Work Capability Assessment

The Work Capability Assessment (WCA) is the test designed and used by the Department for Work and Pensions (DWP) in the United Kingdom to determine whether disabled welfare claimants or those suffering from long-term illnesses are entitled to the main out-of-work sickness benefit: Employment and Support Allowance (ESA). The introduction of the WCA as the gatekeeper to ESA was a crucial part of the out-of-work benefit reforms of 2008 that the next government continued and developed.

The WCA aims to sort sickness benefit claimants into three groups: fit for work; unfit for work but fit for pre-employment training; or fit for neither work nor training. The DWP views this as the first step in a process that helps some disabled people "off benefits and into work" but the testing procedure has proved highly controversial, with concerns loudly expressed about inaccurate decision-making and the difficulties and delays faced by claimants when they launch an appeal.

Atos Healthcare, part of the UK branch of the Paris-based multinational Atos, conducted the core assessment on behalf of the DWP from October 2008 until 1 March 2015, on which date the American firm Maximus took over.

Both Labour and the Conservatives support the principle of ESA – to encourage work and thereby reduce welfare spending – but few observers now see the deployment of the WCA as a success, in economic terms or otherwise. There has been strident criticism not only of the performance of Atos but also of the leadership skills and integrity displayed by senior public officials throughout the long attempt to launch what was once a flagship welfare reform.

Evolution of the 'fitness for work' test

Before 1995, entitlement to the payment known as Invalidity Benefit was decided by a civil servant, using clinical information provided by claimants' own doctors.

In 1995, Invalidity Benefit became Incapacity Benefit (IB) and the now defunct Department of Social Security began commissioning its own medical assessments using the 'All Work Test'. In 2000, the All Work Test was replaced by the Personal Capability Assessment, which was used by DWP-approved doctors to assess new claims and to reassess some existing recipients.

In 2007 the New Labour government passed the Welfare Reform Act that would introduce Employment and Support Allowance as the main out-of-work sickness benefit, with the Work Capability Assessment acting as its gatekeeper. The aims were: to accentuate the positive by "looking at what you can do, not what you can't do"; to make the test for out-of-work sickness benefits more stringent; and to take into account new disability legislation, changes in the workplace and developments in occupational health. Testing capacity was increased by employing nurses and physiotherapists to work alongside doctors, and a semi-structured interview technique based on a computer-generated template was used for the first time.

In early 2011, the Conservative-Liberal Democrat coalition government began the planned expansion of the programme to reassess 1.5 million people whom previous governments had judged to be entitled to Incapacity Benefit. At the same time the DWP revised the framework of the test, with the result that the eligibility criteria became even more stringent: most notably, the 03/11 version awarded no points when a claimant who had difficulty walking could overcome the disability by using a wheelchair, if reasonably practicable.

Official projections then envisaged most former recipients of Incapacity Benefit either moving onto Jobseekers Allowance or into a training programme and then into work. As a result, a saving of at least £3 billion annually in the IB/ESA budget was anticipated by the end of the parliament.

The assessment process

When the New Labour government introduced the 'fit for work' test, it contracted out the core medical component to its existing partner for disability assessments: Atos Healthcare, which was already conducting assessments on people claiming a range of other disability benefits, including Disability Living Allowance and Industrial Injuries Disablement Benefit. On 1 March 2015, the US company Maximus assumed responsibility for carrying out these assessments through its subsidiary, the Centre for Health and Disability Assessments (CHDAUK), also known as the Health Assessment Advisory Service.

The process starts with an assessment by a registered healthcare professional employed by the outsourcing firm, after which an official from the DWP first decides on entitlement to Employment and Support Allowance and then on whether a successful claimant is able to take part in 'work-related activity'. In this way, the process sorts claimants – broadly speaking – into three groups: fit for work; unfit for work but fit for work-related activity (the Work-Related Activity Group); or fit for neither work nor work-related activity (the Support Group). Technically, however, it is more nuanced: the test really tries to establish whether a claimant faces significant extra barriers to work because of their disability. In this way, someone can be classed as 'unfit for work' but still apply for jobs and get them without penalty.

In theory

The assessment process is ultimately a legal one that uses social security legislation as its main reference point (which is why appeals are made to lawyer-led tribunals overseen by the Ministry of Justice). The standard of proof used is 'the balance of probabilities': a claim should be accepted if it is more likely than not that the claimant has a significant disability.

The strength of a claim is largely determined by comparing the claimant's problem with a framework of set criteria, known as 'descriptors', in a procedure that draws on occupational health theory, broad clinical knowledge, and the field of 'functional assessment' – a subspecialty concerned with gauging and validating the practical impact of a physical or mental impairment on a person's daily life and, in the context of the WCA, on their ability to work.

The descriptors are split into 'functional' and 'non-functional' descriptors. The functional descriptors are then subdivided, depending on whether physical or mental function is affected. Each functional descriptor comes with a 'score' of 6, 9 or 15 points that is intended to reflect the relative severity of the impairment; the assessor's core role is to select the most appropriate descriptor for each activity printed on the ESA claim form that the claimant has marked as being difficult for them in their day-to-day life. If the assessor deems that none of the functional descriptors apply – despite what the claimant might have said on the claim form – the total score will be zero. A successful claimant will normally score at least 15 points in total.

For example, the activity 'Manual Dexterity' – hand function – comes with the following descriptors for the assessor to choose from:

• The claimant cannot use a computer keyboard or mouse (9 points)
• The claimant cannot use a pen (9 points)
• The claimant cannot pick up a small object (15 points)
• The claimant cannot press a button or turn a page (15 points and a place in the Support Group)

Only one descriptor may be chosen for each activity, and it should be the highest-scoring option that still accurately describes the loss of function. Someone who can pick up a small object like a coin but cannot use a pen to make a simple mark will score 9 points for that activity.

