Transcript Evidence for Benefit Claims

Evidence for Benefit
Claims
Top Tips for Busy GPs
Helen Haws
Which Benefit? – Working Age
• Out of work
– Employment and Support Allowance (ESA)
• Replaces earnings for those who are out of work and sick/disabled
and pass specific ‘tests’
• Otherwise would have to claim Jobseekers Allowance (JSA)
– Stringent jobseeking requirements/Sanctions
• In or out of work
– Personal Independence Payment (NEW)
• Compensates for additional costs of living with long-term
illness/disability
– Disability Living Allowance (being PHASED OUT for ADULTS)
– Either can be paid alongside ESA – may actually increase
financial amount of ESA
Which Benefit?
• ‘Elderly’ - 65 and over
– Attendance Allowance
– Compensates for additional costs of living with longterm illness/disability
– No mobility element
– But mobility hampers ability to undertake personal care for
oneself
– Can be paid alongside Pension Credit
• Children – under 16
– Disability Living Allowance
ESA - Two Phases
• Assessment Phase - £72.40 per week
– ‘Can’t Work’
• Paid on the basis of a fit note from GP
– Lasts until assessment under criteria is made
• Guide 13 weeks
– And while appealing if decision from DWP is wrong
• Gap during mandatory reconsideration
• Main Phase - £72.40 + £28.75 or + £34.75
– ‘Meet the Criteria’
• Cannot do specific listed activities
– Safely, reliably, repeatably in a timely fashion
– Lasts until reassessment
• Guide 6m – 2 years
The Dichotomy
• Tests for benefits are generally functional
– How does the illness/condition/disability affect the claimant?
• GP is concerned with treatment
– What is the illness/condition/disability?
– How can it be treated/managed?
• Evidence of what is wrong is not sufficient for
entitlement to benefit
– Increasingly the case
• move from DLA to PIP
– NO AUTOMATIC ENTITLEMENTS
• But DS1500 for terminally ill claimants
What Evidence? ESA
• Assessment phase – ‘fit note’
– Statement that claimant is unable to work because of condition
– Every day of the assessment phase of the claim needs to be covered
• Repeat fit notes may be required
• Main Phase
– Evidence of how patient meets criteria required
• Rightly DWP need clear reason to support a payment of benefit
– Criteria are loosely related to work
• Points for problems completing specific ‘work related’ activities
• Need a physical condition to get points under physical ‘activities’
• Need a mental health condition/learning difficulty for points under ‘mental health’
activities
• Need 15 points – 0,6,9 or 15 points per activity
• May need points under more than one activity to get 15 points
– Exceptional circumstances – significant harm test may override points
What Evidence? ESA
• Form completed by claimant - initial form (ESA50)
– GP letter not strictly required
• Existing letters giving diagnosis, consultants letters etc. should be
included with form
– Evidence from someone, or more than one person who knows
the claimant and their difficulties very well is extremely valuable
• Unless GP can provide same level of information on how meet
specific criteria
– Suggest visit to local CAB/other advice agency for help with
completion of form
• ASAP as form completion takes time and appointment may not be
available for a week or more
• Form very difficult to complete – claimant needs more information
than is provided on form to provide relevant answers
What Evidence? ESA
• GP receives medical report (ESA113)
– For a successful claim GP must respond
• And provide relevant supporting information
– Otherwise likely no award will be made
– Consequences for claimant?
• No income as not working
• Jobseeker’s Allowance is usually only other benefit available
– OK for those able to meet stringent criteria, otherwise may result in
» Worsening or addition of mental health condition?
» Inability to concentrate on rehabilitation?
» JSA sanctions = no payment of benefit
» No claim made = no money
• Seek advice from CAB or other advice organisation
– Reconsideration/Appeal
» More often than not successful
» Advice agency will ask GP for additional evidence
What is the Purpose of GP
Evidence?
• To verify what the claimant has said in the
application form
• GP is not the only person who can verify
the information
• However, HIGHLY unlikely for DWP to
award benefit where GP does not provide
sufficient support for the award of 15
points
What if the GP Does Not Know?
