PIP assessment guide part 3: health professional performance

Question 1

3.1  Health professional competencies

Accepted Answer

3.1.1 All HPs recruited for the delivery of PIP assessments (or any parts of these) must meet the following requirements:

be an occupational therapist, nurse, physiotherapist, paramedic, doctor, pharmacist or:
- by exception, another registered health professional, providing the requirements set out at 3.1.2 are met, the individual continues to satisfy quality and probation processes, and only by individual, prior, written agreement with the DWP.
be fully registered with the relevant licensing body (doctors must have a licence to practise)
Have no sanctions attached to registration unless: they relate to disability, or the HP is a doctor who has an Approved Practice Setting (as defined by the GMC from time to time) requirement on the grounds that they have not had their first revalidation post qualification as a doctor
In individual cases, the requirement for HP’s not to have any sanction attached to registration may be waived subject to prior written agreement with DWP (no waiver is required in relation to any sanction relating to disability or an Approved Practice Setting requirement)
Have at least 1 year’s post full registration experience (this refers to either UK registration or equivalent overseas registration for non-UK HPs) or less than 1 year’s post full registration experience by individual, prior, written agreement with the DWP.
Have passed a Disclosure and Barring Service (DBS) check at the appropriate level

3.1.2 Before they are approved to carry out assessments, providers must be able to demonstrate that HPs:

have appropriate knowledge of the clinical aspects and likely functional effects of a wide range of health conditions and disabilities
have appropriate skills in assessing people with physical health conditions, including history taking, observation and ability to perform a relevant examination
have appropriate skills in assessing people with conditions affecting mental, intellectual and cognitive function, including history taking, observation and ability to perform a relevant examination
are able to critically evaluate evidence and use logical reasoning to provide accurate evidence based advice
have excellent interpersonal and written communication skills that include the ability to:
- interact sensitively and appropriately, with particular regard for an individual’s cultural background and issues specific to disabled people
- take a comprehensive, appropriately focused and clear history
- accurately record observations and formal clinical findings
- produce succinct, accurate reports in plain English, fully justifying conclusions from evidence gathered, and dealing appropriately with apparent conflicts of evidence and fluctuating conditions
Use a questioning style that allows the claimant to talk freely about their level of function.

Question 2

3.2  Training of Health Professionals

Accepted Answer

The Clinical Authorship Team (CAT) and Training and Guidance (TAG) Editorial Board

3.2.1 All APs are expected to work collaboratively within the framework of the CAT, the TAG Editorial Board and the DWP to develop, review and update all existing and new Core Training and Guidance Material.

Initial training

3.2.2 APs are required to put in place suitable training programmes to ensure that HPs carrying out assessments meet the competency requirements. They should involve the DWP in the quality assurance process for the development and on-going refinement of these programmes and the quality standards associated with them. Where relevant, training programmes should be based on this guidance and the Core Training and Guidance Material supplied by the DWP.

3.2.3 The training programmes should include, but not be limited to, ensuring HPs have:

an understanding of the legislative framework in which they are working and the legislative requirements for PIP
an understanding of, and an ability to perform, the role of a disability assessor in order to assess claimants with health conditions or disabilities and how these conditions or disabilities affect either their physical or mental function
an up-to-date knowledge of relevant clinical subjects
an understanding of the importance of customer service and equal opportunities and any relevant policies and procedures
an awareness of different cultures and their potential impact on the assessment process
an understanding of the needs of and challenges faced by disabled people
an ability to deal with potentially violent situations
an ability to competently use relevant IT systems
an awareness of mental health and the potential impact this has on the claimant’s journey

3.2.4 Training programmes should involve both theoretical and simulated practical elements, with relevant examinations. Following training, HPs should undergo a written and practical assessment to ensure that the required level of competence has been achieved and that they can demonstrate this to the DWP.

Refresher training and continuous professional development

3.2.5 The AP is required to develop, deliver and evaluate a programme of refresher training and continuous professional development (CPD) on an annual basis for all HPs involved in delivering PIP assessments.

3.2.6 Each HP should be given a personal training plan on an annual basis, containing details of the modules to be delivered to the individual and the timescales in which they will be delivered.

3.2.7 The DWP may require that topics be included in the CPD programme.

Training plans

3.2.8 The AP is required to undertake an annual training needs analysis at organisational level to identify areas of training needs together with priorities for implementation. The scope, objectives and methodology of the analysis will be subject to prior approval by the DWP.

3.2.9 The AP is also required to supply the department with a training plan setting out in detail the manner in which their training programme, both initial training and refresher training / CPD, will be delivered. This plan should be developed in co-operation with the DWP and will be subject to the DWP approval.

3.2.10 Any subsequent changes to the training plan must be submitted to the DWP for approval.

3.2.11 The AP must evaluate the effectiveness of their training and CPD programmes. The format and timescales of the evaluation should be agreed with the DWP.

Condition specific champions

3.2.12 The AP must ensure that Mental Function Champions (MFC) are available to provide advice and support to HPs on health conditions and disabilities affecting mental, cognitive, intellectual and behavioural function.

