Oral evidence: Employment and Support Allowance and Work Capability Assessments, HC 1212Wednesday 14 May 2014

Oral evidence, 14 May 2014.

Witness

Dr Paul Litchfield OBE, gave evidence.

Chair

Dr Litchfield, thank you very much for appearing in front of the Committee for the first time. I don’t know whether this will be the first of many appearances, like your predecessor, but your coming along this morning is much appreciated. One of the things that is often said about the Work Capability Assessment is that it is not really a Work Capability Assessment, but a benefits eligibility test, so there needs to be another test to look at a person’s employability and barriers to work. Do you think the WCA should be replaced by two tests that do those very different things, which might result in a better outcome for claimants?

Dr Paul Litchfield

Being of a certain age, I remember the genesis of the current system. One of the things I thought when I was looking from the outside at the development of the Employment and Support Allowance was that having a second assessment would be really helpful. As you say, it would focus on identifying the support people need to get into and remain in work. As I understand it—I came into this a little less than 18 months ago—the second, work-focused assessment was put into abeyance in 2010 for all sort of reasons that seem to have been largely practical. As I understood it at the beginning of my review, there is no intention to resurrect it in the near future. Certainly, most people in the world of work and health saw the original design as a positive thing. Whether the practicalities and the practical difficulties that ensued can be overcome is another issue.

Chair

Would an assessment such as a WFHRA—a work-focused health-related assessment—or something similar make the WCA that Atos or the private contractor carry out less expensive, and could the assessment be simplified if there were two elements to it?

Dr Paul Litchfield

I am not sure about that. If one has the premise that eligibility for benefits should be based on capability, you need some sort of capability assessment. The practical issue is how you translate that into practical support for people who are deemed to have capability for work or work-related activity. One of the things one finds in trying to support people with health problems who are in work is that if you don’t supply that support, which needn’t be overly complex, they don’t succeed.

Chair

But isn’t there a psychological difference between someone going into an assessment that will decide whether they get the money or not, and someone going into an assessment that is much more discursive about the barriers to work and may be help-focused, rather than punitive assessment-focused?

Dr Paul Litchfield

Absolutely. I don’t know if I would use the word “punitive”, but certainly in terms of determining eligibility for a benefit, that is quite a different interaction, between the person making the assessment and the individual being assessed, from one where somebody is being assessed to see how one can help them. They are quite different. Whatever one has in terms of an assessment for benefit, I think that is always going to be an issue—how you make sure that people feel that the process they are going through is fair, which is one of the things that I tried to focus on in my review.

Chair

You recommended that less emphasis should be placed on the points obtained by each claimant in the Work Capability Assessment and that the calculation should simply be used to assess whether the threshold for benefit has been reached. How would you change the system to have less emphasis on points?

Dr Paul Litchfield

I can see the value in having a points-based system. What one is trying to do, in a system that is conducting a very high number of assessments over multiple sectors, is to take an assessment and ensure that it is applied consistently. Having a points-based system allows you to take expert opinion, which is the way the test was designed, and translate it into something that a non-expert can apply in a consistent way. I get that, and it is important for the mechanics underpinning the assessment. My worry, when I started looking in detail at the assessment, was that there seemed to be an undue focus on those points. That has two consequences, really. One is that, because there are points, people assume that there is a linear relationship—that 18 points means twice the lack of capability of nine points, for example. That most certainly is not the case. We took quite a lot of time going back to determine how the assessment was developed in the first place. It was very much about whether you did or did not qualify for the benefit. It was trying to determine which side of the threshold people sat. The points are a way of getting there, but we certainly could not find any mathematical relationship between them. People assume there is a relationship because those points are there. I saw examples of people with the best of intentions arguing about or trying to move somebody from one set of points to another, even though it would make no difference whatsoever in terms of their eligibility for benefits. I think that focus on points is a distraction from the real issue. It can also imply a degree of sophistication that is not there.

Chair

Would it be better if it was some kind of sliding scale?

Dr Paul Litchfield

I think that if one is going to have a sliding scale, that would confer a considerable number of benefits. To move beyond my terms of reference and think more broadly about the way that one could use that sort of system, if there was a reliable sliding scale, at different points in the economic cycle one could shift the threshold to match the labour market. With the current system, you cannot do that. One might assume—talking to a lot of people, the assumption did exist—that one could do that with the current system. You cannot; it is very much either side of the 15-point threshold. If you had a sliding scale, it would allow you to have a more dynamic system, but to create that one could not start from where we are at the moment. One would have to go right back and create an assessment based on a different set of parameters.

Chair

So you would have to get rid of the descriptors that they currently have?

Dr Paul Litchfield

I think you would have to create a system that was based on a completely different set of premises. We would be talking there about fundamental research. My estimate, in ballpark terms, would be a minimum of five to seven years to get something like that designed and tested, so it is a long-term project.

Chair

Other advanced economies have the same problems that we have with assessing people and their fitness for work. So there is nowhere else internationally that does it better than we do, or does it differently?

Dr Paul Litchfield

There are certainly people who do it differently. Whether they do it better is a subjective opinion, which I do not think I am qualified to comment on; but certainly when one looks at other systems, we comment in the report about both the Netherlands and Denmark, where they assess things in a different way that takes into account the impairment to earnings that people have suffered as a way of determining benefit. That is one way of doing it. I have looked a bit more closely recently at the New Zealand system. Again, that is more similar to ours, but looks at things in different ways. The capability assessment, which they are just in the process of implementing, is at the back end of the process rather than at the front end, as we apply it.