If a claimant is capable – in narrow terms – of carry out a particular action but cannot do so reliably, repeatedly, in a timely manner, safely and without significant pain, they should be treated as being incapable of carrying out that action.

The physical functional descriptors cover these activities:

• Mobilising
• Standing and sitting
• Reaching
• Picking up and moving an object
• Manual dexterity
• Making yourself understood
• Understanding others
• Finding your way around
• Continence
• Consciousness

The mental functional descriptors cover:

• Learning tasks
• Hazard awareness
• Planning and problem-solving
• Coping with change
• Getting about
• Coping with other people
• Behaviour

The non-functional descriptors – which have no points attached but instead have a simple 'yes' or 'no' answer – apply when:

• The claimant cannot eat or drink
• The medical condition is life-threatening and uncontrollable
• The claimant will probably die within 6 months
• The claimant's health would be at real risk if they were found fit for work

Other factors that might be taken into account include:

• The claimant is pregnant
• There is a risk to others
• Intravenous therapy is being administered
• The claimant has cancer

A 'yes' answer to a non-functional descriptor question or – for most but not all activities – a 'top score' in one area will usually qualify the claimant for the Support Group (but several scores of 9, for instance, will not).

The process also usually gathers a large amount of information about the claimant's day-to-day life, to build up a picture of what is officially termed their 'Typical Day'.

In summary, the process uses fixed criteria and a system of points in an attempt to:

• Identify those claiming ESA who have no significant disabilities.
• Identify those claiming ESA who, because of the nature of their disability, do face significant barriers to work.
• Identify those claiming ESA who have one or more severe functional disabilities, who are then not required to prepare for work in the future.

The healthcare professional:

• Answers factual questions that have a bearing on eligibility, such as: "Is the claimant an expectant mother?" or "Is the claimant being treated with radiotherapy?".
• Delivers clinical judgements, such as on whether the claimant is at substantial risk or terminally ill.
• Estimates the date of any future clinical recovery, based on their medical knowledge.

And a face-to-face assessment will gather detailed information about the claimant's day-to-day life.

In practice

The process starts with a healthcare professional approved by the DWP scrutinizing the ESA claim form and deciding whether to seek further evidence from the claimant's GP or another appropriate source. If the evidence shows that a claimant probably has both limited capability for work and limited capability for work-related activity (in other words: the claimant would be likely to get a 'top score' for certain functional activities, or a non-functional descriptor would probably apply) then a face-to-face assessment is not normally required, the claimant is recommended for the Support Group and the higher rate of ESA is usually granted. Otherwise, the healthcare professional arranges a face-to-face assessment – usually in an examination centre, but occasionally in the claimant's home.

At face-to-face assessments, the assessors – who are nurses, doctors or physiotherapists – are guided and prompted by a computer programme, designed by Atos in conjunction with the DWP, called the 'Logic-integrated Medical Assessment' or 'LiMA'. A large amount of lifestyle data and some clinical information is obtained from the claimant and is entered into the computer by the assessor. As the assessment progresses, LiMA tries to gauge both the impact of the disability on the person's daily life and the person's fitness for work – but while LiMA suggests options to the assessor, it is ultimately the healthcare professional who is responsible for making the recommendations.

As well as taking a clinical history and exploring the claimant's 'Typical Day', the healthcare professional will make general observations of the claimant's hearing, mobility and posture, etc. and there may be a short physical examination. The claimant's mental state will to a large degree become apparent as the interview progresses, but specific questions might be asked in order to elucidate any disordered thinking, abnormalities of perception or cognitive impairment.

During the face-to-face assessment, if it becomes clear that the claimant qualifies for the Support Group on the grounds of severe functional disability, the interview should be brought to an early close and the finding recorded on the claimant's file.

After the interview and examination the findings are summarised in free text using Standard English prose, and a typed report constructed from pre-set LiMA options is sent electronically to the DWP. The whole report attempts to record the findings and to justify the recommendation by comparing and contrasting the disabilities described by the claimant against the criteria – the descriptors – constituting the legal framework of the test (as well as considering the other factors, such as whether there would be a substantial risk if the claimant were declared fit for work). This report normally concludes with the points score together with a final recommendation on fitness for work and a prognosis.

If assessors encounter practical difficulties or are unsure how to apply the test's criteria in specific cases, telephone advice is available.

These assessments have been criticised for their repetitive impersonal style, while the reports have been criticised for several aspects of their overall quality as well as for the accuracy of their recommendations. Poor evidence-gathering before an assessment, a 'computer says no' attitude to eligibility, and a reluctance to recommend successful claimants for the Support Group are perceived as historic faults in the system. The reliability of LiMA in gauging disability has never been independently demonstrated.

The decision-maker

The task of the DWP official is to establish from the evidence whether or not the claimant has 'Limited Capability for Work' i.e. whether they are entitled to ESA at all; if they are, officials then have to decide on whether the disabled person has 'Limited Capability for Work-Related Activity' i.e. whether they are capable of taking part in 'work-related activity'. If the person qualifies for ESA but is deemed not to have limited capability for work-related activity, they will be placed in the Work-Related Activity Group (WRAG) and will normally take part in job-coaching and training.

In the July 2015 Budget, it was announced that new claimants put into the WRAG after April 2017 will receive no more money than if they were on Jobseekers Allowance.

In practice, when the assessor's report is sent by the outsourcing firm to the DWP it already contains the assessor's opinion on fitness to work and on suitability for the Support Group, but it is an official that makes the final decision. This decision takes into account: the assessor's recommendation; any other available medical evidence, e.g. another DWP report, for example one from a previous Disability Living Allowance assessment; and the legal aspects of social security regulations pertaining to entitlement to benefits.

