsider, though the onus is on the claimant to initiate this. If the result of this formal review 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 tribunals take evidence from appellants and observe them during the hearing but the medical member of 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, but they do not use LiMA nor set out to delineate the claimant's 'Typical Day'.

At the reconsideration stage the DWP reverses 20–25% of its own fit-for-work decisions, while a further 15% are reversed later by tribunals. Looking at the overturn rate based on the rulings from independent legal hearings, since mid-2013 most appellants who have got as far as a tribunal have seen the DWP's decision overturned by that tribunal.^[37][38][39]

The work-related activity group compared to the support group

The latest data show that two-thirds of new claimants now qualify for the Support Group, while less than a quarter are declared fit for work. The remainder – less than a seventh – are put in the Work-Related Activity Group or 'WRAG'.^[37]

The WRAG generally contains people with less severe disabilities than those in the Support Group.

However, the WRAG and the Support Group both contain people whom a disability analyst has deemed to face significant extra barriers to work because of their ill-health or disability. Members of both groups have been accepted by the DWP as being entitled to ESA, though 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".^[40]

The clinical prognosis has no bearing on whether the claimant is placed in the WRAG or the Support Group (except when the claimant is terminally ill). At the end of a WCA, the assessor gives an estimate of the timescale for return to work, but again this prediction has no bearing on whether the claimant goes into the Support Group or the WRAG – it is used by the DWP to decide when to review the claimant again.

In practice, people almost always go into the Support Group because one of the following applies: they have one or more relatively severe restrictions of function, such as being unable to move over more than a short distance; their health would be at risk if found fit for work; they are receiving intensive treatment as an out-patient; or they are terminally ill. But at first, the DWP envisaged that the two categories of ESA would contain people with few differences in their level of disability. At the planning stage, the intention was to use the WCA to identify claimants who, though their underlying condition was not necessarily expected to improve, might nevertheless become more employable through some of the following: focussed rehabilitation, such as learning Braille; the use of an aid, such as a walking frame; or an adaptation to the workplace, such as a bespoke computer keyboard built around the disability. But in practice, the help given to people in the WRAG has been predominantly delivered through the generic Work Programme. As a report produced for the mental health charity MIND concluded, it would be wrong to suggest that people in the WRAG are 'fit to work'; that their impairments are expected to improve any more rapidly than those of claimants in the Support Group; or that the barriers they face are primarily a lack of relevant work experience or the need for advice on how to apply for a job.^[41]

The WRAG is seen by the DWP as containing people who are more likely to return to work in the future because their disabilities are less severe than the disabilities of people in the Support Group; this argument assumes that it is the severity of a disability rather than its type that determines the size of the barrier a disabled person faces when looking for work.

As an illustration of the difference in health between those in the WRAG and general jobseekers, figures released by the DWP in August 2015 showed that people in the WRAG are nearly four times more likely to die than people on Jobseekers Allowance.^[42]

2011–2013: the test meets a barrage of criticism

The first 'fit to work' assessments using the WCA format took place in October 2008, but the test only came to the attention of the general public after March 2011 when the DWP began to reassess welfare recipients it had previously judged to be too ill to work. Although, technically-speaking, claimants were simply being evaluated for transfer onto a new benefit with more stringent eligibility criteria than before, the purpose of the process was not made clear to the claimants 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.^[43] 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".^[44]

The WCA was then loudly criticised: in Parliament,^[45] by the Catholic Church,^[46] by the medical profession,^[47] by welfare rights advisers,^[48] and by disability organisations and protest groups.^[49][50][51] In 2012, 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"; in the same year, MPs debated the WCA and Atos Healthcare.^[52] Since then there has been considerable pressure applied by parliamentarians of all parties^[53] – but particularly by Michael Meacher,^[54] Tom Greatrex ^[55][56] and Sheila Gilmore – for improvements to the 'fitness to work' assessment. Greatrex also wrote to the Prime Minister to bring to his attention allegations made by a whistleblower 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; Greatrex described the response as "woefully inadequate".^[57]

Patients with brain damage,^[58] cancer, multiple sclerosis and Parkinson's Disease have been found fit for work.^[59] On 24 April 2013, a woman who was a double heart and lung transplant patient died in hospital only days after she had been told that her Incapacity Benefit was being stopped and that she was fit for work.^[60][61]