Chair

Can you clear something up about the points system and at what stage different people know about them? We met with some Atos assessors who have been doing what I think was a pilot for the alternative assessment. They told us that, as assessors, they do not see the points; they just tick the relevant boxes or fill in the box as they are going through the interview, and it is only the decision maker who sees the points that the person has achieved. That was news to us. Is that the case? Is that how it works? Who generates the points?

Dr Paul Litchfield

The points are generated on the basis of the assessment carried out by the health care professional. I am sure that it is entirely accurate to say that the health care professional does not see the points. However, if you have any degree of experience at all, you know which descriptors equate to which points, and it does not take a great deal of mathematical ability to work out what you are saying in terms of a point score. Even if people do not actively think about it, I am sure it is running through their mind when they are doing the assessment. It is quite right that decision makers are the ones who see the points.

Chair

So it might be that you have an experienced assessor who knows that if they tick that box they will generate three points and an inexperienced assessor who has no idea or cannot remember because they are inexperienced. Would that help to explain the difference and why, on one day, an individual gets no points, but then goes to appeal and gets 15 points? It has always been quite difficult for us to grasp how it could be that wrong when the same person presents not with a variable condition, but with exactly the same disability or ill health, but to a different person.

Dr Paul Litchfield

I suspect that there are several answers to that. One is a different interpretation of the same information that is presented. The second is that, when one is looking at appeal, quite often there is additional information that is taken into account. Certainly in the appeals that I have witnessed, that was a significant factor in coming to a different conclusion from the one that was originally determined by the Department.

Chair

In response to your recommendation that there should be less emphasis on points, the DWP said that it was going to review how we communicate the point scores to claimants. Do you think that is enough?

Dr Paul Litchfield

I think it is a start. I think it is also the way in which decision makers are trained to look at points and understand that this is not a linear scale. I think that bit of learning—which, as I say, was new to me—appeared to be new to some other people in the Department whom I spoke to and who had made the assumption that it was much more of a straight-line scale. So I think communicating what the points mean more effectively to decision makers would be a valuable contribution.

Chair

We have talked about the descriptors. In answer to my question, you said it would take seven years to start from scratch again. Do you think the descriptors are basically wrong at the moment? Do they need a major overhaul?

Dr Paul Litchfield

I haven’t looked at the Evidence-based Review in detail yet. It hadn’t been published at the time I wrote the report for the fourth review. I have read the review. The way I tend to work is that I like to mull things over, so I want to examine in much more detail what was actually said in the Evidence-based Review. But to come back to your question: are the descriptors wrong? No. Could they be altered? Of course they can, but every time you alter a descriptor you are altering the whole basis of the assessment. If you change one thing, you have to be very careful about the unintended consequences there might be for the whole of the assessment. So there is a policy decision to be made about whether one fixes things as they are at the moment, or with any revisions that have come out of the Evidence-based Review that end up being accepted, or one starts with the design of a totally new system.

Chair

But the Evidence-based Review will inform your second year.

Dr Paul Litchfield

It will indeed and it is going to be an important part of what we comment on in the fifth-year review.

Sheila Gilmore

In terms of the whole issue of points, the reason claimants have become so concerned about it is that it determines eligibility for benefits. Inevitably people will think that is really important and therefore query how this is arrived at. In terms of people feeling confident in the system, is it not really important that we get this done better?

Dr Paul Litchfield

I think it is extremely important, in terms of having a system that is perceived as being fair, that people understand the basis on which a decision has been arrived at. What worries me is that people focus on “I should have had nine or 12 points instead of six”, when actually it doesn’t make a difference to their eligibility for benefits. Understanding the reason why you have or you haven’t qualified for a benefit is critical, but having that very strong focus on points, which came over very forcibly to me during the course of the review, can be unhelpful.

Sheila Gilmore

Where do you think that comes from? I can understand why it comes from claimants, because they focus on that as a way of perhaps improving their position or arguing their case.

Dr Paul Litchfield

I think it comes from there. I think it comes from the way that the Department’s processes are constructed. I think it comes from a variety of different areas. Certainly from the Department’s point of view, explaining more clearly to everyone involved in making these decisions what the point system actually means, and how the whole assessment process was constructed, would be helpful in their understanding and therefore their communication to people making a claim about why they have come to the decision that they did.

Glenda Jackson

Does the decision maker know what is behind that? They know what the descriptors are. So they know what is awarded. When they have that, they are in a position, are they, with the individual sitting across from them, to question it then and there?

Dr Paul Litchfield

Yes they are. Of course, they are not sitting across from the individual, which is one of the other points I comment on in the report. But certainly if they get through on the telephone when they are making the decision assurance call, it is the focus of part of the discussion they have with the person then. So the statement that, if you like, generates the points is something they have available to them so they can talk about that and they can talk about the evidence that has gone into determining whether it is that statement that is most appropriate, or whether it is one of the other statements that is appropriate.

Glenda Jackson

But these claimants are not unknown, presumably. They have a history of benefit claims.

Dr Paul Litchfield

Not necessarily. It could be a first claim.