In 2014, 20% of fit-for-work recommendations from assessing healthcare professionals were overruled by a DWP decision-maker (up from 8% in early 2013).

The independent tribunal

If the claimant disagrees with the decision, he or she is entitled to ask the DWP to formally reconsider, though the onus is on the claimant to initiate this. If the result of this formal review is unfavourable to the claimant, he or she can then appeal to an independent tribunal – consisting of a judge, a doctor and a layperson – operating under the auspices of the Ministry of Justice. The tribunals take evidence from appellants and observe them during the hearing but the medical member of the panel does not physically examine them; otherwise, the tribunals use the same legal process and the same set of criteria as the DWP and its outsourcing partner, but they do not use LiMA nor set out to delineate the claimant's 'Typical Day'.

At the reconsideration stage the DWP reverses 20–25% of its own fit-for-work decisions, while a further 15% are reversed later by tribunals. Looking at the overturn rate based on the rulings from independent legal hearings, since mid-2013 most appellants who have got as far as a tribunal have seen the DWP's decision overturned by that tribunal.

The Work-Related Activity Group

The Work-Related Activity Group (WRAG) is the cohort of successful ESA claimants whom the DWP thinks are likely to to be able to find work in the future after receiving extra help and support. The WRAG generally contains people with less severe disabilities than those of people in the Support Group. However, the WRAG and the Support Group both contain people whom a disability analyst and the DWP have deemed to face significant extra barriers to work because of their ill-health or disability.

Those in the WRAG are required to take part in 'work-related activity' as a condition of their benefit. The DWP has not defined 'work-related activity' precisely but so far it has not involved applying for jobs, taking part in work placements or undertaking any form of provisional employment. The DWP says: "Claimants identified for this group will take part in work-focused interviews with a personal advisor and have access to a range of support to help them prepare for suitable work" and tells claimants their advisor will "help with things like job goals and improving your skills". Pre-employment training is delivered through the Work Programme, which aims to find people jobs within two years.

As an illustration of the difference in health between those in the WRAG and general jobseekers, figures released by the DWP in August 2015 showed that people in the WRAG are nearly four times more likely to die from their illness - or a new one - than claimants on Jobseekers Allowance, some of whom also have a disability.

Incapacity Benefit reassessment programme

At first, the WCA was only used to gauge fresh applications and to reassess some successful post-2008 claims. The plan to expand the programme to retest long-term recipients whose sickness benefit claims had begun before 2008 - a plan that had been a key component of ESA from the very beginning - was expected to be put into practice at some point after 2010.

Professor Harrington

Section 10 of the Welfare Reform Act 2007 states that:

The Secretary of State for Work and Pensions shall lay before Parliament an independent report on the operation of the assessments under sections eight and nine [the 'limited capability for work' and the 'limited capability for work-related activity' assessments - the two parts of the WCA] annually for the first five years after those sections come into force.

New Labour submitted no review of the first full year of the WCA's deployment in 2009. In June 2010, the Conservative Secretary of State for Work and Pensions asked Professor Malcolm Harrington, a doctor and an expert in occupational health, to review the performance of the WCA. Professor Harrington was assisted by a small team from the DWP and his work was overseen by an Independent Scrutiny Group that included the National Clinical Adviser to the Care Quality Commission and the Chief Executive of the mental health charity MIND.

In November of that year he published his first report. The Guardian summarised Professor Harrington's opinion as being that the test was "impersonal", it "lacked empathy" and it was too reliant on "computer systems and drop-down menus". In the executive summary of his report, he wrote:

I found that the WCA is not working as well as it should. There are clear and consistent criticisms of the whole system and much negativity surrounding the process...[but] I do not believe the system is broken or beyond repair. I am proposing a substantial series of recommendations to improve the fairness and effectiveness of the WCA. If adopted, I believe these changes can have a positive impact on the process.

He made 25 recommendations. The changes he advised to the core assessment were:

• The criteria for judging mental function and cognitive ability should be refined
• "Champions" should be identified within Atos to spread best practice for gauging mental and cognitive disabilities
• Each report should be summarised in plain English
• The claim form should be redrafted

As Professor Harrington was conducting his first annual review, the DWP's in-house medical experts were in any case changing the physical and mental descriptors and toughening up the test. The new criteria were piloted in late 2010 and a rolling programme of one-day conversion courses for assessors began soon afterwards. In February 2011, Professor Paul Gregg, an economist and one of the original architects of ESA, warned that the WCA was "badly malfunctioning" and urged further pilot studies before the more stringent 03/11 version was used as the default assessment. Nevertheless, the mammoth Incapacity Benefit reassessment programme got underway in the spring of 2011, using the new version of the test.

The evidence-based review of the mental health criteria.
In his first annual review published in November 2010, Professor Harrington asked MIND, Mencap and the National Autistic Society to "provide recommendations on refining the mental, intellectual and cognitive descriptors". Professor Harrington would listen to their ideas and then make recommendations to the DWP. He did this in April 2011, once the initial recommendations had also been considered by an independent scrutiny group. The following month, six experts in mental health - including the chief executive of MIND - warned in a letter to The Guardian that the WCA was "deeply flawed".
The DWP's medical experts were not convinced by the evidence presented by Professor Harrington: they did not agree that the existing descriptors were not working properly; they saw no evidence that the proposed system would be any better; and they felt that the changes would make the assessment unnecessarily complicated.
The DWP decided to set up an 'evidence-based review' - overseen from start to finish by Professor Harrington and to run in parallel with his annual reports for Parliament - to look at the proposed changes to the mental health criteria used in the WCA. But in his third and final report, Professor Harrington lamented that "the evidence-based review has unfortunately taken longer to develop than is ideal". One reason it had taken longer to develop was that the scope of the review had been broadened to cover the physical descriptors as well, and had mutated into an evaluation of an entirely new assessment.
This 'evidence-based review' did not publish its findings until December 2013 - three years after it had originally been conceived - by which time most of the Incapacity Benefit reassessment programme had been completed.
The review concluded that the proposed alternative assessment was less accurate than the WCA and that "the WCA produced consistent results on the whole, and is an accurate indicator of work capability as compared with expert opinion".