3.2.13 In addition to satisfying the requirements set out in section 3.1, MFCs should have at least 2 years post full registration clinical experience in the management of conditions affecting mental health, intellectual, cognitive and behavioural function.

Question 3

3.3  Approval / revocation of health professionals

Accepted Answer

3.3.1 Before an HP can carry out PIP assessments they must go through a formal approval process to ensure they meet the DWP’s requirements in relation to experience, skills and competence. Failure to demonstrate that HPs have reached or maintained the necessary standards or co-operate with feedback and/or retraining will result in approval being refused/revoked.

3.3.2 Approval for an HP must be conferred by the DWP on behalf of the Secretary of State for Work and Pensions. This will, in turn, be based on the recommendation of the AP who must provide evidence that the HP has demonstrated that they meet the required standards.

3.3.3 This section describes processes to be followed during the live-running of PIP assessment contracts.

Approval process

3.3.4 The approval process must be undertaken:

for all new recruits
for all HPs who have not completed PIP assessments for 12 months or more
for all existing employees who have not worked on PIP before

3.3.5 There are 5 stages in the approval process:

Stage 1 – training

This should involve all trainee HPs undergoing a DWP-approved training programme, which should include both theoretical and practical simulated assessments (including face to face, telephone and video assessments, paper-based reviews and SREL advice) to ensure that they can meet the competence and knowledge requirements.

Stage 2 – assessment of competence

Once Stage 1 is complete, the AP should carry out an assessment of whether the trainee HP meets the required competence and knowledge standards. This should include written elements e.g. assessment reports and paper-based reviews and practical elements e.g. advice on SREL cases and assessing when assessments are appropriate and or when further evidence should be requested.

Stage 3 – supervision

Once stage 2 has been successfully completed by the trainee HP, they will have provisional approval to carry out assessments on claimants, including face-to-face, telephone and video assessments, paper-based reviews and SREL advice. At this point, the AP should keep evidence to demonstrate that the HP meets the required competence standards. Assessments should initially be supervised until the AP is satisfied that the HP is continuing to meet the required standards in an operational setting. The number of assessments that must be supervised is at the discretion of the AP.

From Stage 3 to approval, trainee HP reports are subject to 100% audit.

Once stage 3 has been successfully completed by the trainee HP, they will be able to carry out assessments without supervision but subject to 100% audit until full approval is given by the DWP.

Before the HP moves into stage 5, they must achieve five or more audited Acceptable and/or Acceptable with Feedback reports and no more than one audited Unacceptable report in a rolling ten assessments. HPs move through this stage, learning from the audit feedback of their cases.

Stage 5 – Preceptorship

Following stage 4, the trainee HP is supported by an experienced HP, who has met the required standards, is quality audit trained and has 2 or more years’ experience completing PIP assessments. The HP is subject to observation before, during and after assessment. Reports are reviewed with the HP to provide individual feedback and guidance. HPs must demonstrate competency in:

preparation (including appropriate use of further evidence)
consultation (including customer care and appropriate questioning)
accurate documentation of evidence gathered during assessment
completion of the assessment report

Reports are deemed competent when no amendments are required to any element of the assessment. There is a requirement for competency to be demonstrated in cases involving physical and mental health conditions prior to full approval.

Full approval

3.3.6 The AP will be able to seek full approval from DWP for an HP once that HP has shown an ability to consistently apply the competence standards.

3.3.7 All cases which contribute to approval must be cases where advice is given either on a PA2, PA3 or PA4.

3.3.8 If an AP trains a new recruit in more than one modality of assessment (face-to-face/TA/VA), the required grades to satisfy Stage 4 of the process can be achieved in any modality (or combination), provided the Stage 4 requirement is met. HPs will then need to satisfy Stage 5 in each separate modality prior to full approval.

3.3.9 APs with HPs who are approved in one area of assessment only, will be able to seek approval from DWP for a HP to carry out other assessments as follows:

If already approved for paper-based reviews or SREL, the HP will require upskilling to cover any additional written or practical elements prior to seeking approval in face to face, telephone, or video assessments, or vice versa. In these instances, HPs will be subject to meeting the competence standards at Stage 4 and Stage 5 of the approvals process before seeking full approval to carry out the additional assessment type.
If already approved for one of either, a face to face, telephone or video assessment, the HP will require upskilling to cover any additional written or practical elements prior to seeking approval in other types of assessment (not PBR or SREL). In these instances, HPs will be subject to meeting the competence standards at Stage 5 of the approvals process before seeking full approval to carry out the additional assessment type.

3.3.10 The AP must supply DWP with evidence demonstrating that the HP has achieved the required standard if requested. The Secretary of State reserves the right to not approve an HP if there is any concern that an individual does not satisfy one or more of the required criteria, regardless of the actions or views of the AP.