Glenda Jackson

And also it could be somebody who has never worked in that particular Jobcentre before. I understand that. But that seems to me to be the area where, if we are going to reduce the number of appeals, it should happen.

Dr Paul Litchfield

One of the things that I recommended in the review was that there should be a more personal interface between the decision maker and the person making a claim, because it is not someone in the Jobcentre that is doing this work; it is somebody in the Benefits Centre, which is divorced—sometimes geographically by quite a long distance—from the person involved. While there may be telephone contact with that person, there is almost never face-to-face contact. Maybe I am old-fashioned, but I feel that face-to-face contact is a much better way of generating trust.

Glenda Jackson

Sorry to keep on. I accept the point about new claimants, but, for historic claimants, someone somewhere within Jobcentre Plus or DWP must have a history of that individual’s health, be it mental or physical. Surely that should weigh very strongly when it comes to assessing what the computer has said.

Dr Paul Litchfield

One of the issues that the Department is looking at is ensuring that that history is available to decision makers—

Glenda Jackson

Oh, they are.

Dr Paul Litchfield

Because, at the moment, it is not always available to decision makers, so they may or may not have information related to previous assessments, whether that is in relation to Employment and Support Allowance or its predecessor, or indeed the other benefits. One of the points that I make in the review is that a number of other related but slightly different assessments are coming on line and, at the moment, there does not appear to be any process to ensure that information, where appropriate, is shared there. It just strikes me as common sense that if a decision maker has as much evidence as is available to the Department, that should be there for them to be able to use.

Dame Angela Watkinson

We have heard accounts from individual claimants of medical evidence from doctors or consultants being either ignored, disregarded or overruled by assessors. Did you find that during your review?

Dr Paul Litchfield

I did not see specific examples of it. I certainly heard examples quoted of it by a number of people. I think one has to differentiate between a medical report which is focused on medical issues and a report which is focused on capability. A lot of people in the health care professions do not necessarily comment on capability when writing reports, so you will often see a medical report that is full of important things about investigations and diagnosis and even prognosis in a medical term, but that does not mention at all that person’s ability to do day-to-day tasks, let alone their ability to work. One has to weigh medical evidence on the basis of what it is telling you that is useful and relevant to the decision that you are trying to make.

Chair

We were in Newcastle yesterday and a welfare rights worker used the example of one her clients whose GP had filled in a DS 1500, which is for terminal diagnosis, which was then discounted by, I think, a decision maker. How can that happen? Or should that happen?

Dr Paul Litchfield

Stuff happens. It sounds very odd to me, certainly something like that which is not about capability for work. This is terminal illness—

Chair

It is just not believing what the doctor had written.

Dr Paul Litchfield

That surprises me. I certainly did not come across any examples of that sort of thing. I am not saying that it would not happen; I have forgotten the numbers, but, as we are talking about a system with 100,000-plus cases being dealt with every month, mistakes happen. But it does sound odd to me.

Mr Thornton

If you remember, Chair, one of the Atos people who was a doctor said, “The doctor’s doing the DS 1500”—

Chair

They filled the wrong form in, but it seemed strange. Actually, as it turned out, this client was in hospital at the time and was seriously ill.

Teresa Pearce

On that point, you have seen that doing Work Capability Assessments is very process-driven job and we heard that it is very boring. Do you think that the people who do it get some sort of compassion fatigue so that they do disbelieve things? I have had an instance with housing: a letter from the police saying this person was in danger of violence from an ex-partner and needs to be moved, and the housing department said that the police write those letters all the time, because they get compassion fatigue. Did you see any of that with the tedium of the job?

Dr Paul Litchfield

I didn’t. We are talking about the health care profession—

Teresa Pearce

Yes.

Dr Paul Litchfield

Who do the face-to-face assessment. I didn’t come across that, no. When I have visited Benefit Centres, I very much doubt that the poor performers are put in front of me. I suspect I have the better performers put in front of me. Nevertheless, I did not see that. Indeed, both in terms of health care professionals and decision makers—I comment on it in the review—I was impressed by the degree of diligence and compassion that was shown. I sat in on some assessments, and in all of those I felt that if I had been the person being assessed, the manner of the person carrying out that assessment would have satisfied me. But that is not to say that compassion fatigue does not exist. You are quite right, and one sees it in other contexts. It is a risk. It is something that I, as a health care professional, along with all others, need to be particularly alive to. Just because you see something all the time, it does not mean that it is not very special for the person who is experiencing it.

Debbie Abrahams

Out of a group of about 120, there were two counts of a DS 1500 being ignored. I appreciate your saying that that has not been your experience. Again, we were impressed with the group of professionals we saw, but it does seem to be very variable and patchy. In your reviews, how are you going to make sure that you pick up on that variation?

Dr Paul Litchfield

There are several elements there. First, this is news to me about ignoring, or interpreting differently. It is something I will pick up on in the year 5 review, because it is something that merits my looking at. In terms of ensuring there is consistent quality, I think it comes down to having the right experience with people carrying out the assessments. That is something I comment on in the review. It comes down to training. Again, I have commented in the review on enhancing training both for health care professionals and decision makers. Then it is making sure that the quality assessment framework, which the Department applies to its own decision making, considers not just the process elements, which I think it is very strong on, but the outcome elements, so that one looks at the decisions that are being made and reviews them, not just at whether all of the steps in the process are being carried out correctly. So I think there is a range. It is, I suppose, trying to implement a quality circle within the process. It does exist, but, like any quality circle, it can be improved.

