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 ill or disabled welfare claimants are entitled to the main out-of-work sickness benefit: Employment and Support Allowance. The assessment is a key component of the 2007 welfare reforms that the subsequent government continued and developed.

The WCA sorts 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 harsh decision-making and the difficulties and delays faced by claimants when they launch an appeal.

Atos Healthcare, part of the multinational company Atos, conducted the core assessment on behalf of the DWP until 1 March 2015, on which date the American firm Maximus - trading as the Centre for Health and Disability Assessments - took over.

Politically, Labour and the two former coalition parties remain in broad agreement on the principles behind the programme of welfare reforms begun in 2007, but few people now argue that the WCA itself has been anything but a failure, even in simple economic terms.

Seven years since it was introduced, questions remain about whether the test will ever work.

Background

Before 1995, entitlement to Invalidity Benefit was decided by an adjudication officer but largely based on the opinion of the claimant's general practitioner.

In that year, Invalidity Benefit was replaced by Incapacity Benefit (IB) and the Department of Social Security began commissioning its own medical assessments using a procedure called a Personal Capability Assessment (PCA). The change came about partly as a result of the view that a clinical assessment by a person's GP would not necessarily reflect functional impairment. It has also been noted that obstacles to work such as pain and fatigue are difficult to gauge objectively.

In 2007 the New Labour government passed the Welfare Reform Act which - for fresh claims, initially - would replace Incapacity Benefit with Employment and Support Allowance (ESA) and the Personal Capability Assessment with the new Work Capability Assessment (WCA) the following year. 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.

To comply with the terms of the 2007 Act the DWP appointed Professor Malcolm Harrington, an academic with a background in occupational health, to review the WCA system in 2010. In November of that year he published an initial report that included 25 recommendations. The second year of his review was to include refining the criteria relating to people with mental health problems and conditions that can fluctuate in severity from day to day (in 2012, ministers decided to replace Professor Harrington; his successor was Dr Paul Litchfield, a senior figure in the Royal College of Physicians' Faculty of Occupational Medicine).

In early 2011, the Conservative-Liberal Democrat coalition government brought forward the planned expansion of the programme to assess once again the 2.5 million people whom the DWP had previously judged, before the introduction of the WCA, to be entitled to Incapacity Benefit. At the same time the DWP revised the framework of the test, with the result that the eligibility criteria became even more stringent: 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 many hundreds of thousands of claimants of Incapacity Benefit moving onto Jobseekers Allowance or into a training programme and then into work. As a result, a saving of £3billion annually in the IB/ESA budget was anticipated by the middle of the parliament.

The assessment process

When the New Labour government introduced the 'fit for work' test, it contracted out the medical 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. On 1 March 2015, Maximus assumed responsibility for carrying out these assessments.

Ideally, the intention of the process is first to decide whether or not the claimant has 'Limited Capability for Work' i.e. whether they are entitled to ESA at all; if they are, the process then tries to decide whether they have 'Limited Capability for Work-Related Activity' i.e. whether they are able to participate in pre-employment training. If the person qualifies for ESA but is deemed not to have limited capability for work-related activity, they will be required to take part in mandatory training and will receive a lower rate of ESA than those who are deemed to have limited capability for work-related activity (but the ESA they do receive will nonetheless be paid at a higher level than if they were only receiving Jobseekers Allowance).

In practical terms, this constitutes healthcare professionals scrutinizing the paperwork and deciding whether further evidence from claimants' medical attendants is needed. If the evidence shows that a claimant probably has both limited capability for work and limited capability for work-related activity then a face-to-face assessment is not normally required, the claimant is placed in a category known as 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 doctors, nurses or physiotherapists, use a semi-structured interview technique - designed in conjunction with the DWP - to try to gauge the impact of the disability on the person's daily life and to assess the person's fitness for work. General observations of the claimant's hearing, mobility and posture, etc. are made 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, the interview should be brought to an early close and the finding recorded on the claimant's file.

After the interview and examination a report is typed and sent electronically to the DWP - a report which attempts to illustrate the claimant's 'Typical Day' and to compare and contrast the disabilities described by the claimant against the criteria constituting the legal framework of the test (as well as considering other factors, such as whether there would be a substantial risk if the claimant were declared fit for work). This report normally concludes with a points score intended to reflect the level of disability, together with a final recommendation on fitness for work. If the assessment has been carried out in the claimant's home, the report is usually written by hand. If assessors encounter practical difficulties or are unsure how to apply the test's criteria in specific cases, telephone advice is available.