Submitting HPs for approval

3.3.11 When the AP is satisfied that the HP has successfully completed all 4 stages of the approval process the following information should be sent to DWP upon request:

the HP’s name and work address
the AP’s assurance that the relevant register has been checked for that HP’s profession, they can confirm that they are registered and have 1 years post-registration experience
a list of the training the HP has completed and the dates that it was completed
a list of all the examinations/assessments the HP has completed, including dates and whether they have failed or passed. Where the HP had more than one attempt to pass a module, the AP should list the dates and the results in each instance
the dates of all the 5 assessment reports the HP has completed at stage 4 and stage 5 and the audit grade. Any unacceptable reports at Stage 4 must include the assurance that the report has subsequently been amended and audited to an acceptable grade.
assurance from the clinical lead that he/she is satisfied the HP has reached the standard necessary to carry out PIP assessments

3.3.12 The DWP will review the HP’s papers and approve them. DWP will maintain a database of approved HPs. If the status of the HP changes the AP should advise DWP as soon as possible.

Maintenance of approval

3.3.13 The HP’s ongoing approval is dependent upon the HP undertaking PIP assessment work for the AP and fulfilling the following criteria:

the HP continues to satisfy the required quality standards
the HP completes any mandatory training required
PIP assessment work includes any work that requires the HP to use their knowledge of PIP assessment policy in their regular role, for example direct functional assessment of claimants, consideration of claims at initial review and audit.

3.3.14 The AP should fully support the HP to meet the requirements for professional revalidation.

3.3.15 The AP should keep records for each HP containing all information relating to quality – for example, on training, CPD, quality monitoring, rework, and complaints.

Revocation of approval

3.3.16 The DWP reserves the right to revoke approval – both provisional and full approval – at any time where there is concern that an individual may no longer satisfy one or more of the required criteria. This is at the discretion of the DWP and is irrespective of any action that the AP is undertaking.

3.3.17 The AP must consider whether the circumstances surrounding any revocation of approval warrant them informing the HP’s professional body.

3.3.18 Revocation of an HP’s approval should routinely be sought for a number of reasons:

termination of contract
resignation
deceased
change of job role no longer requiring approval
absence from work for 12 months

More information on these areas is covered below.

3.3.19 The AP should inform the DWP where any of the above apply, together with any relevant documentation if requested.

3.3.20 The AP should ensure that the DWP is informed immediately of any HP who fails to continue to meet DWP’s required HP Quality Standards. The DWP may consider revoking its Approval in respect of that HP. The AP should acknowledge that the DWP may ask the AP to demonstrate that HPs meet the DWP’s required HP Quality Standards at any point during the Term.

Absence from work

3.3.21 If the absence is for a period of less than 3 calendar months, the HP may resume their normal duties afterwards.

3.3.22 If the absence is for a period of more than 3 but less than 6 months, the HP should be subject to targeted quality audit on their return to ensure the required standards are being met. The number of assessments audited will be at the discretion of the AP.

3.3.23 If the absence is for a period of more than 6 but less than 12 months, the AP should return the HP to Stage 4 of the approval process, requiring them to undergo 100% audit. The HP will be required to complete Stage 4 and Stage 5 again before full approval is resumed.

3.3.24 If the absence is for a period of more than 12 calendar months, the AP should seek revocation of approval from DWP. To carry out PIP assessments in the future, the HP must go through the full initial approval process again.

Resignation, deceased or change of role

3.3.25 When the HP informs the AP of their intent to leave or change role, the AP should then seek revocation of approval from DWP, stating the date of their final assessment.

Administrative processes

3.3.26 The detailed administrative processes to support the approval and revocation requirements have been shared separately with the AP.

3.3.27 The AP must maintain details of approvals / revocations of approval. The detailed content is to be agreed with DWP and shared with DWP on request.

Question 4

3.4  Quality audit

Accepted Answer

3.4.1 Audit processes are in place for auditing justifications for initial review and the quality of assessments through:

DWP Independent Audit (random sample); and
the AP – approval-related audit (trainee), assessment report only

3.4.2 Audit has a central role in ensuring that decisions on benefit entitlement, taken by DWP, are correct. It supports this by confirming that independent HP advice complies with the required standards and that it is clear and medically reasonable. It also provides assurance that any approach to assessment and opinion given is consistent so that, irrespective of where or by whom the assessment is carried out, claimants with conditions that have the same functional effect will ultimately receive the same benefit outcome.

3.4.3 Assessment reports subject to audit will be examined and graded ‘acceptable’, ‘acceptable: HP learning required’, ‘acceptable: report amendment required’ and ‘unacceptable’ in accordance with the quality audit criteria in section 3.5.

3.4.4 More detailed guidance on how justifications for initial review and assessment reports should be audited and the criteria to be used are set out in section 3.5.3.

3.4.5 The DWP also recommends that the AP undertake additional audit activity to ensure quality standards are being met, including:

new entrant audit (recently approved)
rolling audit
targeted audit

DWP Independent Audit

3.4.6 The DWP Independent Audit Team carries out lot-wide audit, which is an audit of a controlled random sample from across each contract Lot, feeding in to routine performance reporting for DWP.