Chair

Just to be clear, I think there was only one example of a DS 1500 being ignored. The other example was someone whose medical report said that they were a suicide risk and had already attempted suicide. That was ignored and the person went on to commit suicide before they got a determination. I think the family pursued it. Again, that ignoring of the medical evidence caused a huge amount of distress, as you can imagine. It was very powerful.

Sheila Gilmore

One of the things that causes a lot of stress is the number of repeat assessments. You make one recommendation about one group who perhaps should have a five-year period before being reassessed. Do you think that could be taken further? We repeatedly hear how choked up the system is—there are delays and lots of people—and yet repeat assessments continue to happen a lot of the time. Do you have a view on that even wider than in your recommendation?

Dr Paul Litchfield

In terms of that recommendation, the element that struck me most forcibly was that for people with severe conditions—I picked particularly on people with severe brain conditions because those were the cases that were reported to me the most often—and particularly with deteriorating conditions, it did not seem terribly logical to me that you would call those people up for review after a relatively short period. Now, I recognise that one never wants to write people off, and I think that is absolutely important, which is why I suggested that as a start, perhaps, one should implement a longer review for that group. Perhaps it is pragmatism on my part in trying to get things done in large organisations over very many years, but I think that if you ask for something that seems eminently reasonable, you are more likely to get it, and you can build from there. If you ask for something that is much more difficult, you might not even get past first base.

Sheila Gilmore

I see that, but one of the problems we are faced with is that we have had a Minister announcing that because there is a backlog, he is going to suspend reassessments for an unspecified period—it is very unclear—so people still do not know whether they are happening or not. From the evidence yesterday, reassessments still seem to be happening, despite what the Minister has said. The phrase that comes to me is “rod for own back.” To some extent, the delays and the huge workload that seems to be going through the system are exacerbated by insisting on such things. The response is often that we do not want to leave people for ever doing nothing, but surely there is some sort of happy medium here.

Dr Paul Litchfield

I am sure there is. Other recommendations that relate to that are: after somebody has been through an appeal—I certainly had brought to my attention cases where literally a few days after the appeal result came through, so did the request for a reassessment—I recommended that there should be at least a period of perhaps six months. One might think of that as a cooling-off period, if you like, but I think we should certainly introduce some sort of gap there. The other element, in terms of suggestions around potentially redesigning the process, is that I think there is potential for doing more, particularly with review cases, on a papers-only basis. If one shifts the way in which the process is designed, one can achieve that so that those face-to-face assessments—which can be hugely valuable but, I recognise, can also be very distressing for people—are not the automatic default, if you like, but are commissioned on the basis of a conscious decision by a decision maker that that is something that will help to provide information that will make for a better decision. If one did those things, it would provide a rational approach to reducing the caseload.

Sheila Gilmore

These issues like not calling people back in just after an appeal are not new. You are finding it now, but we have been hearing this for four years and probably longer. Why is this still not being tackled? Is some guidance needed as to what is an appropriate period for recall?

Dr Paul Litchfield

I made the recommendation, and I do not recall that recommendation being made explicitly before, although I do recall it being commented on. By making it a specific recommendation, it elicits a response from Government. We will see the action that results from that, but at least it is the one thing I could do to prompt that activity.

Mr Thornton

We have gone through a lot of this already, but I would like to know how you think your recommendations for improving perceptions of the WCA fairness have been taken up. Are they being looked at?

Dr Paul Litchfield

I think it is early days. The report was published in December and the Government’s response came out a couple of months ago. Most of my recommendations, and certainly those relating to the perception of fairness, seem to have been accepted, albeit in some cases with the caveat that they need to be looked at in more detail. Part of this year’s fifth-year review, which I am doing, will be to look at that and to see what progress is being made. I do feel it is fundamental: it is at the heart of the whole report that if people in general in society do not feel that this is fair, it will never be successful, so we really have to work on that. What I have tried to do in the review is to give practical suggestions for how that might be achieved. Many of them are quite little things, but sometimes little things can make a big difference.

Mr Thornton

I noticed something yesterday when we were in Newcastle that may not be being attended to. I have a great deal of experience and a large part of my professional career involved interviewing people for financial services. One thing that was very evident when I was being trained and when I was training other people was that people do very well at the training stage—they know exactly how they are supposed to react, pass with flying colours and go on to get a job—but very often within a very short period, sometimes days, they are not following the process in the way they were trained and they are not interacting with the person on the other side in the way they were trained. We have all heard about the building society thing—“Oh, computer says no”—and that is in a commercial environment where someone is paid more if more people take their products. It happens there, where there is a financial incentive to do better. I used to go out and train people and then go back and retrain them. I would tell the supervisors in charge, “Look, you’ve got to keep going back and checking that they’re doing it. They are not doing the process particularly I trained them in—a process that reflects what you want to achieve.” I am just wondering about Atos and the reason why. The people we saw yesterday seemed very competent and said they were getting the right answer out of people, but how many of them are actually doing what they are meant to be doing, and how many are just going, “Okay. Okay. Okay. Sorry, that’s it.”? I suspect that there are far more than we think. What do you think?

