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First do no harm?  Health regulatory bodies must make it clear that health professionals employed to carry out PIP and WCA Assessments are in breach of their professional code.

One of the fundamental principles taught to all health care students the world over is ‘primum non nocere’ meaning ‘first do no harm’. The deluge of first hand evidence being presented to Westminster’s Work and Pensions Committee for their inquiry into Personal Independence Payments (PIP)  and Employment Support Allowance (ESA)assessments  is shining a blindingly bright light on the extent to which this principle is being flouted by  health care professionals employed by private companies such as Capita and ATOS.  One of the big concerns the Committee has heard about is how PIP and ESA assessors are qualified to assess the impact of multiple, serious and complex physical and mental health conditions on people's lives, and how those conditions can affect the assessment process itself.[1]

Among the widespread and distressing experiences reported by vulnerable people include being asked insensitive questions about self-harm or suicide, a total lack of awareness among assessors as to how mental health conditions fluculate and a widespread lack of expertise in respect of complex physical and mental health conditions.

The grave consequences of such unprofessional conduct are now well known, particularly for people’s mental health.  There is a growing body of evidence[2] that establishes a link between PIP and ESA assessments and increased mental ill health and suicides. A recent longitudinal ecological study published in the Journal of Epidemiology and Community Health[3] found that each additional 10,000 people reassessed using the Work Capability Assessment was associated with an additional 6 suicides, 2700 cases of reported mental health problems and the prescribing of an additional 7020 antidepressant items. The most significant adverse impacts on mental health were found in the most deprived areas included in the study. Analysis of NHS figures by the Disability News Service has shown that the proportion of people claiming the main out-of-work disability benefit who have attempted suicide doubled between 2007 and 2014.[4]

None of what the Work and Pensions Committee is hearing from people who are disabled or ill is new to the Right 2 Work; Right 2 Welfare (R2W) group , who have been campaigning for protections from exactly such harm for many years now.  R2W is currently carrying out a survey with people who are dependent on range of social security benefits including ESA and PIP, and the experiences they are hearing about from people are strikingly similar to those being brought before the Work and Pensions Committee. One survey respondent, a woman with a long term psychiatric condition, forced to go through a PIP assessment for a second time because Capita had lost all of her data, described the effect the assessment process was having on her: “ it would really drive you over the edge” before asking “do they want people to die?”.

If such disturbing first-hand evidence from people themselves were not enough, the fact that the overturn rate of PIP and ESA decisions on appeal/at tribunal stage is so strikingly high underscores the reality that these assessments are not fit for purpose, and that those health care professionals who undertake them are in breach of their own professional codes.

This article examines those professional codes of conduct and demonstrates how health care professionals, by conducting PIP and ESA assessments on behalf of private companies under the current regime, cannot comply with the professional standards required of them by their regulatory bodies.  While the focus below is primarily in relation to individuals with mental health conditions[5], the problems in relation to physical health assessments are equally serious, as has been highlighted by the Work and Pension’s Committee inquiry.    It calls for urgent intervention by the relevant regulatory bodies to prevent further harm being done, as well as by the Department for Communities.

The Department for Communities has contracted Capita to carry out Personal Independence Payment (PIP) assessments and ATOS to conduct Employment Support Allowance (ESA) assessments.[6] Assessors employed by these two private companies come from a range of professional healthcare backgrounds – nurses, paramedics, occupational therapists and physiotherapists. These professions are regulated by two main bodies – the Health Care Professions Council (HCPC) and the Nursing and Midwifery Council (NMC)[7].  All health professionals employed by Capita and ATOS must be registered with these bodies and as such must comply with their respective professional code or set of standards. The most relevant of these standards in the context of PIP and ESA assessments are summarised below.

The Health Care Professions Council Standards include the following standards:

Work within the limits of your knowledge and skills (3.1) you must keep within your scope of practice by only practising in the areas you have appropriate knowledge, skills and experience’. Professionals are instructed that they ‘must refer a service user to another practitioner if the care, treatment or other services they need are beyond your scope of practice’ (3.2)

Identify and manage risk (6.2) ‘you must not do anything, or allow someone else to do anything, which could put the health or safety of a service user, carer or colleague at unacceptable risk’ (emphasis added).

Be honest and trustworthy (9.2) ‘you must be honest about your experience, qualifications and skills’

Make sure you have consent (1.4) ‘you must make sure you have consent from service users or other appropriate authority before you provide care, treatment or other service’ (emphasis added)

The Nursing and Midwifery Council (NMC) which regulates the nursing profession has a similar set of standards which all registered nurses must comply with. Among the standards included in their Code are:

-respect and protect people’s human rights (1.5)

-recognise and work within the limits of your competence (13)

-ask for help from a suitably qualified and experienced healthcare professional to carry out any action or procedure that is beyond the limits of your competence (13.3)

All of the evidence from PIP and ESA claimants themselves, but also from a wide range of reputable charitable and professional bodies, such as Citizens Advice and the Royal College of Psychiatrists, as well as academic researchers, demonstrates how all of these professional standards are invariably being breached by health care professionals carrying out PIP and ESA assessments on people with mental health conditions.[8]

There is no question but that assessors are working outside the limits of their knowledge, skills and competence in respect of assessing mental health conditions.  PIP assessors undertake five weeks initial training. Staff employed need not have had any previous experience in relation to mental health. In its submission to the Work and Pensions inquiry into ESA and PIP assessments the Royal College of Psychiatrists stated that ‘training of assessors does not provide them with knowledge and skills to undertake reliable assessments of people with mental health conditions”. [9]

Assessors are not adequately trained to recognise or respond appropriately to individuals who are experiencing suicidal thoughts or are at risk of suicide. Information received by PPR through a Freedom of Information requests indicated that neither Capita nor ATOS assessors undertake any recognised, accredited training in suicide intervention, such as ASIST or safeTALK[10].  