The Multiple Sclerosis Society of Great Britain produced a report describing the experiences of 1,780 of its members who had undergone DWP disability assessments. 57% said the test they underwent did not accurately measure the effect of their condition, while more than a third felt the face-to-face assessment had caused their condition to relapse or deteriorate.^[62]

Criticism has been directed at the test over its ability to deal with mental health problems.^[63] In an attempt to remedy this, Atos Healthcare 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^[64] – a response to one of two key recommendations made by Professor Harrington. The other legacy of his tenure was the introduction in 2011 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.^[65] Nevertheless, the DWP insisted that assessors still write summaries, saying that decision-makers found them helpful when trying to understand the main reports. This summary, though time-consuming for Atos assessors, made little discernible impact on the level of criticism of the WCA.

In 2012, The Independent reported that 43 complaints against Atos doctors and nurses were being investigated by the General Medical Council or the Nursing and Midwifery Council^[66] but Atos later countered that the number of formal complaints is small in comparison to the total number of assessments. At a meeting in June 2012 British Medical Association doctors voted that the WCA should be ended ‘with immediate effect and be replaced with a rigorous and safe system that does not cause unavoidable [sic] harm to some of the weakest and vulnerable in society’.^[67]

In 2013 the Public Accounts Committee of MPs chaired by Margaret Hodge heard evidence that, in 2011/12, Atos was paid £112 million to carry out 738,000 assessments. At that point in 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).^[68] 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"^[69] and concluded: "The Department's got to get a grip of this contract!".^[70]

Also in 2013, the UK Statistics Authority disproved a widely-reported ministerial statement that "nearly a million" Incapacity Benefit recipients had dropped their claims rather than be reassessed by Atos. Andrew Dilnot, chairman of the UK Statistics Authority, found that the figure appeared to "conflate" new claims for Employment and Support Allowance with long-term Incapacity Benefit recipients coming up for reassessment.^[71][72]

On 22 May 2013, a tribunal carrying out a judicial review ruled that the WCA process was unfair to people with cognitive impairment and other mental health issues: the upper tier tribunal said that such claimants were at a disadvantage when gathering and presenting evidence in support of their claims.^[73] The DWP disagreed.^[74]

In the same month, a Freedom of Information request by Reading councillor and Chair of Reading Borough Council’s Access & Disabilities Working Group, Pete Ruhemann, revealed that: "28 of the 140 medical assessment centres, or 20 percent, do not provide wheelchair access," and, "[m]any, including the larger centres, are on the second or third floor". Furthermore, the "great majority do not have associated parking".^[75] The councillor characterised this national situation as, "a disgrace".^[75] It has been revealed that Atos has already made an out-of-court settlement with one user, "for disability discrimination […] over access."

Also in May, a doctor who had resigned from Atos after refusing to downgrade his rating of the disability of 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" and accused the DWP of "pulling strings behind the scenes" to boost the number of fit-for-work recommendations being made by the outsourcing firm. The news report drew attention to unduly harsh interpretations of the criteria for awarding points, on key abilities such as mobility and mental concentration, that the former mental health lead had claimed were being taught to WCA assessors^[76][77][78] – to which Atos replied that it was the DWP that was responsible for setting the training curriculum, not Atos.^[79]

Quality of the reports

The major criticism of the reports written by WCA assessors was that their recommendations were often inaccurate: people were being declared fit for work when they weren't, while others who were entitled to ESA were being recommended for the Work-Related Activity Group when they belonged in the Support Group.

Other criticisms came from several sources:

• Claimants. People going through the test sometimes said that comments attributed to them about their ability to carry out everyday tasks did not reflect what they had told the assessor in the interview
• Outside observers. Professor Harrington, who reviewed the WCA's performance in 2010, 2011 and 2012, felt that generally the reports did not adequately explain how the recommendation on fitness for work had been reached. This was because reports typed on the computer were constructed largely from preset 'one-click' phrases - albeit ones that could be modified manually by the assessor. He therefore recommended that reports be summarised in plain English. At the behest of the DWP, Atos trained its assessors to do this in 2011. Two years later, the Chartered Society of Physiotherapists told Professor Harrington's successor that some reports were "comprehensive and easy to read" but others were "poorly drafted, contradictory and contained typing errors"^[80]
• The DWP. In the summer of 2013, the DWP said that, despite Professor Harrington's earlier work, it was still the case that reports too often contained insufficient justification of the recommendation made on fitness for work.