At the end of 2013, The Guardian quoted Professor Harrington as saying: "I would have preferred to do a roll-out [the IB reassessment] in the second year [2012]" and as having told the DWP this before the Incapacity Benefit reassessment programme began. The DWP told the newspaper: it had no record of a warning of this kind being given; Professor Harrington had not raised the speed of the roll-out in his interim report to ministers in May 2011; and his "remit was to assess the effectiveness of the Work Capability Assessment, not whether to reassess Incapacity Benefit claimants". Furthermore, the minister responsible for the WCA when the scheme was expanded had said in Parliament in 2012 that beforehand Professor Harrington had told him: "I believe the system is in sufficient shape for you to proceed with incapacity benefit reassessment".

When asked later about this discrepancy, Professor Harrington replied:

Can I clarify this once and for all? In my first year - before the first report, that is - I said to [the minister] that, left to my own devices, I would prefer it if they would postpone the IB migration until I had got at least one review in, so they could just deal with the new claimants and would not be confused by another group of people coming in - a completely different group of people, as you well know. He did not say no; it was just obvious that it was a political done deal and they were going to go ahead and do the IB migration whatever.

2011

From March 2011, the WCA was used to reassess more than a million established recipients of ESA's forerunner Incapacity Benefit and some people on Income Support; until that point, none of these recipients had undergone a WCA (some had undergone a Personal Capability Assessment or an All Work Test between 1995 and 2008, and all had been declared 'unfit for work' by previous governments, according to the criteria in use at the time). Although, technically speaking, claimants were now being evaluated for transfer onto a new benefit with different and more stringent eligibility criteria than before, the purpose of the process was not made clear to the people going through it – nor to the wider world, where it was often assumed that when an application for ESA from an established IB claimant was unsuccessful, it meant that there had never been anything really wrong with the claimant in the first place. As a parliamentary report that was compiled at an early stage of the 'migration' of IB claimants onto ESA concluded: "It has caused controversy because some people previously considered disabled and entitled to invalidity benefits are now being found fit-for-work".

The test was criticised over its ability to deal with mental health problems. To address this, in 2011 Atos trained selected assessors to be 'mental function champions' who provided mainly telephone advice to other assessors on mental health issues as they related to the WCA's criteria – a response to one of two key recommendations made by Professor Harrington. The other legacy of his tenure was the introduction of the 'personalised summary statement'. This was intended to be a written explanation to the claimant in plain English of how the assessor's recommendation had been reached, but the DWP decided not to send them to claimants; instead, the department sent a 'decision-makers justification' written by a civil servant. Nevertheless, the DWP insisted that assessors still write summaries, saying that decision-makers found them helpful when trying to understand the main reports. The summarisation process introduced in 2011, although time-consuming for Atos assessors, made little discernible impact on the level of criticism of the WCA.

Professor Harrington declared in November that "The WCA has, in my view, noticeably changed for the better".

2012

The WCA continued to trigger protests outside Atos buildings in London and elsewhere. The test received more criticism in Parliamentand pressure was applied by many parliamentarians – but particularly by Michael Meacher, Tom Greatrex and Sheila Gilmore – for improvements to the 'fitness to work' assessment.

Parliament's Office of Science and Technology analysed the WCA's performance and found that "the number of fit-for-work decisions being overturned on appeal has led to questions about the reliability of the assessment process". A parliamentary committee heard evidence from welfare advisors that, in nearly two out of three successful appeals to tribunals against fit-for-work decisions, appellants were seeing their points rise from zero in the original assessments – meaning that the original WCA had detected no relevant disabilities at all – to at least 15 points after the tribunals had independently assessed their claims.

In the same year, The Independent reported that 43 complaints against Atos doctors and nurses were being investigated by the General Medical Council or the Nursing and Midwifery Council but Atos later countered that the number of formal complaints was small in comparison to the total number of assessments. At a meeting in June, British Medical Association doctors voted that the WCA should be ended ‘with immediate effect and be replaced with a rigorous and safe system that does not cause unavoidable [sic] harm to some of the weakest and vulnerable in society’.

DWP ministers decided to replace Professor Harrington once he had submitted his final report in 2012, although he maintained an oversight role with the evidence-based review that he had suggested be set up in 2010 and that published its findings at the end of 2013. As his successor they appointed Dr Paul Litchfield, another occupational health specialist and one who had played a key part in designing the WCA's mental and cognitive function descriptors in 2006.

2013

There was more criticism of the WCA: in Westminster, by the Catholic Church, by the medical profession, by welfare rights advisers, and by disability organisations and protest groups.

A Freedom of Information request revealed that: "28 of the 140 medical assessment centres, or 20 percent, do not provide wheelchair access," and, "[m]any, including the larger centres, are on the second or third floor". Furthermore, the "great majority do not have associated parking".

The Work Programme firms responsible for training people in the Work-Related Activity Group had "ongoing concerns about the accuracy of the WCA" and they rated earlier improvements to the WCA as only "4 or 5 out of 10".