3.4.7 The sample should include SREL cases, paper-based review and consultation outputs, with supporting justifications for initial review. Forms PA5 and PA6 (supplementary advice) are not included in the independent audit.

3.4.8 The independent audit sample size has been designed in conjunction with DWP analysts. The model produces an appropriate sample size to specified margins of error.

3.4.9 AP targets are for:

a minimum of 97% acceptable initial review/assessment reports; and in addition
a minimum of 85% of assessment reports must be assessed as ‘acceptable’ or ‘acceptable: HP learning required’

3.4.10 During stage 4 of the HP approval process HPs should be subject to 100% audit to ensure that they are consistently able to apply the competence standards (see 1.37).

New entrant audit

3.4.11 Once an HP has been approved, the DWP recommends that they continue to be subject to regular audit until the AP is satisfied that consolidation of skills has been achieved. The frequency and volume of monitoring should be determined by the AP.

Rolling audit

3.4.12 Rolling audit is an audit of the work of each HP on a regular basis to assess the quality of their work on a continuing basis, ensure maintenance of standards and for on-going approval.

3.4.13 The DWP recommends that the AP ensure that an appropriate proportion of a HP’s assessments are subject to audit in every 3-month period. The number of cases that will need to be subject to rolling audit may be affected by the number of examples of that HP’s work which have formed part of other audit activity – for example, cases selected as part of the lot-wide audit. Some HPs will not need rolling audit at all because they are regularly audited in random or targeted audit activity.

Targeted audit

3.4.14 Targeted audit is audit activity triggered where a quality, rework or complaint issue has been identified to establish whether there is evidence of an on-going problem or where it is felt that auditing should be carried out to ensure the required standards are met.

3.4.15 Targeted audit is carried out at the discretion of the AP or at the request of DWP – for example, where rework volumes are significantly high indicating problems with quality, or where successful appeals indicate that the evidence was insufficient.

Case review

3.4.16 A Case Review is a quality review carried out on closed cases that does not fall under any of the other quality review categories. These may be carried out either with a specific focus on a type of case due to a trend, a specific focus on a HP, a regular rolling review or for other reasons. HPs may also undertake Self Case Reviews on closed cases based around reflective learning to aid personal reflection and learning development.

Observations of the HP

3.4.17 In addition to audit, the AP will undertake observations to evaluate HP competence for the end-to-end assessment process including:

preparation (including appropriate use of FME) for the assessment and consultation (where applicable)
undertaking the consultation, including claimant care and appropriate questioning
accurately documenting evidence gathered during an assessment
completing the Assessment Report

The DWP reserves the right to periodically observe HPs undertaking assessments.

Experience of auditors

3.4.18 The AP should put in place processes to ensure that individuals carrying out audit and case review activity are Approved HPs and have demonstrated the requisite skills, knowledge, and experience to carry out their roles. Where possible, they should have been carrying out PIP assessments for a minimum of 12 months.

Live cases

3.4.19 Unless there are extenuating circumstances, audit activity should be carried out while cases are “live” and before they are submitted to DWP. As such all audit activity should be carried out swiftly to avoid delay to the case.

3.4.20 If a case is identified as requiring amendment after it has been returned to DWP, as the advice may be misleading, contact should be made with the relevant CM.

Feedback

3.4.21 The AP should put in place processes to ensure that appropriate feedback is given to HPs as a result of auditing.

Alteration of acceptable report amendment required and unacceptable reports

3.4.22 Where assessment reports have been graded as ‘acceptable: report amendment required’ or ‘unacceptable’, remedial activity should be taken before the case is submitted to DWP. This activity should be undertaken by the HP who carried out the original assessment, unless there are circumstances that prevent this e.g. the HP has left the business or is on extended leave.

3.4.23 Where justifications for initial review have been graded ‘Acceptable’, ‘Amendment Required’ or ‘Unacceptable’, remedial activity may apply to the AP processes following audit.

3.4.24 Any changes made to forms should be justified, signed and dated. It should be made clear that any changes are made as a result of audit activity.

3.4.25 Where necessary a new report form should be completed.

Maintaining records

3.4.26 The AP should keep records of all audit activity described in this section, including iterations of all audited reports. These records should be retained for a minimum period of 2 years.

Question 5

3.5  Quality audit criteria

Accepted Answer

3.5.1 These audit quality requirements apply to cases audited under DWP independent audit. However, the AP may wish to use the same criteria for other audit activity, such as rolling and targeted audit.

Audit of the initial review

3.5.2 The AP should document a fully justified choice of further action taken during the initial review, including the justification for the assessment channel allocated. This documentation must be provided to the DWP as it may be subject to audit.

Grading for justifications for initial review

3.5.3 Justifications are graded as ‘acceptable’, ‘acceptable: HP learning required’, ‘acceptable: amendment required’ or ‘unacceptable’ in accordance with the following criteria.