These assessments have been criticised for their repetitive impersonal style, while the reports have been criticised for several aspects of their overall quality and for the accuracy of their recommendations.

Upon receipt of the WCA report a civil servant makes the final decision, taking into account non-medical aspects of social security legislation and any other available medical evidence, e.g., a sick-note or another DWP report, for example one from a previous Disability Living Allowance assessment. As many as 20% of fit-for-work recommendations from assessing healthcare professionals are overruled by a DWP decision-maker.

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. At the reconsideration stage 20-25% of initial fit-for-work decisions are reversed and a further 15% are reversed by tribunals (or to look at it another way: historically, as many as 40% of appellants who have got as far as a tribunal have seen the DWP's decision overturned).

Concerns over accuracy

The Work Capability Assessment has been widely and publicly criticised: in the media, in Parliament, by the Church, by the medical profession, and by protest groups. MPs didn't debate Atos Healthcare in relation to the Work Capability Assessment in Westminster Hall until 4 September 2012. Since then, there has been considerable pressure applied to Iain Duncan Smith, the minister for the DWP, by many including Michael Meacher and Tom Greatrex who have campaigned for the reform of the fitness to work assessment. Greatrex has also written to the Prime Minister to demand an investigation of allegations made by a former Atos assessor that Work Capability Assessments are biased against the claimant.

Controversially, patients with serious conditions such as brain damage, terminal cancer, severe multiple sclerosis, and Parkinson's Disease have been found fit for work. On 24 April 2013, a woman who was a double heart and lung transplant patient died in her hospital bed only days after she was told, after a Work Capability Assessment, that her allowance was being stopped and that she was fit for work.

Criticism has been directed at the test over the ability of assessors to deal with complex mental health problems and conditions whose symptoms vary with time. 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 and its criteria. The introduction of mental function champions was 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. Nevertheless, the DWP insisted that assessors still write summaries, saying that decision-makers found them helpful when trying to understand the main reports. This summarisation, though time-consuming for Atos assessors, made little discernible impact on the level of criticism of the WCA.

At a meeting in June 2012 British Medical Association doctors voted that the Work Capability Assessment should be ended ‘with immediate effect and be replaced with a rigorous and safe system that does not cause unavoidable harm to some of the weakest and vulnerable in society’. The vote has not been acknowledged by Atos or by the UK Government, although it was reported in the media at the time.

In 2013 the Public Accounts Committee made up of MPs and chaired by Margaret Hodge, heard that in 2011/12 Atos was paid £112.4 million to carry out 738,000 assessments. 38% of appeals against the Department for Work and Pensions (DWP) were successful. The Committee declared the Work Capability Assessments resulted in too many wrong decisions being overturned. Whilst Atos are paid to make the assessments, it is the government who pays for the tribunal appeals, with £500 million being the cost to the taxpayer for these appeals. "The Department's got to get a grip of this contract", concluded Margaret Hodge, saying "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 contracts 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."

Also in 2013, the UK Statistics Authority challenged Grant Shapps' claim that 878,300 benefit claimants dropped their claims rather than be assessed by Atos. Andrew Dilnot, chairman of UKSA, found that the figure appears to "conflate" new claims, where the claimant might simply have recovered, with established claimants coming up for reassessment.

On 22 May 2013, a decision in a judicial review brought by two individuals with mental health problems ruled that the Work Capability Assessments were not fair to people with cognitive impairments and other mental health issues, because the upper tier tribunal felt that these claimants were at a disadvantage when attempting to gather and present evidence to support their own claims. The DWP disagreed.

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". The councillor characterised this national situation as, "a disgrace". 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 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 subsequent news report drew particular attention to widespread and unduly harsh misinterpretations of the assessment's system for awarding points, on key abilities such as mobility and mental concentration, that the former assessor had claimed were being promulgated through the training programme for new WCA assessors – to which Atos replied that it was the DWP that was responsible for setting the curriculum for new assessors, not Atos.

Atos exits the WCA contract

On 22 July 2013, the barrage of criticism of the Work Capability Assessment appeared to be vindicated when the DWP announced that in June it had directed Atos to put in place a 'quality improvement plan' - as part of which, all WCA assessors would be obliged to undergo complete retraining - and said it would be bringing in new providers to carry out assessments, at this point supposedly in addition to Atos. The move was said to follow a retrospective audit of 400 Atos reports produced over a six-month period in which the DWP claimed that it had found 164 that were unsatisfactory - yet the DWP said that these "unsatisfactory" reports had nevertheless come up with the correct recommendation on fitness to work.