The 'quality improvement plan': assessors retrain or leave

On 22 July 2013, the DWP announced that it had directed Atos to put in place a 'quality improvement plan' and said it would be bringing in a new firm to carry out the assessments, at this point supposedly in addition to Atos to boost capacity. The DWP said the move followed an audit of reports produced in the six months to April 2013 (when Atos furnished more than 300,000 recommendations on fitness for work) in which the DWP said that it had found 164 that were given a 'C' grade for the quality of the report. The DWP went on to say: "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."^[81]

The 'quality improvement plan' amounted, almost entirely, to the retraining and re-evaluation of all Atos WCA assessors. Officially, its purpose was to ensure that a full record was made of the claimant's 'Typical Day' (where the assessor asks the claimant to describe how they carry out everyday tasks) and a full explanation of the recommendation on fitness for work was given in the report. Technically, this latter requirement meant that even small details of questionable significance had to be rigorously evaluated.

The retraining had begun in June (the DWP held this news back for a month; the announcement appeared on the same day as the news of the birth of a royal baby) and it went on until the late autumn of 2013. The handbook used by assessors was revised in-house, although the update - which had a new focus on how to gauge mobility, continence, vision, mental health and risk, and included specific advice on how to assess claims from people suffering from motor neurone disease - was not made public until 2015.^[82]

The immediate impact of the retraining was an increase in the average time taken to carry out a face-to-face assessment - from around 50 minutes to about 80 minutes - and an increase in the already-high attrition rate of Atos assessors (this more rapid loss of assessors was at least partly voluntary, although a DWP director told Parliament in December 2013 that some assessors had left because they could not pass the re-evaluation).

In the second half of 2013, a long-term trend emerged: the number of people on ESA began to rise, as did the proportion of claimants going into the Support Group.^[37]

In the summer of 2014, the BBC reported a backlog of more than half a million new claims caused by longer assessments and a dearth of assessors – unintended consequences of the 'quality improvement plan' begun the previous year.^[83]

Atos quits the contract

In the middle of 2013, the Coalition's attitude towards the WCA underwent a sea-change. PricewaterhouseCoopers were called in to audit 'quality issues'^[81][84] and in the autumn reshuffle the Prime Minister ordered the incumbent of the ministerial post with responsibility for the WCA to return to the backbenches.^[85] In December, in a statement to the Work and Pensions Committee, the new Disabilities Minister criticised the test and blamed the Labour government which introduced it, describing the assessment process as a "mess" that the Coalition had been obliged to pick up when it came to power.^[86]

Meanwhile, Atos called in its own firm of auditors and began to secretly negotiate an early exit from its £500m WCA contract with the DWP in Great Britain (but not in Northern Ireland, where the contract with the devolved Department for Social Development remained intact).^[87][88] In February 2014 the French firm went public, citing death threats to its staff, criticism from Labour MPs and its own opinion that the WCA was "not working" as the reasons why it wanted to quit.^[89] At the same time, the company removed the 'Atos Healthcare' branding from its occupational health division and rebadged it as 'OH Assist'.^[90]

In March 2014, when responding to Dr Paul Litchfield's review of the WCA's performance in 2013 – in which the 'quality improvement plan' was barely mentioned^[91] – the Disabilities Minister poured more scorn on the WCA process and once again blamed the previous Labour government. The minister said: "...the system we inherited from the previous administration was not fit for purpose. The process was riddled with problems..." and declared that as well as extending the testing process to assess more than 1.5 million people already on Incapacity Benefit, ministers and officials had been trying to fix the problems since coming to power.^[92] At the same time, the minister told 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 (but which was erroneously represented by some media organisations as Atos being 'sacked').^[93][94]

The DWP continued to employ the French firm to assess most new claims for the Personal Independence Payment (PIP).^[95] In July 2015, Atos began to reassess long-term recipients of Disability Living Allowance for suitability for transfer to PIP.^[96] The Veterans Agency had voiced no concerns about the work of Atos doctors in the assessment of claims for War Pensions made by former members of the UK's Armed Forces.