Justification for case routing (initial Review)

Case routing decision and rational for case routing decision	A	Case routing correct based on all the available evidence and case routing decision is adequately justified
Case routing decision and rational for case routing decision	A	PBR preferred route but despite all efforts HP unable to obtain adequate evidence to support PBR and call to exam necessary
Case routing decision and rational for case routing decision	AF	Case routing correct and justification supports but doesn’t fully explain the decision
Case routing decision and rational for case routing decision	AA	Case routing correct but justification fails to support the decision
Case routing decision and rational for case routing decision	U	Case routing incorrect based on all the available evidence
Case routing decision and rational for case routing decision	U	Call to exam with significant risk of harm to the mental or physical health of the claimant or others
Case routing decision and rational for case routing decision	U	No justification given to explain case routing decision or justification given is not medically reasonable or logical

Areas to be audited for assessment reports

3.5.4 When auditing cases, the AP should look at the entire case at the point at which it is finalised and due to be returned to the DWP, considering both the final output and the processes followed.

3.5.5 Reports should be audited in 4 areas:

opinion
information gathering
further evidence
process

3.5.6 Attributes break the areas down into subcategories that must be considered.

Grading for assessment reports

3.5.7 Reports are graded as ‘acceptable’, ‘acceptable: HP learning required’, ‘acceptable: report amendment required’ or ‘unacceptable’ in accordance with the following criteria.

Area	Attributes	Acceptable	Unacceptable
Opinion	Descriptor choice Prognosis advice Qualifying period/prospective test recommendation SREL advice Reliability criteria Justification	Clinically probable advice based on all the available evidence HP learning required: Clinically possible advice but evidence supports consideration of an alternative opinion or descriptor choice Report amendment required: Clinically improbable advice such that the descriptor choice is highly unlikely but would not lead to a wrong award if left unchanged Clinically improbable prognosis advice - award duration recommended considered to be too long/too short. Adequately justified HP learning required: Justification which supports but doesn’t fully explain the advice or the descriptor choice Report amendment required: Justification which fails to support the advice or the descriptor choice but doesn’t suggest an alternative award	Clinically improbable advice such that the descriptor choice is highly unlikely and would lead to a wrong award if not changed Justification which fails to support the advice or the descriptor chosen and would suggest an alternative award
Information gathering	History (including variability) Examination Observations	Sufficient information gathered to support robust advice HP learning required: Information gathered lacks detail but unlikely to have an adverse effect on advice Report amendment required: Omission that has limited potential to change advice	Major omissions such that advice cannot be relied on and correct award cannot be reasonably determined
Further evidence	All relevant stages	Sufficient further advice appropriately sought and referenced HP learning required: Reference to relevant evidence incomplete; important evidence not sought or insufficient attempt to gather it; evidence requested from an inappropriate source Report amendment required: In additional support needs case either: important evidence not sought or insufficient attempt to gather it	Critical evidence not sought or insufficient attempt to gather it so that correct award cannot be reasonably determined
Process	Case handling Usability	Clear report which conforms with guidance and professional standards HP learning required: Frequent spelling or grammar errors, use of jargon and unexplained abbreviations that are not in common use Report amendment required: Omission or error (such as harmful information / call to exam) with minor risk of adverse consequence; directive advice on entitlement; unclear medical information critical to advice clarity	Major omission or error (such as harmful information / unexpected findings / call to exam) with significant risk of harm to the mental or physical health of the claimant or others

3.5.8 For the avoidance of doubt, a report must be graded:

Unacceptable if the Unacceptable criteria applies to one or more of the Attributes
Acceptable Report Amendment Required, if none of the Unacceptable criteria applies and one or more of the Acceptable Report Amendment Required criteria Attributes apply
Acceptable HP Learning Required, if none of the Unacceptable nor Acceptable Report Amendment Required criteria applies and one or more of the Acceptable HP Learning Required Attributes apply
A report may only be graded Acceptable if none of the other criteria apply to any of the Attributes

Justification for case routing (initial review)

Case routing decision

Rationale for case routing decision

Acceptable	Case routing correct based on all the available evidence and case routing decision is adequately justified PBR preferred route but despite all reasonable efforts HP unable to obtain adequate evidence to support PBR and call to exam necessary
Acceptable with feedback	Case routing correct and justification supports but doesn’t fully explain the decision
Acceptable with amendments	Case routing correct but justification fails to support the decision
Unacceptable	Case routing incorrect based on all the available evidence Call to exam with significant risk of harm to the mental or physical health of the claimant or others No justification given to explain case routing decision; or justification given is not medically reasonable or logical

Question 6

3.6  Clinical governance

Accepted Answer

3.6.1 The AP shall adhere to clinical governance standards to ensure a systematic approach to improving quality of service and safeguard high standards of clinical care covering the seven pillars of clinical governance and must provide evidence of compliance with clinical governance standards.

3.6.2 Clinical governance should be implemented at three levels: individual HP, their line manager and at an organisational level. There are three steps to gathering and reviewing clinical governance data:

Step1 – identify and document systems, processes, and procedures in place against part of the clinical governance standards.
Step 2 – evidence data – quantitative & qualitative data behind step1, that shows current status, any learnings and outcome, identifying good practice and gaps.
Step 3 – evaluate data trends over time that shows learnings identified & changes implemented, outcome, good practice, and gaps.