Dr Paul Litchfield

You may well be right. Certainly one of the things I recommend in the review is revalidation of health care professionals. Just because you pass a driving test—as I did in 1971, I think it was—doesn’t mean that you are still a good driver however many years on it is, and it is the same with health care professionals. Certainly in the medical profession these days, we revalidate generally every five years. It struck me that having some form of revalidation for health care professionals would be a sensible enhancement. I have not been privy to the detail, but I know that negotiations are going on by the Department in terms of new contracts, and it may well be that the Department would wish to consider putting something in.

Mr Thornton

It is not just the revalidation; it is actually the continuous, effective training and supervision all the way through, day to day, to ensure that people are keeping up with the right way of doing it. It is quite a tough management system to do that.

Dr Paul Litchfield

I think it is, but there are ways of doing that, whether it is Ofsted-type things, periodic sitting-and-watching assessments, or routine recording which is monitored regularly. There are ways of doing that but, yes, I take your point and I agree entirely.

Mr Thornton

Moving on from that, one thing that you recommended is suitable and sufficient previous experience of dealing with people with mental health problems so that they can contextualise their findings at assessment, and have the ability to understand mental health difficulties and problems without being overwhelmed by them. Do you think the Government are responding to this recommendation? Should there be different types of assessors with different skills interviewing different people?

Dr Paul Litchfield

The Government’s initial response was to ask for some help in determining “suitable and sufficient”, and I can understand that. I have to say that when the boot is on the other foot and you are working for an employer when the regulator in a health and safety context says you need to provide suitable and sufficient training and you ask for clarification, you tend to get the response, “Well, that’s for you to determine.” We have had some discussion and I am happy to help to give some advice and guidance on what suitable and sufficient looks like, but at the end of the day it has to be for the Department to stipulate that and for the provider then to be held to account for delivering against that. But in general terms, I don’t think we are talking about people who have had training as a psychiatrist, for example. I think it is having sufficient general experience of dealing with the broad range of issues. For example, general practitioners see an awful lot of people with mental health problems, but there are other branches of medicine. A pathologist, for example, could in theory be employed on this contract, because they have a primary medical qualification, but I very much doubt they have any current or relevant experience in dealing with mental health problems.

Mr Thornton

They are not looking for that in people they are examining, are they?

Dr Paul Litchfield

Their bedside manner is said not to be terribly good, yes.

Mr Thornton

If there were a certain number of assessors who had more mental health training than others—so if it was recognised that some cases were difficult, and they could be given an appointment with one of them—do you think that might be helpful?

Dr Paul Litchfield

One of the changes that has been made as a result of Professor Harrington’s recommendations is the introduction of mental health champions. That does seem to have been helpful, but mental health champions are a resource that is available to other health care professionals or, indeed, decision makers over the telephone. It is a compromise between the practical difficulties of trying to match individual people making a claim with the skills of the health care professional, and then coping when you find that, actually, what you knew in advance is not what the real issue is and that can often be an issue with mental health, as opposed to the other approach, which I think I favour, which is to make sure that everybody has suitable and sufficient experience in dealing with the common things that come up and that they then have appropriate training to help them to deal with that. So I think training up the mass of health care professionals is probably—certainly for those common conditions—a better approach than trying to do the rather complicated matching, which would be another approach.

Mr Thornton

It is just making sure that they can recognise the signals and what someone is talking about there may not be underlying problem at all?

Dr Paul Litchfield

Absolutely, and being able to contextualise it.

Kwasi Kwarteng

You mentioned Professor Harrington’s recommendations, and I wanted to ask you about the idea that information gathered up during the WCA should be shared with the Work Programme providers. I just wanted to know what your thinking is about the urgency that you want the Department to show in implementing these recommendations.

Dr Paul Litchfield

First off, it struck me that it was the only one of Professor Harrington’s recommendations where there appeared to have been little or no progress. The other recommendations, in my opinion, had either been fully implemented or at least there was material progress being made in terms of implementing them, but that one had not. When I delved into it a bit, there appeared to be a lot of procedural process, sometimes legally based issues around why it could not be done. I felt therefore a fairly strong recommendation to get on with this was appropriate. It is certainly something that I will be looking at again this year. I have already met with some work providers to try and understand better what would help them to assist people, particularly following this work-related activity group, but again, rather like making sure that decision makers have access to as much information as is already available to the Department, it just seems odd that you are collecting a whole load of information which could be of value and then you are not using it. I am sure there are difficulties, but I feel that perhaps we need a little more oomph in terms of overcoming those.

Kwasi Kwarteng

Following on from that, were you happy with the Government’s response to your recommendations?

Dr Paul Litchfield

Do you mean in general, or on that one specifically?

Kwasi Kwarteng

I seem to have trodden on—

Chair

Carry on Kwasi—

Kwasi Kwarteng

I was taking a slightly more free-flowing approach to these proceedings. I was thinking about what you were saying about the implementation of Professor Harrington’s recommendation about specifically sharing information, and what you thought more generally about the Government’s response to your recommendation.

Dr Paul Litchfield

They said they were looking at it and that they would try to do it, but again, it is something I will specifically focus on this year and see where we are getting to.