At the same time, the Coalition's attitude towards the WCA underwent a sea-change. PricewaterhouseCoopers were called in to audit 'quality issues' 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. 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.

Meanwhile, Atos abruptly backtracked on a promising arrangement to carry out fitness-for-work assessments on the Isle of Man 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).

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. At the same time, the company removed the 'Atos Healthcare' branding from its occupational health division and rebadged it as 'OH Assist'.

In March 2014, when responding to Dr Paul Litchfield's review of the WCA's performance for the DWP published the previous year, 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 the 2.5 million people already on Incapacity Benefit, ministers and officials had been trying to fix the problems since coming to power. 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 contract early (but which was erroneously represented by some media organisations as Atos being 'sacked').

The DWP nonetheless continued to employ Atos to carry out the bulk of its Personal Independence Payment assessments (and the Veterans Agency voiced no concerns over the quality of the work of Atos doctors when assessing claims for War Pensions).

Over the summer, it emerged that there was a backlog of more than half a million ESA claims caused by longer assessments and a dearth of assessors - unintended consequences of the 'quality improvement plan' begun the previous year.

Maximus wins the WCA contract

At the end of October 2014, the DWP announced that the US firm Maximus would take over the WCA contract from Atos in March 2015, five months short of the planned termination date of the five year Atos contract. Maximus would be paid £595m to carry out the work capability assessments over a three-year period. 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. However, concerns were expressed about whether this was truly the start of a new chapter when it emerged that the assessments would continue to take place in buildings that were often difficult for disabled people to access and that key former staff were transferring to the new provider.

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 500,000-600,000 ESA claims and boost capacity in the future.

Economic effectiveness

A government study, obtained through a Freedom of Information Act request in 2012, found that one-half of the people in the study who had been declared "fit for work" after a WCA remained unemployed and without income.

More recently, the National Institute of Economic and Social Research analysed the effectiveness of the WCA process in reducing the IB/ESA claimant count. It found that the broad downward trend since 2004 in the number of people claiming out-of-work sickness benefits continued - at a faster pace - from 2011, only for the trend to abruptly reverse in the second half of 2013.

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

Jonathan Portes, formerly a senior economic adviser to the DWP and later the Chief Economist at the Cabinet Office, has described the post-2010 incapacity benefits reforms as "the biggest single social policy failure of the last fifteen years".

But after the General Election in May 2015, a spokesperson for the new Conservative government said welfare reform was about creating "a complete shift in welfare culture" and pointed to the large number of jobless people who had found work during the economic recovery that began in 2013- as part of which, the number of people claiming Jobseekers Allowance (JSA) fell back dramatically to pre-recession levelsand a consequent saving of up to one billion pounds a year was anticipated in JSA costs (although the hundreds of thousands of jobless claimants on the WCA waiting list were not included in the JSA claimant count).

Reliability and credibility

In 2011, the DWP's own data showed that between January and November of that year 10,600 sick and disabled people died within six weeks of their benefit claim ending; it is widely believed 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 some people who died of natural causes, after which their benefit payments ceased (the Information Commissioner has ordered the DWP to disclose further information on the total number of people who died within a year of their WCA since May 2010; the DWP sought to withhold this information, claiming that it would not be in the public interest to disclose the figures because the data might be misinterpreted).

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 but Atos has countered that the number of formal complaints is small in comparison to the total number of assessments.

In 2013, government figures were cited in Parliament to show that of the claimants put into the 'Work Related Activity Group' - which prepares claimants for future work - in 2011, 1300 died within six weeks (there are perennial questions about the wisdom of trying to rehabilitate people who suffer from 'progressive conditions' - diseases that are only going to get worse - to which the DWP has never been able to give a satisfactory answer).

In 2014, a campaigning MP asked the UK Statistics Authority to analyse 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. The DWP has 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 giving its reasons for exiting the contract to carry out the core assessment, Atos said: "In its current form, the WCA is not working for claimants, for DWP or for Atos Healthcare" but at the end of 2014 the medical reviewer of the WCA for parliament 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".

In 2015, the Prime Minister asked a former president of the Royal College of Physicians to consider whether the WCA could be used to identify claimants with remediable conditions and then require them to undergo compulsory treatment or lose their entitlement to social security benefits. 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". It soon emerged that such ideas had been considered and rejected before and the proposal vanished without trace.