3.6.3 The department may appoint an independent body to review clinical governance implementation by the AP of the clinical governance standards to:

Assure that clinical governance standards are being implemented and monitored by relevant parts of DWP and the AP.
Identify and review evidence gaps identified and how they have been addressed.
Highlight risks and how these could be removed or managed.
Share and facilitate the development of best practice.
Build a culture of trust, transparency, information sharing and constructive challenge.

This is to demonstrate commitment to continuous quality improvement, safeguarding high standards and providing assurance to the DWP Board, and the public, that regardless of which part of the country a customer is assessed in, they would receive similar standards of service.

Rework

3.7.1 Where the DWP considers that assessment reports are not fit for purpose it may return them to the AP for rework, which will be carried out at their expense.

3.7.2 The criteria are that reports will be:

Fair and impartial
Legible and concise
In accordance with relevant legislation
Comprehensive, clearly explaining the medical issues raised, fully clarifying any contradictions in evidence
In plain English and free of medical jargon and unexplained medical abbreviations
Presented clearly
Complete, with answers to all questions raised by the DWP
Of a sufficient quality that the DWP is able to make a decision on the claimant’s entitlement

3.7.3 The AP should develop procedures for accepting, recording, and dealing with rework quickly and effectively.

Rework action

3.7.4 The AP should develop procedures for accepting, recording, and dealing with rework quickly and effectively.

3.7.5 In some cases it may be necessary for an additional consultation to be carried out, either with the original HP or a different HP. The impact of any such consultations on claimants should be considered when making the decision to carry out a repeat consultation. Where possible, further consultations should be avoided so as not to place extra burdens on claimants. However, this should not compromise the quality of the advice to DWP.

3.7.6 If clerical report forms are being used, rework activity should result in the production of a new report form (PA2, PA3 or PA4).

Challenging rework reason

3.7.7 Any challenge to the reason DWP has returned a case to the AP for rework must be made via the nominated rework single point of contact (SPOC).

3.7.8 The AP SPOC must contact the nominated DWP SPOC to make the challenge. The final decision on whether the case requires rework rests with DWP.

Feedback and record keeping

3.7.9 The AP should establish procedures to ensure that feedback is provided to HPs whose reports require rework.

3.7.10 The AP should record the feedback given and remedial action taken as a result of rework. The AP should consider targeted audit of HPs where rework is required.

Question 7

3.8  Assessment quality feedback from HM Courts and Tribunals Service

Accepted Answer

3.8.1 The PIP assessment specification made clear that PIP assessment providers may receive feedback from HM Courts and Tribunals Service (HMCTS) about the quality of the assessment reports. The AP should consider this feedback and take the appropriate action.

3.8.2 Where a medical member of an appeal tribunal identifies that an assessment report is below the standard expected of the AP, they may consider giving feedback on the report to the AP in question. The criteria are that reports will be in line with requirements at paragraph 3.7.2.

3.8.3 The AP will need to work with the DWP and HMCTS to develop the processes for receiving this feedback.

3.8.4 The AP will also need to develop internal processes for recording referrals from HMCTS, action taken and responding to HMCTS. This should include processes for considering feedback from HMCTS, and where they agree that quality is not fit for purpose, steps to ensure that the feedback is passed to the relevant HP where appropriate and that any necessary improvement activity is taken.

Question 8

3.9  Complaints

Accepted Answer

3.9.1 A complaint is an expression of dissatisfaction about the services delivered by the AP which originates from a claimant. They may be made verbally or in writing by the claimant or their representatives.

3.9.2 The AP should put in place processes to effectively manage complaints.

Serious complaints

3.9.3 A complaint in which there is an allegation of professional malpractice against an HP is classed as a ‘serious complaint’. This includes, but is not limited to, allegations of:

assault / injury during the course of an assessment
inappropriately intimate examinations
abuse relating to any protected characteristic under the Equality Act 2010
theft or fraud
criminal activity

3.9.4 The AP should develop processes to manage serious complaints separate to the overall complaints processes, with escalation routes to appropriately senior staff.

3.9.5 Where a serious complaint is made against an HP, the DWP should be informed immediately. The AP should also consider suspending the HP from carrying out PIP assessments until any investigations into the complaint have been completed.

3.9.6 The AP should liaise with the DWP on the outcome of any investigation into a serious complaint. If a serious complaint is upheld, the AP should consider:

liaising with the relevant professional body (General Medical Council, Nursing and Midwifery Council, Health Care Professions Council etc).

Question 9

3.10  Fees for further evidence

Accepted Answer

3.10.1 DWP pays fees for general practitioner factual reports (GPFRs) from GPs and SR1 forms completed by doctors who are registered with the General Medical Council (GMC).

3.10.2 Fees are not paid by DWP for other sources of evidence, such as hospital factual reports from NHS hospitals and clinics; local authority-funded clinics; or factual reports / GPFRs completed by professionals other than GPs or consultants.