Maximus and the health and disability assessment contract

At the end of October 2014, the DWP announced that the US firm Maximus – trading as the Centre for Health and Disability Assessments and the Health Assessment Advisory Service – would take over the contract from Atos in March 2015, only five months short of its natural end point.^[97][98] Maximus would be paid around £595m ($900m) to carry out Work Capability Assessments and a small number of other disability assessments over a period of three and a half years (equivalent to approximately £170m ($250m) per annum, although the exact amount depends on how close the firm gets to the DWP's target of a million WCAs a year: if the firm underperforms, it will earn less; if it exceeds the target, it will earn more).

On signing the contract, Maximus said that 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.^[99] However, concerns were expressed about whether this was truly the start of a new chapter when it emerged that, because it was the DWP that owned or leased most of the real estate, the assessments would continue to take place in buildings that were often difficult for disabled people to access. Some disability groups were alarmed to discover that key former senior staff from Atos and the DWP were going to transfer to the new provider, along with most of Atos's remaining assessors.^[100]

The president of the new outsourcer's health services division acknowledged that hundreds more healthcare professionals would have to be recruited in order to clear the backlog of ESA claims and boost capacity in the future.^[101] One strategy adopted by the firm was to raise the top pay offered to new nurses to almost £40,000 a year. In September 2015, anonymous healthcare professionals complained to Private Eye that they had been "lured" from secure NHS jobs by the prospect of a substantial pay rise, only to find themselves unemployed when they either didn't pass the exacting tests set for newly-recruited disability assessors by the DWP or they otherwise failed to complete their probationary period with the US firm.^[102] In response to the news report, Maximus said: "Inevitably, some people do not meet the required standard or voluntarily exit".

At the end of October 2015, the DWP's director-general of finance assured a parliamentary committee that the backlog of claims would eventually vanish altogether, saying: "The arrears figure...is probably nearer to 600,000 [sic] now...we are confident that [Maximus] will over-achieve the amounts of work over and above the forecast that was set".^[103]

At the start of November 2015, in a quarterly conference call with investors, the CEO of Maximus said that the backlog had fallen by a third since March.^[104] But Maximus's senior management team warned its shareholders that:

• "We're not achieving certain performance metrics, most notably volume targets"
• "The challenges we faced with the [WCA] contract resulted in reduced earnings outlook for fiscal year 2016" (which, in the United States, runs from 1 Oct 15 to 30 Sep 16)
• For "fiscal year 2015" (1 Oct 14 to 30 Sep 15, in which time Maximus held the WCA contract for seven months), revenues were at least $35million lower than anticipated
• Although recruitment of healthcare professionals had improved, their training and retention was still a problem
• The shortfall of assessors was expected to last until "the end of summer 2016"

On the same day, the price of shares in the company fell sharply, losing more than 20% of their value.^[105]

In January 2016, the National Audit Office (NAO) published its evaluation of the DWP's health and disability assessment contracts. It said:

• The backlog of ESA claims was 280,000 in August 2015 (with a further 130,000 more recent claims also waiting for a WCA)
• The cost of each WCA had risen from £115 under Atos to £190 under Maximus
• Maximus was facing "significant challenges with staff failing to complete training requirements"
• Half of the health professionals recruited by Maximus to carry out WCAs did not complete their basic training
• The DWP "allowed bidders to make assumptions about staff training that it knew were overly optimistic and difficult to achieve".^[106][107]

The NAO also implied that the target set by the DWP of one million assessments a year - which, once the backlog had been cleared, would allow the DWP to order hundreds of thousands of reassessments of people who had already undergone a WCA and been granted ESA - was too ambitious, saying: "One experienced bidder withdrew from the process because it could not meet the required number of assessments".^[108] The next month, the most senior official in the DWP told a parliamentary committee that of all the bidders for the £595m WCA contract, only Maximus and one other unnamed firm had submitted bids "above the line" that anticipated hitting the DWP's target of one million assessments per year.