Chair

We hear a lot about mental health—even in the assessment by Professor Harrington there was a lot about mental health and, indeed, there was a lot about it yesterday in the evidence we got—but there is also the group with learning disabilities and autism. Some of the people in my constituency who work with that group of claimants are very, very critical of the form of questioning, because questions are often set on the computer but are not phrased in a way that someone with a learning disability or autism can understand. There seems to be no credence given or, when the carer or parent goes along with them to the interview, they are basically told to shut up and are not allowed to speak, even though they are trying to point out that he or she does not understand the question phrased and it will have to be phrased totally differently. There is no sense that there is any proper training for assessors in how to deal with that group of individuals.

Dr Paul Litchfield

I have not looked specifically at the training for that, but it is a good point and I will look at that this year. In terms of companions, it is something I comment on specifically. The rules state that a companion is perfectly entitled to be present if the individual wants that. We certainly came across examples of that not being properly applied, or the perception of the individual and their companion that their evidence was not taken seriously. All my experience in occupational medicine is that having someone else there can often be extremely helpful, particularly in the case of people with learning difficulties. I have recommended that the Department improves the guidance on that. I think it is absolutely critical for that group that questions are framed in a way that they are likely to understand, that testimony from those who know them best is taken fully into account and—again, something I found in the review—that inferences are not drawn on the basis of oblique questioning. That is when you ask something and then draw an inference on capability based on indirect questioning. First, I think that, particularly with that group, that can lead you into errors. Secondly, I think that if you draw conclusions in that way, it undermines trust—people think you are trying to catch them out. I think all of those things apply, and I hope the Department will pick up on all of them.

Nigel Mills

Starting on that last point, the use of oblique references is fundamental to how they carry out their assessments. They ask you how long you can watch TV for and how you cook your dinner. They do not ask you, “Can you lift something from here to here?” That would change the whole thing.

Dr Paul Litchfield

I think there is a difference between indirect and oblique. The example I put in the review was a woman who was asked if she had a cat and, on the basis of that, all sorts of conclusions were drawn about her degree of manual dexterity, which came down to whether she could use a tin opener. I do not have a cat, but I am told that cat food does not often come in tins these days and that, if it does, it is a ring pull. Apart from the potential error in that logic flow, I think most people would feel that was oblique questioning, which seems designed to catch people out. Indirect questioning is fine, because people will often not have recent experience of the things you are interested in in terms of their capability for work, but they will do things in their day-to-day lives which you can make legitimate comparisons with. I think that is fine; it is indirect. It is the oblique element that I did not really like.

Nigel Mills

Can I take you to the issue of additional evidence, which has obviously raised a lot of, “They ignored all the medical evidence I took with me and just used all the indirect things I had said against me,”? How do you see that working? I suppose my first question is: should the assessor—Atos or its successor—go through all that evidence and weigh it in, should it be for the decision maker to look at the assessment, compare that with the evidence and come to a decision, or is it a bit of both?

Dr Paul Litchfield

Fundamentally, what I would like, and have recommended, is that the Department looks at a redesign of the process. I completely agree with Professor Harrington. The decision maker should be at the heart of the process. The decisions about eligibility for benefit are societal ones. They are lay decisions, not medical decisions. Let us say that one had the decision maker at the front end of the process, looking at the information that had been submitted by the person making a claim—the ESA50. One of the recommendations I made was that we encourage the submission at that stage of additional information that might be helpful and, in particular, non-medical evidence from people such as carers and support workers. That evidence is there up front. The decision maker then decides what additional information is required. That may be medical reports; it may be a face-to-face assessment. Then, having that information available, the decision maker makes the final decision. On the question whether the health care professional, if they are involved in that assessment process in the middle, has access to that additional medical evidence, that may or may not be helpful. What one is looking for there is an objective assessment of what people can and can’t do, so it probably is helpful that they have it, but it isn’t necessarily always the right thing to do.

Nigel Mills

I cannot remember whether it was you or your predecessor who commented that it seems a bit strange that you pay a lot of money to get an independent assessment and then systematically ignore it. Is that what you are suggesting?

Dr Paul Litchfield

That was me, and that particularly relates to the rising rate of decision makers overturning the decisions—health care professionals do not make decisions—overturning the results of the assessment made by health care professionals. By the time you reach—we’re back to points—the level just below eligibility for benefit—when we looked at the data, the rate of overturn was well over 50%. Paying money to a health care professional to give you an assessment if you are going to overturn that decision in more than 50% of cases does not seem terribly logical. There are two ways of looking at that. One is that there need to be better health assessments and more confidence in health assessments. There is quite a bit in the review about how there appears to have been a breakdown in trust between decision makers and health care professionals, which I think is quite a complex issue; all sorts of reasons may underpin it. But I do think it is something that the Department and whoever the new providers are need to address.

Sheila Gilmore

Is that partly because decision makers are getting more information? Is that the problem? This is the information that Nigel was talking about in terms of whether it should come in at the beginning. Is the difference there because when the decision maker is looking at it, they are looking at the WCA assessor’s report, but also other things that have—

Dr Paul Litchfield

Some of the time, but certainly—of course, of necessity, I sat in with a relatively small number of decision makers, so the sample is not statistically valid, but certainly I saw several examples of where the report by the health care professional simply wasn’t felt to be right. It just didn’t ring true to the decision maker. That may be a completely valid conclusion, but it does imply a degree of lack of trust between the two groups. When I talked to decision makers and, indeed, health care professionals, it did not seem to me to be a relationship of somebody dealing with a trusted adviser. It was very much “them and us.” That was brought home to me quite forcefully in Northern Ireland. The health care professionals had been in-house in the system over there until very recently, and the relationship there between the decision makers and the health care professionals appeared significantly better than what I discovered in Great Britain.