The Public Accounts Committee of MPs chaired by Margaret Hodge heard evidence that over the previous financial year, Atos had been paid £112 million to carry out 738,000 assessments. At that time, 38% of appeals to tribunals were successful and the committee's view was that too many wrong decisions were being made, only for the decisions to be overturned later (while Atos was paid by the DWP, it was the Ministry of Justice that paid for the tribunal appeals, with £500 million being the potential cost of these appeals over ten years). Hodge said that the DWP got "far too many decisions wrong on claimants’ ability to work...at considerable cost to the taxpayer" and added that this can "create misery and hardship to the claimants themselves". She also remarked: "We saw no evidence that the Department was applying sufficient rigour or challenge to Atos given the vulnerability of many of its clients, the size of the contract and its role as a near monopoly supplier. We are concerned that the profitability of the contract may be disproportionate to the limited risks which the contractor bears" and concluded: "The Department's got to get a grip of this contract!".

When carrying out a judicial review, a tribunal ruled that the WCA process was unfair to people with cognitive impairments, learning difficulties and other mental health issues. The DWP had said that, ultimately, it was reasonable to expect all claimants to establish their legal case as to why they should continue to receive sickness benefits without any special help from the DWP, but the upper tier tribunal said that such claimants were at an unfair disadvantage when gathering and presenting evidence in support of their claims. The DWP disagreed.

Supporting evidence
When a claim form is received by the outsourcing company it is scrutinised by a healthcare professional. If it gives a consistent account of a severe disability that is corroborated by attached documentary evidence, ESA will probably be awarded on the basis of the paperwork alone. If a claimant does not write a coherent account of their disability nor provide appropriate written evidence that backs up their claim, the healthcare professional is authorised to request a report from the claimant's GP.
In practice, GPs' reports were infrequently sought by Atos between 2011 and 2013. If claimants sought them instead, then their doctor, often feeling overburdened by these requests, might charge them as much as £130, while some GPs refused to provide claimants with supporting evidence at all (GPs are not contractually obliged to provide these reports to their patients, only to the DWP's outsourcing partner, if it requests one, which must then be provided to the firm free of charge).
Claimants could therefore find themselves in a Catch-22 situation:
1. The DWP said it was for claimants to find and present the medical evidence to back up their claims
2. GPs would refuse to provide this evidence to claimants - though they would give it to Atos if the firm asked for it, but the firm rarely did
Furthermore, Atos assessors only had access to medical information held by the DWP if it was stored electronically on LiMA, the computer system predominantly used after ESA was introduced for new claims in October 2008. The Incapacity Benefit reassessment programme reviewed more than a million claims, all of which, by definition, dated back to the time before ESA began. The original 'basis of claim' was therefore not normally available to assessors, although the DWP's decision-makers could access it at a later stage of the process.

Whistleblowing

In May 2013, a doctor who had resigned from Atos after refusing to downgrade his rating of the disability of a mentally ill claimant blew the whistle on biases in the testing process to the BBC and said: "These assessments need to be done independently, impartially, considering all the evidence and with proper use of medical knowledge – and that's just not happening at the moment. Pressure is being put on healthcare professionals in many cases to come up with a particular outcome, really regardless of the facts of the case" and accused the DWP of "pulling strings behind the scenes" to boost the number of fit-for-work recommendations being made by the outsourcing firm. The news report drew attention to unduly harsh interpretations of the eligibility criteria, on key abilities such as mobility and mental focus, that the former 'mental function champion' had claimed were being taught to WCA assessors as off-the-record "bogus rules of thumb" during basic training, to which Atos replied: "We do not deviate from government guidelines in our training". Tom Greatrex MP wrote to the Prime Minister to bring to his attention the whistleblower's allegations that the core assessment was "skewed" against the claimant. Downing Street made no reply but simply passed the letter back to the DWP, which issued a non-specific statement. Greatrex described the response as "woefully inadequate".

Response from Atos

In August, the whistleblower expanded on his allegations in a first-hand account published in the British Medical Journal. When responding in the same journal, the clinical director of Atos wrote, with regard to the claim that documentary evidence was frequently missing or never sought prior to an assessment, that the company expected its assessors to gather much of the relevant evidence during the face-to-face assessment. She also echoed the DWP's general position that it expected assessors to make fully justified recommendations on fitness for work.

In relation to the claim that Atos assessors had been taught unofficial and inaccurate interpretations of the test's criteria, she did not deny that the "bogus rules of thumb" had been taught during training, but she emphasised:

All reports must fully comply with the Department for Work and Pensions guidance contained within the WCA Handbook; all our practitioners are expected to be fully aware of this guidance and are responsible for ensuring that the advice they offer complies with it...All practitioners are fully responsible and accountable for the reports they produce.

She also confirmed that Atos auditors might ask a doctor to "consider amending a report" - but only if there was a problem with its "quality".

Quality of reports

Professor Harrington, when reviewing the WCA's performance in 2011, felt that reports did not adequately explain how the recommendation on fitness for work had been reached. This was because the reports were designed to be constructed from preset but editable 'one-click' options: reports were largely inventories of how claimants performed mundane tasks, with recommendations on fitness for work added at the end. Professor Harrington therefore recommended that reports be summarised in free text using plain English. At the behest of the DWP, Atos trained all its WCA assessors to do this in 2011. At the end of that year, the DWP said the Harrington summaries were proving "particularly useful to Decision Makers" in understanding how Atos's recommendations had been reached.

In 2012, Citizens Advice said that, the Harrington summaries notwithstanding, it was the recommendations themselves that were the problem: people were being deemed fit for work when they weren't.

In 2013, the Chartered Society of Physiotherapy found that some reports were "comprehensive" and "easy to read" but others were "poorly drafted" and "contained typing errors", while some were described as "contradictory".