In early February, the general manager in charge of the WCA contract at Maximus told Parliament's Public Accounts Committee:

• The WCA contract was an "assumption-based contract" and "we own the assumption" (about whether targets would be hit)
• A quarter of recommendations on fitness for work were being made on the paperwork, without a face-to-face assessment taking place
• When Maximus took over in March 2015, the backlog was 550,000
• On 1 December 2015, the backlog was 110,000
• In January 2016, around 75,000 assessments were performed (which would be 900,000 in a year)
• 186 doctors were working on WCAs at Maximus
• 748 assessors had transferred from Atos
• 70% of new assessors came from outside the NHS
• 1241 prospective assessors had been offered contracts, but only 364 had completed their training and been "accredited" by the DWP
• There was now a full complement of assessors at Maximus - around 1200 'full-time equivalents' (including about 90 still in basic training) - although many of the newer assessors still needed mentoring by more experienced healthcare professionals in order to hit the quality targets set by the DWP.^[109]

In the same month, the WCA process attracted more negative headlines when reassessment proceedings were initiated against a military veteran in the advanced stages of Alzheimer's disease^[110] and the most injured survivor of the London terrorist bombings of 2005.^[111]

Credibility of the 'fit for work' test

In 2012, the Public Accounts Committee in Parliament learnt that in nearly two out of three successful appeals to Ministry of Justice tribunals, appellants were seeing their points scores rise from zero in the original assessments – meaning that the assessors and DWP decision-makers had detected no relevant disabilities whatsoever – to 15 points or more after the tribunals had independently assessed the claims.^[112]

In the same year, 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 he put more than one in eight successful claimants into the Support Group (rather than the Work-Related Activity Group), he would be subjected to an increased level of management scrutiny through a mechanism known as "targeted audit".^[76] Both the DWP and Atos later admitted using "norms"^[113] to set the rate at which they expected assessors to recommend that claimants be put in the Support Group but they denied that "targeted audit" meant that there was a target for getting people off benefits, or that the norms artificially suppressed the number of claimants ultimately placed in the Support Group; Atos explained that the process merely detected outliers and was intended to ensure consistency across the firm's nationwide team of assessors: if an audit showed no cause for concern, no action would be taken against the healthcare professional.^[114]

In 2013, the Work Programme's training providers - outsourcing companies who coach and train people in the Work-Related Activity Group - complained about the process to Parliament: the firms had "ongoing concerns about the accuracy of the WCA"; they rated earlier improvements to the WCA as only "4 or 5 out of 10"; claimants who were "clearly unfit for any type of work-related activity" were nonetheless being put in the Work-Related Activity Group; and even "claimants with terminal cancer, whose life expectancies were shorter than the work-ready prognosis" had been referred to them for pre-employment training.^[115] Medical charities have perennial questions about the wisdom of trying to rehabilitate people who suffer from diseases that are only going to get worse.^[116][117]

In 2014, an MP asked the UK Statistics Authority to analyse and explain the high overturn rate of fit-for-work decisions by independent tribunals, as well as by the DWP itself at the pre-tribunal 'Reconsideration' stage.^[118] The MP's request was passed back to the DWP, after which nothing more was heard. The DWP has elsewhere^[81] suggested that this high overturn rate demonstrates the effectiveness of the system's checks and balances; critics say that it demonstrates the unreliability of the core assessment. When, in early 2014, Atos gave its reasons for seeking to exit the contract to carry out the core 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".^[119] But at the end of 2014 the DWP-appointed reviewer of the WCA – who viewed the test as "by no means perfect" but nevertheless adequate – declared that "we have taken the WCA about as far as it can sensibly go in terms of modification and adjustment" and warned that "there is no better replacement that can be pulled off the shelf".^[120]

In February 2015 during the 'long campaign' to fight the General Election in May, the Prime Minister proposed using WCA findings to earmark people suffering from conditions that might respond to further intervention and then require them to undergo treatment or lose their entitlement to social security benefits.^[121][122] The Conservative MP Sarah Wollaston – a former GP and the chair of Parliament's select committee on health – described the plan as "unworkable" and "illegal".^[123] It soon emerged that similar ideas had been considered and rejected by the DWP before;^{[124][125][126]} no more was heard of the Prime Minister's proposal^[127] until the story resurfaced five months later, seemingly unworked on in the interim.^[128][129] Professor Dame Carol Black had been asked to study the proposal in February and the request was re-announced through official channels in July. She was then expected to report back by the end of 2015; by January 2016, no report had been published.

