The report containing results and conclusions from the Evidence-Based Review (EBR) of the Work Capability Assessment (WCA) was published on Thursday 12 December 2013.
The EBR report, which is long and quite complex to read at times, can be downloaded from the DWP website:
Dr Charles Shepherd describes why the EBR was carried out, who carried it out, how this was done and then summarises the key points to emerge.
During 2010 and 2011 a Mental Health Group (MHG) and a Fluctuating Conditions Group (FCG) were set up and asked by the DWP and Professor Malcolm Harrington (who carried out the first three independent annual reviews of the WCA) to produce testable proposals for an alternative version of the current Work Capability Assessment (WCA).
A copy of the report prepared by the FCG can be found here:
The intention was to produce a points based medical assessment of fitness for work for people claiming the Employment and Support Allowance (ESA) that is more fair and effective for those who have fluctuating medical conditions and/or mental health conditions.
The Forward ME Group represented people with ME/CFS on the FCG. Dr Charles Shepherd represented Forward ME and helped to produce the alternative assessment (AA).
The position taken by the ME/CFS charities is that the current WCA is a very blunt and insensitive way of measuring fitness for work in people who do not have the necessary physical and mental endurance to hold down a job. The fact that around 40% of people are successful on appeal indicates that the WCA is not fit for purpose and is letting people down who need this support.
The remit from the DWP was not to change the various activities of everyday function (eg mobility, lifting, navigating) that are assessed in the current WCA – although the FCG did recommend the inclusion of additional questions relating to fatigue and pain. We were asked to concentrate on producing changes to the way in which the point scoring descriptors in the WCA measure the level of impairment for each specific activity.
Both groups independently agreed that there should be a significant shift in emphasis in the AA towards a multidimensional approach. This would measure both severity of limitation and frequency of limitation in a matrix format in relation to all the various activities and tasks that make up the current WCA.
We also made a number of other recommendations as to how the WCA could be improved – in particular the inclusion of a semi-structured interview that would capture additional information as to whether a person was fit for work. More information on the semi-structured interview can be found in Annex 3 on page 70.
The FCG and MHG subsequently produced a multidimensional AA that assessed severity and frequency of both physical and mental limitations of function – this is included as annex 2 on page 61 in the report. The current WCA is included as Annex 1 on page 52.
We produced the AA to a very strict DWP timetable and without any financial or statistical assistance. In addition, there was no opportunity to pilot and refine our recommendations – especially the way in which points would be scored – before the evidence based review (EBR) took place. So while we stand by our belief that the overall approach we took is sound, this placed the AA at a considerable disadvantage once it was tested against the current WCA because the AAt cannot be regarded as a finished product.
The EBR was completed in September 2013. The key findings are as follows:
THE MULTIDIMENSIONAL ASSESSMENT (AA)
1 Claimants were more likely to score 15 points of more with the AA (44%) when compared to the WCA (20%). This finding came as no surprise to the FCG and MHG – given our belief that far too many people with genuine and disabling health problems are unfit for work and are being passed as fit for work under the current point scoring system.
2 In general, claimants were more likely to score points across a larger range of activities in the AA when compared to the WCA.
3 The AA was better at detecting limitations in specific areas of functioning – even if they were relatively moderate.
4 The AA included descriptors that would score 3 points (the WCA does not have a 3 point score). The 3 point scores were deliberately included to help people with low levels of functional impairment across a range of mental and physical activities.
5 The semi-structured interview style of assessment was well received by both claimants and health professionals. Claimants expressed a preference for the semi-structured interview in order to discuss aspects of how their condition affected them that would not be explored in detail during a regular WCA discussion. Health professionals also reported gathering useful information during these discussions.
6 Where someone was considered to have a limited capacity for work by the expert panels, the panels were more likely to agree with the AA.
The expert panels consisted of groups of medical experts who assessed people on fitness to work who had also been assessed using both the AA and WCA.
THE CURRENT WORK CAPABILITY ASSESSMENT (WCA)
1 The WCA corresponded more closely with the expert panel opinions across a range of indicators when compared to the AA.
2 The WCA fitness to work outcome was the same as the view of the expert panels in 77% of cases; the equivalent figure for the AA was 65%.
3 The WCA and expert panels were more likely to agree when panels felt someone was fit for work.
Overall, the report concluded:
There was no evidence that the AA was a significant improvement on the WCA in terms of the accuracy or reliability of findings. However, the AA did reveal some areas – namely the way in which limitations and their fluctuations are noted, and the style of assessment discussion – which have relevance for ongoing refinement of the WCA.
ROLE OF THE EXPERT PANELS
Both groups (FCG and MHG) have major concerns about the protocol by which the expert panels came to their conclusions as to whether the people they assessed were ‘fit for work'. This is because:
1 Only the paperwork was reviewed – there were no face to face interviews with the claimants.
2 People were considered to be fit for work in the vast majority of cases (83%) only due to the fact that one or more theoretical modifications to the working environment, or working hours, would be made – this included flexible or alternative hours in 50%, aids or adaptions in 47%, home working or working in another place in 23%, and a support worker in 24%.
3 The expert panels were sceptical as to whether these aids, adaptions and adjustments could actually be made in the real world.
4 There was no clear definition as to what the DWP regards as fit for work.
We therefore believe that a significant proportion of the people assessed by the expert panels as being ‘fit for work” and not therefore eligible for ESA would only have (a) a limited range of work options open to them and (b) would require considerable assistance in sustaining meaningful employment at the same time. A significant proportion may therefore have been more appropriately placed in the ESA Work Related Activity Group (WRAG) rather than being passed as fit for work and claiming JSA.
More information on the role of the expert panels can be found in Chapter 5 on pages 36 – 40. The questionnaire used by the expert panels is included as Annex 4 on page 80.
We also believe that there were a number of other significant flaws in the way the EBR was carried out:
1 Some conditions – eg Parkinson's disease – were represented by either very small numbers or not at all. In relation to ME/CFS the report (page 19) states that 21 cases were assessed. The 600 claimants who volunteered for the research were not therefore a representative sample of people with fluctuating medical conditions.
2 There were no cases of Parkinson's disease or multiple sclerosis in the booster groups
3 People who were found to be unfit for work at the initial WCA interview, and placed in the Support Group, were excluded from the EBR. This meant that the group being examined was largely either fit for work or suitable for placement in the WRAG.
I believe that the Alternative Assessment, which allowed more people to score more points, assessed frequency/fluctuation in impairment in a far more detailed manner, and included a semi-structured interview to obtain additional information on state of health/disability, is far more fair and effective way of assessing fitness for work, or limited capability for work, if a points based system has to be used.
However, the way in which the expert panels came to their conclusions about fitness to work when the AA was compared to the WCA means that the DWP will not be replacing the current WCA with the AA.
Even so, the work we have been doing for the past three years has identified a number of areas where I believe the WCA could still be significantly improved. So I hope that the DWP will now take this opportunity to look in particular at the way in which work is defined in relation to people who fall into the gray area between fit for work and not fit for work, and how fluctuation in severity and frequency of impairments should be measured.
If the DWP fails to address a number of key areas where the current WCA is failing to produce fair and effective assessments, a significant number of people with fluctuating medical conditions and mental health conditions who are genuinely unfit to work will continue to have their ESA claims refused and wrongly find themselves relying on job seekers allowance.
The DWP will now be considering the findings and conclusions in the report over the coming weeks. When this process is over I hope that they will continue to with consult with representatives of fluctuating medical conditions and mental health conditions to make some much needed improvements to the WCA.
Dr Charles Shepherd
17 December 2013