Retraining of assessors

On 22 July 2013, the DWP announced that it had put in place a 'quality improvement plan'. The DWP claimed the move followed an audit of reports produced in the six months to April 2013, during which time Atos had furnished the DWP with more than 300,000 recommendations on fitness for work. The DWP said it had found 164 cases - around 1 in 1800 recommendations - where the report had scored only a 'C' (on a scale of A to C) but which had nevertheless been helpful to the DWP in judging entitlement to ESA (inadequate reports are returned to the outsourcer for a 'rework'). The DWP explained: "A ‘C’ grade report does not mean the assessment was wrong, and the recommendation given in a ‘C’ grade report may well be correct, but, for example, their reasoning for reaching that recommendation may lack the level of detail demanded by the DWP."

This 'quality improvement plan' had begun in June and amounted, almost entirely, to the mandatory retraining of every Atos WCA assessor. The WCA Handbook was overhauled, although the changes were not made public until 2015. The redrafted guidance had a new focus on how to gauge mobility, continence, vision, mental health and risk, and included specific advice on how to assess claims from people suffering from motor neurone disease.

At the same time, the government called in the audit firm PricewaterhouseCoopers to carry out a much wider audit than the one conducted by the DWP into report quality: the firm investigated problems with the DWP's own quality assurance processes.

In the aftermath of the whistleblowing and the subsequent retraining, the number of 'full-time equivalent' healthcare professionals working on WCAs fell from around 1200 to fewer than 750.

By the end of 2013, a new trend had emerged: the number of people on ESA had stopped falling and had begun to rise.

Atos quits the contract

In the middle of 2013, Atos called in its own firm of auditors and then began to secretly negotiate an early exit from its £500m WCA contract with the DWP in London (but not in Belfast, where the contract with the DWP's devolved Northern Irish counterpart - the Department for Social Development - remained intact). In February 2014 the French firm went public, citing death threats to its staff, criticism from Labour MPs and its own opinion that the WCA was "not working" as the reasons why it wanted to quit. At the same time, the company removed the 'Atos Healthcare' branding from its occupational health division and rebadged it as 'OH Assist'.

The next month, the Disabilities Minister told Parliament that the contract with Atos was in the process of being brought to a premature close, with Atos paying a "substantial financial settlement" to the DWP as part of a mutual agreement to terminate the WCA contract early (but which was erroneously represented by some media organisations as Atos being 'sacked').

The DWP continued to employ the French firm to assess most new claims for the Personal Independence Payment (PIP). The Veterans Agency voiced no concerns about the work of Atos doctors in the assessment of claims for War Pensions made by former members of the UK's Armed Forces.

Maximus and the WCA contract

In the summer of 2014, the BBC reported a backlog of more than half a million new ESA claims caused by longer assessments and a dearth of WCA assessors – unintended consequences of the 'quality improvement plan' begun the previous year.

In the autumn, the DWP announced that the US firm Maximus – trading in the UK as the Centre for Health and Disability Assessments and the Health Assessment Advisory Service – would take over from Atos in March 2015.

The DWP hoped that a rewritten contract and a new outsourcing partner would mean the start of a new chapter in disability assessment, but Atos's senior executives complained that their firm had been lambasted simply for "applying the legislation the government had laid out", adding that it was "massively over-simplistic" to think that choosing a different outsourcer would, in itself, deal with the flaws in the WCA process.

Maximus said it would improve evidence-gathering prior to a face-to-face assessment, introduce specialist assessors for particular types of disability and communicate more effectively with claimants. The firm acknowledged that hundreds more healthcare professionals would have to be recruited in order to clear the backlog of ESA claims and hit the new contract's target of one million WCAs a year.

The DWP's ambitious new target

The DWP hoped that once the backlog had been cleared, having the capacity to order one million assessments a year would allow it to order hundreds of thousands of reassessments of people who had already undergone a WCA and been granted ESA, in the belief that many would have recovered from their disabling condition and so could be taken off ESA. Repeated assessments were one of four key tenets of ESA from the very beginning, but the programme was put on hold in early 2014 in order to deal with the growing backlog of new claims.

At the end of October 2015, the DWP's director-general of finance was bullish about hitting this higher target when he appeared before a parliamentary committee, saying: "We are confident that [Maximus] will over-achieve the amounts of work over and above the forecast that was set".

But at the start of November, Maximus's senior management team warned its shareholders that:

• "We're not achieving certain performance metrics, most notably volume targets"
• "The challenges we faced with the [WCA] contract resulted in reduced earnings outlook for fiscal year 2016"
• For fiscal year 2015, the contract had generated at least 35 million dollars less than expected
• Although recruitment of healthcare professionals had improved, their training and retention was still a problem
• The shortfall of assessors was expected to last until the autumn of 2016

On the same day, the price of shares in the company fell sharply, losing more than 20% of their value.

National Audit Office

In January 2016, the National Audit Office (NAO) published its evaluation of the DWP's health and disability assessment contracts. It said:

• The cost of each WCA had risen from £115 under Atos to £190 under Maximus
• Maximus was facing "significant challenges with staff failing to complete training requirements"
• The DWP "allowed bidders to make assumptions about staff training that it knew were overly optimistic and difficult to achieve".

The NAO also implied that the target set by the DWP of one million assessments a year was too ambitious, saying: "One experienced bidder withdrew from the process because it could not meet the required number of assessments". The next month, the most senior official in the DWP told a parliamentary committee that of all the bidders for the £595m WCA contract, only Maximus and one other unnamed firm had submitted bids "above the line" that anticipated hitting the DWP's target of one million assessments per year.

Public Accounts Committee

In early February 2016, the senior executive in charge of the WCA contract at Maximus told Parliament's Public Accounts Committee:

• The WCA contract was an "assumption-based contract" and "we own the assumption" (about whether targets would be hit)
• When Maximus took over in March 2015, the backlog was 550,000
• On 1 December 2015, the backlog was 110,000
• In January 2016, around 75,000 assessments were performed
• 186 doctors were working on WCAs at Maximus
• 748 assessors had transferred from Atos
• 1241 prospective assessors had been offered contracts; 364 had completed their training and been "accredited" by the DWP
• Despite the high attrition rate of new recruits, there was a full complement of assessors at Maximus - around 1200 'full-time equivalents', including some still in basic training - but many of the newer assessors still needed mentoring by more experienced healthcare professionals in order to hit the quality targets set by the DWP.

