Medical Assessments PIP
& ESA
PIP & ESA – The Similarities
• Medical assessments to determine eligibility, with
regular review (very few get 10 year reviews).
• Face to face assessments, carried out by a private
company (ATOS or Capita) on behalf of DWP. Usually
an appointment at an assessment centre, although
there may the possibility of a home visit
• Some cases may be assessed on papers only, if the
written evidence (including claim form) is strong
enough and properly supported.
• The assessment report is passed to a DWP decision
maker (DM).
• You may receive a phone call from DWP before final
decision is made
When Might You Have To Attend A
PIP/ESA Medical Assessment
• You have made a new claim for PIP or for ESA
• You are receiving PIP or ESA and you are called for a
review
• You have received Incapacity Benefit, Income Support,
or Severe Disablement Allowance since before 2008,
and you are called for a WCA to be transferred to ESA
• You have been receiving Disability Living Allowance, but
you now have to make a new claim for PIP instead
– your fixed term award of DLA expires
– you notify DWP that there has been a change in your
care or mobility needs
– You turn 16 years of age
ESA Entitlement Conditions
ESA
•
•
A person is entitled to ESA if they have limited capability for work A
person has limited capability for work if—
(a) his capability for work is limited by his physical or mental
condition, and
(b) the limitation is such that it is not reasonable to require him to
work
A person will be placed in the support group if they have limited
capability for work-related activity
A person has limited capability for work-related activity if—
(a) his capability for work-related activity is limited by his physical or
mental condition, and
(b) the limitation is such that it is not reasonable to require him to
undertake such activity.
The detail is in regulations
Incontinence Treated Differently in
LCW and LCWRA
• Within LCW –
Absence or loss of control leading to extensive
evacuation of the bowel and/or bladder, other than
enuresis (bed-wetting), despite the wearing or use of
any aids or adaptations which are normally, or could
reasonably be, worn or used
• Within LCWRA –
Absence or loss of control over extensive evacuation of
the bowel and/or bladder, other than enuresis (bedwetting) despite the presence of any aids or adaptations
normally used. At least once a week experiences loss
of control leading to extensive evacuation of the bowel
and/or voiding of the bladder.
ESA – Exceptional Circumstances
Exceptional circumstances
• LCW –
Because of your physical or mental health condition or learning
disability, there would be a substantial risk to the mental or
physical health of any person, including you, if you were found
not to have limited capability for work. And the risk could not be
reduced by a significant amount by reasonable adjustments
being made in your workplace or by your taking medication to
manage your condition that has been prescribed by a registered
medical practitioner who is treating you.
• LCW –
Because of your physical or mental health condition or learning
disability, there would be a substantial risk to the mental or
physical health of any person, including you, if you were found
not to have limited capability for work-related activity.
MS And PIP
• PIP has no equivalent of the requirement for ‘continual
supervision’ that existed in Disability Living Allowance
(DLA)
• The PIP supervision test is very a high hurdle to jump,
but it might mean, for example, that a person with a
history of status epilepticus may get the high rate care
(even if their fits were comparatively rare – not
assured)
• In practice the supervision requirement may depend
on an assessment of whether the person dealing with
particular aspect of MS is capable of recognising the
symptoms early enough to take pre-emptive action.
PIP – A DWP Case Study
Pete is 19 and lives with his family. He works from home in the family
business as he is not allowed to drive. He is unable to take part in sport
as he is worried about having a fit. These have been more frequent
since puberty and his neurologist keeps his treatment under constant
review to try to reduce his fit frequency; he is currently having a mix of
either grand-mal or petit-mal fits most days and sometimes more than
once a day.
He is occasionally incontinent during a grand-mal fit and falls asleep for
a while afterwards. Between fits he is fairly independent although he
only takes a shower if a family member is in the house and he never
cooks when alone – in the past he has suffered injuries including scalds
and burns in the kitchen. He has little or no warning of a fit and
previously he has received cuts and bruising from fits while outdoors.
He never goes out unaccompanied because of the risk and danger
from traffic or from members of the public.
• What level of PIP could Pete expect ?
PIP – DWP Case Study – Result 1
Likely descriptor choices –
Daily Living
1 Needs supervision to either prepare or cook a simple meal
4
2 Can take nutrition unaided
0
3 Can manage medication, therapy and monitor a health condition unaided, or with the use of an
aid or appliance
0
4 Needs supervision or prompting to bathe
2
5 Can manage toilet needs or incontinence unaided
0
6 Can dress and undress unaided
0
7 Can communicate unaided and access written information unaided, or using spectacles or contact
lenses
0
8 Can engage socially unaided
0
9 Can manage complex financial decisions unaided
0
Mobility
10 Needs supervision, prompting or a support dog to follow a journey to a familiar destination 15
PIP – DWP Case Study – Result 2
Total points
Daily living activities = 6 (no daily living component entitlement)
Mobility activities = 15
(enhanced rate mobility component)
Explanation
Daily living
Although Pete has fits on most days, which are unpredictable
with minimal warning, he is independent in all daily living
activities other than cooking and bathing, where having a seizure
would result in significant risk. He therefore only requires
supervision for these activities.
Mobility
He requires supervision whenever he goes out, because of the
significant risk of injury.
Be Very Careful at the Medical
• The Health Care Professional (HCP) may
appear to be friendly and ask you your
favourite TV program. If you say East Enders,
for example, they will ask whether you
watched a recent episode. - If the answer is
‘yes’, they will conclude that you can sit in a
chair without falling out or without suffering
any discomfort and you can concentrate for at
least 30 minutes. Also your memory is OK.
Be Very Careful at the Medical
• Don’t walk across the car-park, someone may
well be watching;
• Ask for a disabled car-parking space.
• Ask if they have a lift, DON’T walk up stairs.
• Ask for a home visit;
• Don’t answer the door yourself;
• Don’t offer the HCP tea and biscuits, they are
not on your side.
Be Very Careful at the Medical
• You should be accompanied and supported at all
times;
• Ask for and insist upon a recording of the meeting
with the HCP – it is your right.
• If, and ATOS may well do so, insist and say that
you are unable to continue with the medical
assessment unless you have a recording of the
meeting.
• Have copies of all your PIP/ESA paperwork with
you – the HCP may not have everything.
Links
Up-to-date information can be found here:
Individuals: https://www.gov.uk/pip
Advisers:
https://www.gov.uk/government/publications
/the-personal-independence-payment-toolkitfor-partners/the-personal-independencepayment-pip-toolkit-for-partners