3.10.3 The DWP sets its own fees for factual reports and information where a fee is payable and the AP should not negotiate individual fees with doctors (GPs or hospital staff). Payment for evidence other than the GPFR or SR1 should be discussed with the DWP on a case-by-case basis.

General practitioner factual reports

3.10.4 As independent contractors, GPs are permitted to receive a fee for completing GPFRs and providing factual information unless the information required is included in their contractual agreement.

3.10.5 Where it is permissible to pay a fee, this should be the standard fee determined and paid by the DWP – currently £33.50 for a GPFR and £17.00 for an SR1 completed by a GP (although the AP will usually not need to seek SR1s from GPs). If the GP’s surgery is VAT registered, VAT should also be paid in addition to the appropriate fees.

Hospital factual reports

3.10.6 Under a longstanding agreement (Health Service Circular 1999/001 which is sometimes referred to as the “concordat”) hospitals and Trusts are obliged to provide hospital case notes (or copies), X-rays and Factual Reports, on request, within laid down time scales, and free of charge to the DWP and the AP working on their behalf.

3.10.7 Hospital factual reports from NHS hospitals, hospitals that have trust status, and clinics financed from the NHS or local authority are therefore provided free of charge and should not be paid for.

3.10.8 Care should be taken to ensure the hospital etc. is funded by the NHS. Private hospitals are not covered by the agreement with the NHS.

3.10.9 The responsibility to provide factual reports lies with the hospital, and requests should be addressed to the hospital as opposed to a particular member of staff – though the requests may specify the type of information that would help (e.g. from a physiotherapist).

3.10.10 No fee is payable to the person completing the report.

3.10.11 Sometimes hospital staff state that they are not contracted to carry out this work on behalf of the hospital. If so, they should ask the hospital to arrange for someone else to complete it on behalf of the hospital.

Rejecting requests for payment

3.10.12 The APs are responsible for making payments for the above evidence types where they have sought them, with DWP reimbursing the fees paid.

3.10.13 Where requests are made for payments that do not meet the above criteria, the AP should issue a notice rejecting the request.

3.10.14 Requests may also be rejected where a professional has responded to a request that would normally be payable but the response was not of an acceptable standard and provided no help in the case – for example, where the professional has made no effort to provide useful information – or the professional has returned their report significantly later than the date requested. However, judgement should be applied when making such decisions, as incomplete returns may be as a result of professionals having insufficient information about the claimant, rather than an unwillingness to help. Such rejections are likely to be rare.

Question 10

3.11  The principles of good report writing

Accepted Answer

Clarity

3.11.1 Good quality reports should:

be legible
be written in clear English
be succinct
use appropriate language
explain technical terms
avoid medical jargon
avoid internal contradiction
be correct
be complete

Clear English

3.11.2 When HPs explain medical reasoning or expressing opinion, it is essential that there should be no misunderstanding. As in all forms of medical (and other) writing the guiding principles should be that HPs:

use familiar words
use short words in short sentences
make every word count

3.11.3 Use of vague or ill-defined words such as ‘may’, ‘possibly’, ‘occasionally’, ‘sometimes’ do nothing to refine an account of a case; they merely generate uncertainty. The HP should assist the CM by providing quantifiable data wherever possible.

Appropriate language

3.11.4 PIP assessments are serious matters that have a direct bearing on benefit entitlement. As such flippancy in reports is not appropriate. Light-hearted remarks about the claimant, the domestic environment, the forms, the benefit and the system in general should not be made as these can cause offence and difficulty.

3.11.5 Reports should not include terms which could cause offence. Appropriate language should be used when describing the claimant, for example ‘overweight’ or ‘obese’ as opposed to ‘fat’. Unless it is essential to the determination of the claim, any information that may be construed as a value judgement should be avoided in advice. For example, comments about the claimant appearing dishevelled are inappropriate, unless they are part of the evidence supporting a level of self-neglect due to mental health problems.

Explanation of technical terms

3.11.6 Attempts to express medical terms in non-technical language can often be difficult and confusing. It is usually preferable to use medical language to describe medical issues and then to explain what they mean.

3.11.7 The functional implications of any findings must be explained in the summary justification. For example, ‘the claimant has reduced shoulder movement – this means that he needs to use an aid to dress and undress and wash and bathe’.

The avoidance of medical jargon

3.11.8 Medical jargon should be distinguished from technical medical language. Jargon is medical slang, or shorthand such as:

SOB++ JVP↑ Ankle oed. R=L AF ∆ ?CCF

3.11.9 Such jargon may not be understood by the DM or the next HP to read it and should be avoided.

Avoidance of internal contradiction

3.11.10 Assessment reports must be internally consistent.

3.11.11 If the HP makes the observation in one part of the report that a claimant has only minor restriction of lower limb function due to osteoarthritis, and in another section gives an opinion that he is unable to negotiate stairs due to painful arthritic knees, the reader will question the point.

3.11.12 If the HP’s opinion does conflict with information provided by the claimant, the HP should fully explain why there is an inconsistency and the evidence on which their advice is based.