Unwelcome press coverage

As the backlog shrank towards zero and the programme to reassess established ESA claimants got going again, the WCA process attracted more negative headlines in February 2016 after the DWP initiated reassessment proceedings against a military veteran in the advanced stages of Alzheimer's disease and the most injured survivor of the London terrorist bombings of 2005. Not long afterwards, a man missing much of his brain was declared fit for work, despite cognitive impairment and problems with mobility.

New Welfare Secretary

In April 2016, sources close to the new Welfare Secretary, Stephen Crabb, told The Sunday Times that a contract with Maximus was "under scrutiny", which the newspaper implied was the WCA contract.

During a quarterly conference call in early May, Maximus senior executives admitted that the original target of one million WCAs a year had been "very, very challenging", then revealed that the DWP had lowered its expectations after carrying out a spending review. The executives said:

The contract was modified to put a greater emphasis on carrying out face-to-face assessments at a reduced level. This will achieve DWP's service goals, while at the same time delivering greater value for money overall. There has also been speculation within the investment community that the contract was under review for cancellation or significant changes. I want to dispel that myth today...We've had personal reassurances from DWP that the Secretary of State has not expressed concern over the continuity of the contract. Further, there's no current plan on making substantial changes or terminating the contract.

The executives were much less positive about a similar-sounding contract between the DWP and Maximus: the 'Fit for Work' contract, which assesses the fitness for work of people who have jobs but who are on sick leave. The Maximus executives said this contract was losing money because of the low volume of referrals and said "all options are on the table", including a "wind down...or a termination of the program".

Credibility of the WCA

Professor Harrington, the first external reviewer of the operation of the WCA, was asked by a parliamentary committee whether he had ever found any evidence that Atos assessors had been put under pressure to reach targets. He replied:

They say not, and whenever I have gone anywhere, they say not. This is purely anecdotal, but there was one Atos assessment centre I went to where the bosses walked out and I was left with a couple of assessors having a cup of coffee at the end of the session, and they told me they were under pressure.

Professor Harrington then immediately added: "That does not prove anything".

In 2012, a GP posed as a trainee Atos assessor and recorded undercover video footage that was later broadcast by Channel 4's investigative current affairs programme Dispatches. In the film, trainers warned the NHS doctor that if on average he were to recommend more than one disabled person per day for the Support Group, he would be subjected to an increased level of management scrutiny through a mechanism known as "targeted audit". When the doctor asked an experienced assessor where this rule had come from, she replied: "DWP". Both the DWP and Atos later admitted that this was the case but they denied that "targeted audit" meant that there was a target for getting people off benefits, or that it artificially suppressed the number of claimants ultimately placed in the Support Group. Atos explained that the process merely detected outliers and was intended to ensure consistency across the firm's nationwide team of assessors: if the assessor's reports met the auditors' expectations, the healthcare professional would not be asked to change their recommendations.

In 2013, the Work Programme's training providers - outsourcing companies who coach and train people put into the Work-Related Activity Group after their WCA - complained about the process to Parliament: claimants who were "clearly unfit for any type of work-related activity" were nonetheless being put in the Work-Related Activity Group rather than the Support Group, and even "claimants with terminal cancer, whose life expectancies were shorter than the work-ready prognosis" had been referred to them for pre-employment training.

When, in early 2014, Atos gave its reasons for seeking to exit the contract to carry out the core assessment, the firm announced that it had come to the conclusion that "in its current form, the WCA is not working for claimants, for DWP or for Atos Healthcare". But at the end of 2014 the DWP-appointed reviewer of the WCA – who viewed the test as "by no means perfect" but nevertheless adequate – declared that "we have taken the WCA about as far as it can sensibly go in terms of modification and adjustment" and warned that "there is no better replacement that can be pulled off the shelf".

In October 2015, the Work and Pensions Secretary joined in the criticism of his department's own test, calling the WCA "unbelievably harsh". Iain Duncan Smith blamed the Labour Party for building in "perverse incentives" that could pressure people with disabilities into accentuating their problems and complained that the system gave doctors a "binary choice", not an opportunity to deliver a more nuanced opinion on claimants' fitness for work.

In April 2016, the new Welfare Secretary said that the WCA had "never worked as intended. The WCA was a mess, it didn't recognise mental health issues and other types of disability".

Post-mortem DWP case reviews

The DWP has carried out internal investigations into the deaths of 49 benefit claimants. Most had died after a WCA. The department was compelled to publish the findings in May 2016 after a long campaign by Disability News Service. The conclusions detailed in the heavily redacted reports included:

1. The Incapacity Benefit reassessment programme lacked a clear system for identifying vulnerable recipients
2. DWP staff did not always check the DWP's database for indicators that claimants were at risk
3. The WCA's medical criteria for identifying risk were not properly applied
4. The failure to apply the department's Six Point Plan for dealing with people with suicidal ideas was "a recurring theme"
5. A "persistent area of possible concern" was "a dislocation between policy intent and what actually happens to claimants who may be vulnerable"
6. Claimants with cognitive problems were not filling in their claim forms in the manner that the DWP had envisaged
7. Requests by claimants for a reconsideration of their decision were not prioritised in a "common sense" way
8. Appeals took too long

Has the WCA caused otherwise avoidable deaths?

The DWP accepts that being found fit for work and therefore no longer eligible for long-term benefits can, in some circumstances, harm a recipient's physical or mental health. For this reason, one of the WCA's eligibility criteria - the non-functional descriptor Substantial Risk - applies where there is, on balance, more than a small risk of harm if the claimant were to be declared 'fit for work'. In these circumstances, the at-risk person should continue to receive their sickness benefit.