Nigel Mills

I am tempted to ask you a question that I asked Professor Harrington earlier. Do you actually feel that there will ever be enough confidence in a private contractor doing this work for the system really to work, or does this actually need to be brought back in-house somewhere if people are to feel it is a fair system?

Dr Paul Litchfield

I think that’s very difficult. There is no doubt that when you are all of one company, it is easier to engender that sense of team working. On the other hand, the operation of an effective system using outsourced providers can work. I suspect it is the way that you set the system up and then work on and develop the relationships over time. One of the things that I recommended that the Department seriously looks at is the co-location of staff because you can get that divorce of two groups, even within a single organisation. Just the fact that you are paid by the same body does not necessarily mean that you work well together. I think it is probably more important that active consideration is given to the development of relationships between the two, and encouraging things like seminars and various other ways of getting people to work together better.

Nigel Mills

I have one last question on additional evidence; I think somebody else will ask you about that last point. You were a bit less certain that additional evidence for mental health patients was a good idea. Can you just talk us through why that is perhaps not quite as necessary as it is for other cases?

Dr Paul Litchfield

It might be my poor use of English, but what I was trying to say was that I didn’t feel that getting medical evidence in mental health cases in every case was the right thing to do. That doesn’t mean that additional medical evidence is not of value—it can be in mental health cases as well as in physical health cases. However, there was a suggestion made—this very strong advice—by some of the groups that we spoke to that, exceptionally, in every single mental health case additional medical evidence should be got up front. The rationale I tried to apply in the review was that getting that evidence may not be the best way to progress, that there were lots of sources of non-medical evidence that could be of more value, and that in many mental health cases, the person you would obviously go to—the general practitioner—may not actually have a good knowledge of that individual. So just saying a black and white, “Yes, you must always get additional medical evidence,” I did not think was the right thing to do. That doesn’t mean that you shouldn’t get medical evidence. I think you should get additional medical evidence, but it should be based on a rational decision of what is going to help you to come to a conclusion in that case. I think it should be a conscious decision to get medical evidence rather than an automatic, “We will always get this.”

Sheila Gilmore

Do you see—

Chair

Hold on, Sheila. We’re up against time and Debbie is coming in.

Debbie Abrahams

My quick question is whether the change in the relationship—[Interruption]—between decision makers and the reports from Atos assessors related to more reports from Atos assessors coming through and awarding people a higher number of points. Does that reflect the quality and improvement programme that they went through last year?

Dr Paul Litchfield

I’m sorry; it was probably the bell, but I missed the beginning.

Debbie Abrahams

There was a quality improvement programme, as I understand it, for assessors. As a result, more reports have awarded a higher number of points. Is that when there was a breakdown—or when you noticed a breakdown—in relationships and more people having their reports overturned?

Dr Paul Litchfield

I suspect not; of course, I can only comment on the point in time when I looked at things, which was 2013, but when one looks at the data in terms of rates of overturn, it’s been a climbing trend over a five-year period. So it’s not something that appears to have happened overnight; it appears to have been a gradual drift, and that would fit with what one knows from other situations where providers of advice become more distanced from the people who are commissioning it.

Sheila Gilmore

One issue that has come up recently—I don’t know if you have been looking at this in your next review—is the reconsideration, which was made mandatory. People are reporting quite lengthy delays in dealing with that, which seems to be a workload issue perhaps, but it causes stress and upset. It also causes financial loss to people because of the rules. In your view, should that be reported on separately? At the moment, if a decision is overturned at the reconsideration, it is counted in the same sort of category as the first decisions, unlike appeals. Is this an area that you would want to look at?

Dr Paul Litchfield

I think it would be an interesting thing to look at. We were not able to do it last year. It is something I will see if we can do this year. Certainly, by including the reconsiderations, of course, as you say, the workload increases very significantly, and that can compound some of the difficulties in terms of delays. The other thing is this is a different client group, so people who perhaps have been on benefit for very many years who are coming for an assessment—

Sheila Gilmore

No, I was talking about the reconsideration stage of the decision-making process.

Dr Paul Litchfield

Mandatory reconsideration—I beg your pardon. Yes, that came in in October, so really too soon for me to be able to comment on in the year-four review. I am certainly looking at that in year five. I have one session with people carrying our mandatory reconsiderations. It is something that I will be looking to comment on in year five. I am sorry I misunderstood you.

Sheila Gilmore

That’s fine.

Chair

That’s okay.

Anne Marie Morris

Briefly—I suspect, almost finally—on the feedback through the summary reasons, which is an improvement on the one-liner, between the judiciary and DWP, how can DWP make better use of that feedback to improve its processes?