In October 2015, the Work and Pensions Secretary joined in the criticism of his department's own test, calling the WCA "unbelievably harsh".^[130] Iain Duncan Smith blamed the Labour Party for building in "perverse incentives" that could pressure people with disabilities into accentuating their problems and complained that the system gave doctors a "binary choice", not an opportunity to deliver a more nuanced opinion on claimants' fitness for work.

Has the deployment of the WCA caused otherwise avoidable deaths?

In 2011, between January and November, the DWP's own figures show that 10,600 sick and disabled people died within six weeks of their benefit claim ending;^[131] 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."^[132]

Nevertheless, there have been numerous media reports of unexpected deaths after assessments where the claimant seems to have been at risk. Mark Wood was a vulnerable man with complex mental health needs, who starved to death after his Incapacity Benefit and then his Housing Benefit – but not his Disability Living Allowance – were stopped as a result of a WCA;^[133] in response to his death, 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.^[134]

Other unexpected deaths have included: a woman with a weakened immune system who died days after the DWP denied her appeal;^[61][135] a depressed man who hanged himself, of whom the Coroner said: "I found the trigger for [his] suicide was his recent assessment by a DWP doctor as being fit for work";^[136] a paranoid man who jumped from a bridge;^[137] and a blind man with brain damage from a previous suicide attempt who killed himself after being found fit for work, and at whose 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”.^{[138][139][140]}

In response to a campaign using the Freedom of Information Act, the Information Commissioner ordered the DWP to disclose the number of people that had died in the 12 months after their WCA since May 2010^[141] – 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 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.^{[142][143][144][145]}

In November 2015, a study published in the Journal of Epidemiology and Community Health 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.^[146] 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 just have been a coincidence. The researchers said they had found no other explanation for the rise.

Economic effectiveness of the WCA and welfare reform

A government follow-up study of 1,100 former incapacity benefits claimants who had been declared fit for work – the results of which were obtained through a Freedom of Information Act request in 2012 – found that more than half of the people in the study reported being without a job and without any income of their own; nearly a third were on Jobseekers Allowance or a similar benefit and only one in eight had found work.^[147]

More recently, the National Institute of Economic and Social Research analysed the effectiveness of the WCA process in reducing the combined Incapacity Benefit (IB)/Employment and Support Allowance (ESA) claimant count.^[148] It found that the broad downward trend since 2004 in the number of people claiming these benefits accelerated in 2011, only for the trend to abruptly reverse in the second half of 2013.^[149]

In October 2014, the government's fiscal watchdog found that between 2010 and 2014 no savings at all had been made in the IB/ESA budget, which remained at more than £13billion a year.^[150] Six months later, the Office for Budget Responsibility raised its forecast for spending on IB/ESA by a further one billion pounds a year, because more claimants than before were being placed in the Support Group.^[151]

Jonathan Portes, former Chief Economist at the Cabinet Office, has described the botched Incapacity Benefit reassessment programme as "the biggest single social policy failure of the last fifteen years".^[149]

But after the General Election in May 2015, the new Conservative government declared that welfare reform was actually about creating "a complete shift in the welfare culture"^[152] and pointed to the large number of jobless people who had found work during the economic recovery that began in 2013 – a trend which had brought unemployment down to a level not seen since the early phase of the 2008 recession; as part of this trend, the number of people claiming Jobseekers Allowance (JSA) had fallen back dramatically to prerecession levels^[153] and a saving of up to one billion pounds a year was hoped for in JSA costs.^[154]

In January 2016, overall unemployment fell to its lowest level since 2005.^[155] New data also showed that the IB/ESA caseload had fallen by 12,000 in one month, although the total number of recipients was still around 2.5 million - only slightly less than in 2011 when the IB reassessment programme was launched.^[156]

References