Inquests and media reports

There have been several media reports of unexpected deaths after assessments where the claimants seem to have been at risk of harm if found fit for work.

Mark Wood was receiving Incapacity Benefit and Disability Living Allowance because of long-term mental health problems, including a "phobia" of some types of food and overvalued concerns about his food's freedom from contamination. He had been losing weight for many months before his WCA. He died, weighing 35kg, after he was declared fit for work and his Incapacity Benefit and Housing Benefit were stopped (the DWP continued to pay him Disability Living Allowance). His family believe that the stress of the WCA contributed to his death. The coroner delivered a narrative verdict, in which he said the final pathological event was "unascertained", but he saw no significant evidence of neglect, self-neglect, suicide or unlawful killing. The DWP admitted that the decision to declare him fit for work was wrong but the department denied that its decision had contributed to his death.

In response to the case, Tom Pollard of the mental health charity Mind said:

Unfortunately this tragic case is not an isolated incident. We hear too often how changes to benefits are negatively impacting vulnerable individuals, who struggle to navigate a complex, and increasingly punitive, system. We know the assessment process for those applying for employment and support allowance is very stressful, and too crude to accurately assess the impact a mental health problem has on someone's ability to work. This leads to people not getting the right support and being put under excessive pressure which can make their health worse and push them further from the workplace. We urgently need to see a complete overhaul of the system, to ensure nobody else falls through the cracks.

Other unexpected deaths where the person seems to have been at risk include:

• A heart-and-lung transplant patient with a weakened immune system who died days after the DWP denied her appeal
• A paranoid man who jumped from a bridge after his benefits were withdrawn as a result of a WCA
• A depressed man who hanged himself, of whom the coroner said: "I found the trigger for [his] suicide was his recent assessment by a DWP doctor as being fit for work"
• A blind man with brain damage from a previous suicide attempt who killed himself after being found fit for work, and at whose inquest the coroner said: “A major factor in his death was that his state benefits had been greatly reduced, leaving him almost destitute and with threatened repossession of his home”.

Epidemiology

A study published in the Journal of Epidemiology and Community Health in November 2015 found an independent correlation between the deployment of the Incapacity Benefit reassessment programme in England and an increase in reported mental health problems, higher levels of antidepressant prescribing and 590 additional suicides. The DWP responded by pointing out that association does not imply causation: the rise in mental health issues when the WCA was deployed after 2010 could just have been a coincidence. The researchers said they had found no other explanation for the rise.

Deaths after WCAs

In response to a campaign using the Freedom of Information Act, the Information Commissioner ordered the DWP to disclose the number of people who had died in the 12 months after their WCA since May 2010 – the DWP had sought to withhold this information, arguing variously that it was too time-consuming, the department was about to publish it anyway or it would not be in the public interest because the data might be misinterpreted. But in August 2015, the DWP was forced to reveal that between December 2011 and February 2014, 2,380 claimants had died after being declared fit for work. However, as Dr Ben Goldacre has explained, an imprecise question in the original FOI request and an unhelpful DWP response – which Goldacre characterised as "essentially a PDF and an excel spreadsheet full of red herrings" – meant that no firm conclusion could be drawn from these figures alone about whether the death rate of people found fit for work is any higher or lower than expected.

Deaths and claims ending

DWP figures show that, between January and November of 2011, 10,600 sick and disabled people died within six weeks of their benefit claim ending; many disability campaigners believe that these deaths occurred after – and even because – the claimants were declared fit for work. The Daily Telegraph has questioned this: it posits that the 10,600 deaths include people who happened to die from natural causes, after which their benefit payments ceased. The newspaper said that when the DWP states "within six weeks", this "does not mean 'within the following six weeks': it means 'within six weeks either side'. What that means is that the large, presumably overwhelming, majority of those 10,600 people died, and then their claims ended because they were dead."

Economic effectiveness of the IB reassessment

The National Institute of Economic and Social Research analysed the effect on the combined Incapacity Benefit (IB)/Employment and Support Allowance (ESA) caseload of the IB reassessment programme. It found that the downward trend in the number of people claiming these benefits accelerated in 2011, only for the trend to abruptly reverse in the second half of 2013.

In October 2014, the Office for Budget Responsibility found that between 2010 and 2014 no savings at all had been made in the IB/ESA budget, which remained at more than £13 billion a year. Six months later, the government's fiscal watchdog raised its forecast for spending on IB/ESA by a further one billion pounds a year, because more claimants than before were being placed in the Support Group.

Jonathan Portes, former Chief Economist at the Cabinet Office, has described the botched IB reassessment programme as "the biggest single social policy failure of the last fifteen years".

The WCA and wider welfare reform

After the General Election in May 2015, the new Conservative government declared that welfare reform was ultimately about creating "a complete shift in the welfare culture" and pointed to the large number of jobless people who had found work during the economic recovery that began in 2013. As part of this trend, the number of people claiming Jobseekers Allowance (JSA) had fallen back dramatically to prerecession levels and a saving of up to one billion pounds a year was hoped for in JSA costs.

In January 2016, overall unemployment fell to its lowest level since 2005. New data showed that the IB/ESA caseload had fallen by 12,000 in one month, although the total number of sickness benefit recipients was little different from what it was in 2011 when the IB reassessment programme was launched.

Cultural impact

In 2015, Ken Loach directed I, Daniel Blake. In the film, the main character, a middle-aged joiner, develops heart disease and so applies for ESA: the WCA is an irrelevant box-ticking exercise, while the DWP is callous, chaotic and Kafkaesque. The film won the Palme d'Or at Cannes in 2016.