Correctness

3.11.13 Correctness embraces a number of principles:

the advice must be medically ‘correct’ – that is it must be in keeping with the consensus of medical opinion
the account must be factually accurate. One of the most common criticisms of HPs by claimants in relation to assessments for existing benefits is that some of the information written in the report is wrong
the terminology must be correct. If the HP uses phrases such as ‘disability’, they must be sure that they know the exact meaning, as there may be specific connotations in disability analysis

3.11.14 Prescriptive language which quotes or reflects phrases used to define conditions for entitlement should be avoided (e.g. ‘reconsideration’).

Completeness

3.11.15 It is very easy to miss out a key factor in a consultation. Good preparation is important and it can be helpful to write down a checklist of all the salient aspects of the case before embarking on the consultation.

Facts versus opinion

3.11.16 A fact is a verifiable statement about the claimant – for example, ‘He takes salbutamol as required for asthma’.

3.11.17 An opinion is the perception or view of an individual – for example, ‘In my opinion, he only has mild asthma’; ‘In my opinion, she requires supervision in the kitchen”. Unsupported opinion should not be included in reports’.

3.11.18 Facts provide strong evidence for opinions because they are verifiable. Facts should be used to support descriptor choice. Opinions are most robust if they are based on fact – for example, ‘In my opinion, his asthma is mild, he takes salbutamol as required for most of the year, adding in inhaled steroids only during the hay fever season’; ‘She is not safe unless she is supervised while cooking, as she has several times burnt saucepans by forgetting them on the hob’.

3.11.19 When the HP evaluates the opinion of a third party that provides evidence – for example, a carer or health professional – the HP should evaluate the strength of the opinion being expressed. The HP’s evaluation should include the level of expertise of the individual offering the opinion; their direct knowledge of the claimant; and whether it is medically reasonable. An unsupported opinion will carry no weight, whereas an authoritative, well-justified opinion from an expert source will carry far more weight, especially if it is supported by factual evidence. The HP should also consider whether the third party is acting impartially or as the claimant's advocate.

Question 11

3.12  Sample quality audit proforma

Accepted Answer

Case routing

Case routing decision

Rationale for case routing decision

Acceptable	Case routing correct based on all the available evidence and case routing decision is adequately justified Payment by results (PBR) preferred route but despite all reasonable efforts HP unable to obtain adequate evidence to support PBR and call to exam necessary
Acceptable with feedback	Case routing correct and justification supports but doesn’t fully explain the decision
Acceptable with amendments	Case routing correct but justification fails to support the decision
Unacceptable	Case routing incorrect based on all the available evidence Call to exam with significant risk of harm to the mental or physical health of the claimant or others No justification given to explain case routing decision; or justification given is not medically reasonable or logical

Opinion

Descriptor choice
Prognosis advice
Qualifying period/prospective test recommendation
SREL advice
Reliability criteria

Justification

Acceptable	Clinically probable opinion based on all the available evidence and adequately justified
Acceptable with feedback	Clinically possible advice but evidence supports consideration of an alternative opinion or descriptor choice Justification which supports but doesn’t fully explain the advice or the descriptor choice
Acceptable with amendments	Clinically improbable advice such that the descriptor choice is highly unlikely but would not lead to a wrong award if left unchanged Clinically improbable prognosis advice - award duration recommended considered to be too long/too short Justification which fails to support the advice or the descriptor choice but doesn’t suggest an alternative award
Unacceptable	Clinically improbable advice such that the descriptor choice is highly unlikely and would lead to a wrong award if not changed Justification which fails to support the advice or the descriptor chosen and would suggest an alternative award

Information gathering

History (including variability)
Examination

Observations

Acceptable	Sufficient information gathered to support robust advice
Acceptable with feedback	Information gathered lacks detail but unlikely to have an adverse effect on advice
Acceptable with amendments	Omission that has limited potential to change advice
Unacceptable	Major omissions such that advice cannot be relied on and correct award cannot be reasonably determined

Further evidence

All relevant stages

Acceptable	Sufficient further evidence appropriately sought and referenced
Acceptable with feedback	Reference to relevant evidence incomplete Important evidence not sought or insufficient attempt to gather it Evidence requested from an inappropriate source
Acceptable with amendments	In additional support needs case, either important evidence not sought or insufficient attempt to gather it
Unacceptable	Critical evidence not sought or insufficient attempt to gather it so that correct award cannot be reasonably determined

Process

Case handling

Usability

Acceptable	Clear report which conforms with guidance and professional standards
Acceptable with feedback	Frequent spelling or grammar errors, use of jargon and unexplained abbreviations that are not in common use
Acceptable with amendments	Omission or error (such as harmful information) with minor risk of adverse consequence Directive advice on entitlement Unclear medical information critical to advice clarity
Unacceptable	Major omission or error (such as harmful information / unexpected findings) with significant risk of harm to the mental or physical health of the claimant or others

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3 Health Professional Performance

3.1 Health professional competencies

3.2 Training of Health Professionals