The Health Care Professionals code requires that they ‘must not do anything, or allow someone else to do anything, which could put the health or safety of a service user at unacceptable risk’. Yet, as referenced above, there is an increasing body of evidence that demonstrates the link between PIP and ESA assessments and increases in mental ill health and deaths by suicide.

The Health Care Professions Council code requires that practitioners ‘be honest about their experience, qualifications and skills’. Yet PPR has had numerous reports of assessors refusing, when requested by individuals being assessed, to disclose information on their relevant experience, qualifications and skills’, stating that they did not have to disclose such information.

Both the HCPC and NMC codes require health care professionals to ask for help from a suitably qualified health care professional, if what they are required to do is beyond the limits of their competence. Yet PPR has also had numerous reports of expert medical evidence from people’s own GPs being completely excluded from the assessment process.

Encouragingly, an increasing number of health care professionals employed by private companies such as Capita and ATOS are resigning, primarily on the basis that their professional reputation is at risk. They are doing so on the basis that a massive gulf exists between what the promotional ‘blurb’ claims they will be employed to do, and what they end up doing on the job. They are also highlighting the lack of any due process for claimants in the assessment process.

Take Capita for example.  Their person specification for Disability Assessors requires that applicants be fully qualified healthcare professionals with a minimum of two years post- qualification experience, and that they hold full registration with the Health Care Professions Council (HCPC) or the Nursing and Midwifery Council ( NMC). The recruitment blurb states that Capita’s employees will ‘combine dignity, respect and medical experience to build a picture of an individual’s health condition’.[11] Assessors will undertake 5 weeks initial training, will be provided with support and coaching throughout training and in their role and will have opportunities for Continuous Professional Development.  Assessors will be required to ‘produce and present comprehensive, structured and impartial reports (to the Department for Communities)’.

Now compare this to the first hand experience of a nurse who resigned from her post as a Disability Assessor with Capita. This whistleblower, who featured in the Belfast Telegraph in November 2017[12], said ‘I knew from the start there would be problems’. She claimed that ‘the place is in chaos. I certainly wouldn’t want my mother or father to go through the PIP process. It is not fair”.

Among the many problems identified with the assessment process were the following: lack of adequate training for writing paper-based reports (PBRs), reports not being fit for purpose, no response from management to complaints raised and lack of consistency between and within departments”.  This lack of consistency in interpreting the PIP guidance was highlighted as a serious problem “in my experience, each practitioner interpreted the PIP guide in their own way and it caused serious problems for practitioners across the board”.  The response of this whistleblower is far from isolated “I know many other healthcare professionals who also resigned due to similar difficulties”.

To date the two main regulatory bodies, the Health Care Professions Council and the Nursing and Midwifery Council have been absolutely silent on this growing scandal. So silent in fact that they themselves face possible action over their failure to take disciplinary action against registered professionals who breach professional standards.  The Professional Standards Authority (PSA), which oversees UK healthcare regulators, is due to consider whether it should examine the failings of both the HCPC and the NMC.[13] The onus has been completely on individual claimants, who are in a very vulnerable position, to raise and pursue complaints against assessors, or in the case of the C4 Dispatches programme aired in April 2016, members of the public.[14]

It is time for these regulatory bodies to regulate. PPR are callingfor the NMC and the HCPC to issue guidance to the effect that any nurse who takes up employment as an assessor for Capita or ATOS is doing harm, and cannot be in compliance with the NMC’s Professional Code. 

As the contracting body,  the Department for Communities also has an urgent responsibility to act on the evidence of harm being caused by PIP and ESA assessments. It must respond to the growing calls for the implementation of the People’s Proposal[15], which would guarantee vulnerable claimants basic human rights protections within the assessment processes, including the right to dignity and respect, the right to information, consultation and representation at all stages of the process and critically, the right to have the primacy of medical evidence in relation to their condition/illness recognised. If the independent review of the PIP assessment process, announced by the Department on 15 January 2018 is to have any meaning it must listen and respond to the weight of evidence from vulnerable people and recommend accordingly that the Department moves immediately to introduce the above protections. 

The need for action, both by the HPC and the NMC and the Department for Communities is urgent, to ensure that no further harm is done. People’s right to health and to life itself are at stake.

 


[3] Barr B et al (2016) J Epidemiology and Community Health: 70: 339-345.doi:10.1136/jech-2015-206209

[5] Department for Communities figures indicate that 39% of PIP claimants and 45% of ESA claimants have a recognised psychiatric condition.

[6] It is worth noting that in 2014 the Department for Work and Pensions ended ATOS’s ESA contract following public and political anger over their distressing, crude and inhumane assessments, yet the Department for Communities has continued to contract ATOS to deliver ESA assessments in NI.

[7] The Nursing and Midwifery Council provided written confirmation to PPR that a nurse who is registered with the NMC will be bound by the code no matter what their job role and if it is public or private sector. Whilst registered they would need to adhere to the code even if working in a role that doesn't require registration.      ( email dated 19 December 2017)

[9] Royal College Psychiatrists evidence to Work and Pensions Committee Inquiry into PIP and ESA Assessments

[10] FOI Response DFC-2017-0091

[15] This support includes 5 Councils passing motions calling for the implementation of the People’s Proposal, as well as endorsement by all political parties bar one, by, by major trade unions including those representing social security staff, and by key community and voluntary organisations.