Dr Paul Litchfield

I think it’s important, and it is a very welcome development. In terms of feedback, I think it’s part of the quality improvement process that I was talking about, so I think the decision maker whose case has been reviewed by the Tribunals Service should know what the outcome has been about, and not just when their decision has been overturned, but also when it has been supported, because you need to get both sides to have a balanced view. The other element, which I have recommended in the report, is that that should be extended and the health care professional who did the original assessment should also see that flow of information. So if the conclusions that they have arrived at have been overturned or supported, they should have a feel for that, too. It may not be practical to do that on a case-by-case basis; it may be something that you communicate in terms of numerical feedback—so 25% of your cases were overturned by decision makers and whatever per cent were overturned by the Tribunals Service—but I think that feedback loop, with qualitative information to supplement any quantitative information in a balanced way, is an important part of getting everybody to improve their performance within the system. So I think it is a very welcome development. I think it is the one that the Department needs to look at how it is going to apply and get the best learning from, but also not just to stop with decision makers and to extend into the health care professionals, who are an important part of the system, too.

Chair

You’ve asked the Department to carry out an impact assessment on the feasibility of changing the process system so that it’s the DWP that sends out the ESA50 rather than Atos, and it decides on whether there will be a face-to-face assessment. Why did you recommend this, and what is the Government’s response to that?

Dr Paul Litchfield

The Government’s response is that they are examining it, so we will see in the course of this year what progress has been made on that and what their—certainly initial—views are. The reasons I recommended it are twofold. The first one is I think it’s important that the decision maker is at the front end of the process, because that does reinforce the injunction that they are in control, so they are the ones who decide how best to get the information. My background over the past 30-odd years has been very practical in terms of delivering and procuring services. It also strikes me that it helps to simplify the whole process. One of the problems I think that we have in the current system is that it has become over-complex. Stripping out some of that complexity would help in speeding things up. If you are not going for as many face-to-face assessments, you are speeding things up.

Chair

That was my next question. Do you think that will reduce the number of face-to-face assessments?

Dr Paul Litchfield

Yes.

Chair

Most definitely?

Dr Paul Litchfield

My opinion is that it will reduce the number of face-to-face assessments. I am sure this doesn’t happen, but you can see a potential conflict of interests if the organisation carrying out assessments is determining whether it should be a face-to-face assessment or papers-only. I am sure it wouldn’t happen, but you could see a situation arising where, if you have professional resource sitting around doing nothing, you push more to face-to-face assessments and if you are under pressure to meet targets, you go for more papers-only. I am sure that does not happen, but it is a risk.

Chair

The Department wasn’t very keen on your idea of co-locating the health care professionals and the decision makers. Why do you think that is important? You have probably touched on that already.

Dr Paul Litchfield

I think it’s important for several reasons. One reason is that I think it encourages joint working between the health care professional and the decision maker. They get to see how each other think—if you can see how people think. They get to see how each other work and get an understanding of how each other think. I think it would make for better decision making. It is much more akin to what happens in the tribunals, where you have a lay member and a medical member. I feel that one element of why there is significant disparity between the decisions arrived at by those two systems is that the Tribunals Service sees the individual and has the opportunity for the medical member and the judicial member to talk about the case. If it is practical, it would be helpful for the Department if we could introduce that for the core ESA assessment and WCA. The other element is that it brings the decision maker and the person making a claim face to face. Feeling that you have had your day in court is an important part of feeling that something is fair. For those three reasons, I think it would be an advantage. I can understand all the practical difficulties that it involves but I think it is worth looking at.

Chair

This is my last question before we lose our quorum—obviously the bells have started ringing. On the paper-based assessments, I have a number of constituents—again we picked up on this yesterday—who are not getting face-to-face assessment and are being put into the WRAG. Of course, they only realise that has happened to them if they are on contributory ESA and, after a year, it has run out. When the WCA was first envisaged, everybody in the WRAG, regardless of whether they were contributory or income-based, would keep the benefit so it didn’t really matter whether they were in the WRAG or the Support Group in terms of the money they got, although it did matter to the conditionality that was on them. That has changed as a result of the 2012 Act, which makes it time-limited. Have you seen any evidence of that or thought about its implications for individuals? They haven’t appealed that they should have gone into the Support Group because they didn’t know, because of the way the letters worked, that they had been put in the WRAG until the money stops.

Dr Paul Litchfield

No. It’s not something I have looked at, at all.

Chair

Is it something that you might look at in your next year’s review?

Dr Paul Litchfield

I will think about how that fits within the terms of reference. I am always alive to not straying—too far, anyway—beyond the terms of reference.

Chair

I had a suspicion that if anybody was on upper rate DLA, that might mean that they got paper-based assessment and went into the WRAG—I couldn’t quite understand why it was the WRAG, rather than the Support Group—but there was somebody yesterday who that had happened to and they were not on upper rate. They were only on the mid-rate DLA, so I was wondering what was distinguishing about the group that has gone through the paper-based assessment. I didn’t know whether or not it was pressure—backlogs building up—and this was a way of dealing with it.

Dr Paul Litchfield

It’s something I clearly need to understand better, so I will certainly look at it.

Debbie Abrahams

May I ask a final question? I have just been contacted by somebody who is commenting on the number of people dying every week as a result of being found fit for work after an assessment. Would you like to comment on that?

Dr Paul Litchfield

I don’t have any information on that. I haven’t seen numbers on that. Clearly, every case is a tragedy.

Chair

Thanks very much for coming this morning. We really appreciate it. We still have questions we haven’t asked, and the same happened in the first session as the time has beaten us, I’m afraid. Everything that you have said is very helpful for us. Good luck with next year’s review. You have listed a whole load of things that you are going to be looking at, and we will watch with interest. Oral evidence: Employment and Support Allowance and Work Capacity Assessments, HC 1212 35