• ESA113 lists different activities that provide points
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Do try to look at the activities – sheet provided
Do say don’t know specifics for client
Don’t say ‘no problem’ or ‘self-cares’ unless absolutely certain
Do mark ALL activities that are likely to be affected by the
condition
• Indicate where effects may be severe
• Comment on pain, breathlessness, danger to health on completion
of activities
– Can say condition is not going to improve if appropriate
• May affect reassessment period
– Can comment on reliability of client’s own evidence if appropriate
– Do explain problems with travelling – anxiety, learning difficulties
Most Frequently Relevant - ESA
• Mobilising
– 50, 100, 200 metre tests
• 15 points for unable to walk or repeatably mobilise 50m
• Without significant discomfort (not just pain)
– Need to meet criteria reliably and repeatably (as often
as is required)
– Mobilising in wheelchair is sufficient
• Questions about wheelchairs used to argue that claimant
could reasonably be expected to use self-propelled
wheelchair and therefore is not entitled to any points
• If wheelchair has not been recommended then say so
– With explanation if appropriate
Most Frequently Relevant - ESA
• Standing and Sitting
– Not mentioned on ESA113 (only transferring
between seats)
– Significant discomfort standing or sitting or a
combination of both without needing to move
away in order to avoid significant discomfort
• 30 minutes, 1 hour
• Provides additional points
Mental Health Criteria
• Initiating and completing personal actions
– Not getting out of bed?
• More days than not?
• Appropriateness of behaviour
– As well as recognised anti social behaviour, crying in
public falls within this category
• Coping with change or social engagement
– Can’t go out
– Requests appointment at quiet times?
– Always accompanied?
Personal Independence
Payment
• Different activity - based test - confusing?!
– Need 8 or 12 points for standard or enhanced award
• Can claim while working
• Work is not relevant to the activity-based test
– Claimants are often entitled to ESA and PIP
• Two components
– Daily living
• Activities are based on long term personal care needs (12 mths +)
– Dressing, washing, cooking, eating, communication, etc. also includes ability to manage a
budget
– Mobilising
• Moving around - essentially walking
– 20, 50 and 200m tests
• Planning and following journeys
Personal Independence
Payment
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Form completed by claimant - initial form - PIP2
There is no equivalent to the ESA 113
DWP say evidence MAY be requested by ATOS
Request may be by letter
– No form
• Request may be by telephone
• BEWARE
• Evidence on initial claim form from a carer and/or person
who knows claimant well is valuable
• Evidence from GP is also vital
– As it is not guaranteed that ATOS will request information
What if the GP Does Not Know
• Advice on what to write/say if GP does not know
– DO say don’t know specifics for client
– But do say condition will make daily living and/or mobility difficult
If appropriate
– DO suggest ALL activities that are likely to be affected by the
condition
• Indicate where effects may be severe
• Comment on pain, breathlessness, danger to health on completion
of activities,
• Comment on reliability with which activity can be completed
– Can say condition is not going to improve if appropriate
• May affect reassessment period
– Can comment on reliability of client’s own evidence if appropriate
– Do explain problems with travelling – anxiety, learning difficulties
if known of likely to occur
Attendance Allowance
• Benefit is based on cumulative hands-on care in relation
to ‘bodily functions’
– Anything the body can do
• includes washing, dressing, eating, communication and walking
• Also constant supervision to avoid danger
• The higher rate is paid when needs are both in the daytime and night-time
– Mentioning any night-time needs is therefore helpful
• There is no mobility component but mobility issues will
add to the care requirements
– Getting to the toilet etc.
DLA for Children
• …and for adults with existing awards
• Benefit is based on cumulative hands-on care in relation
to ‘bodily functions’ as for Attendance Allowance
– Anything the body can do
• includes washing, dressing, eating, communication etc.
• Also constant supervision to avoid danger
• The higher rate is paid when needs are both in the daytime and night-time
– Mentioning any night-time needs is therefore helpful
• There is a mobility component
– 50m test for high rate
– Planning and following journeys test for low rate
Any Questions?
• Aim is to make complicated process work
for claimants
• Want further help?
• Please feel free to contact me
• E-mail [email protected]
• Telephone 01483 776713