The Public Services Ombudsman has recommended significant change into how further evidence is used in assessing and awarding entitlement to Personal Independence Payment (PIP) benefits in Northern Ireland after a finding of “systemic maladministration”.
“The issues I have reported do not point to ‘one off’ mistakes but instead support the need to fundamentally review how further evidence is obtained and applied in the PIP process and how this is communicated,” stated Public Services Ombudsman Margaret Kelly, in a heavily critical report of how the Department for Communities and private sector contractor Capita use further evidence in assessing and awarding entitlement to Personal Independence Payment (PIP) benefits.
PIP is a non means tested benefit for people of working age (16 to 64 years) intended to provide help towards some of the extra costs arising from having a long-term health condition or disability. Over one quarter of a million PIP claims have been registered since June 2016 when the benefit began replacing Disability Living Allowance (DLA).
Given the nature of the benefit, some PIP claimants are the most vulnerable in society and it is recognised that vulnerable claimants may find it more difficult to access and navigate complaints and review mechanisms than other members of the public.
“It is therefore highly likely levels of unremedied injustice are significantly higher for these individuals than amongst the wider population,” the Ombudsman’s report highlights.
The Ombudsman’s investigation focused on the availability and application of further evidence in the administration of PIP. This is evidence which is additional to the claimant’s PIP application form and any evidence that is gathered through face-to-face consultation with a disability assessor. It includes but is not limited to reports from health professionals involved in the claimant’s care, care co-ordinators, prescription lists and care or treatment plans.
The investigation considered a number of issues including how the Department and Capita inform claimants of the role of further evidence in the PIP assessment process; how further evidence is recorded and reviewed and how the Department and Capita investigate and address complaints relating to further evidence.
“My investigation found significant departures from the relevant principles of good administration which I consider to constitute systemic maladministration,” the Ombudsman stated.
The Ombudsman is critical of how the Department and Capita did not use further evidence to inform decision-making at the earliest possible point. The report highlights that the Department refers to ‘new evidence’ being the basis for the overturn of decisions in over 20 per cent of mandatory reconsideration requests. The Department also states that ‘new’ evidence is a significant factor in the overturn of decisions at appeal, for which there is currently a 63 per cent success rate.
“Based on the figures presented… taking mandatory reconsiderations and appeals together, there are at least 21,853 claimants of PIP for whom the eventual award entitlement was not made at the earliest possible point in the process,” the Ombudsman states.
The Ombudsman is critical of how the Department defines this ‘new evidence’. Having observed cases where claimants’ submission of further evidence at appeal included evidence that already existed in their claim file and/or the additional evidence came from sources previously flagged by the claimant but not contacted by the Department or Capita, Kelly says: “To describe such cases as overturned decisions on the basis of ‘new evidence’ is, in my view, misleading given that the evidence or the source of the evidence being relied upon as ‘new’ was often available from the very outset of the claims.”
Kelly adds that the outcome of categorising overturned decisions in this way provides “an inaccurate reassurance” to the public that the internal workings of the Department’s decision-making process are precise and robust.
It is estimated that PIP appeal costs, between April 2017 and March 2021, are nearly £14 million.
Some of the key findings in the Ombudsman’s report included:
• further evidence was requested by Capita disability assessors in only 35 per cent of cases examined;
• despite disability assessors having the ability to request further evidence at all stages, of the 96 claims routed for face-to-face consultation, further evidence was requested in only one case at the assessment stage;
• in addition to passing quality audits, Capita use information about the number of assessment reports completed and submission times to decide bonuses for disability assessors;
• when evidence was requested from health professionals named by the claimant, the request letters sent by Capita were often poorly completed and did not specify what information was sought; and
• in the face-to-face assessments, the evidence from the consultations was often the primary and in some cases the only source of evidence relied upon by the disability assessors when providing their advice to the Department;
Additionally, the Ombudsman found that case managers, the ultimate benefit decision makers, did not routinely request clarity from the Capita disability assessors on assessment reports where advice was not properly explained. “Decision-making on whether or not to request further evidence was overwhelmingly deferred to Capita, despite case managers having the ability to request it and the responsibility to ensure the benefit decision is robust,” Kelly stated.
Adding: “Overall, despite the Department’s and Capita’s contention that further evidence has a key role in the PIP process, it was often the case that it was only at the last stage of the Department’s internal process, following a claimant’s submission of an appeal to the tribunal, that the role of further evidence was elevated.”
The Ombudsman voiced her disappointment at the Department’s “narrow interpretation” of the being customer-focused requirement of all public bodies and says that the approach taken “potentially limited” its ability, as a public service, to treat people in accordance with their individual needs whilst responding flexibly to the circumstances of the case. The investigation found “a lack of openness and clarity” in the Department’s and Capita’s communications to claimants about the role further evidence would play or had played in deciding their entitlement to PIP.
On the topic of being open and accountable, Kelly found record keeping across all stages of the claim process was “poor” and “below the standard of what I would expect”.
Critically, the Ombudsman says that a disparity between the policy intent regarding the role of further evidence and its use and application in reality presents a gap that “does not provide for fairness, or support consistency in the quality of outcomes and experience for individuals”.
In total, the Ombudsman set out 33 recommendations to the Department for improvement.
Communities Minister Deirdre Hargey MLA has committed to bringing the PIP service in-house, however, in June 2021, the Minister confirmed that the contract with Capita had been extended by two years to 2023.
The Minister cited the impact of the pandemic as the reason behind why the process had not been in-housed and the extension was granted.
“There have been proactive discussions with the Department of Health to try to make sure that it can do what it needs to do at its end so that we can move to an in-house model. I am trying to work with it as quickly as possible to do that; indeed, we are doing more than that,” the Minister told the Assembly.
“I have started to in-house the audit function, which will come back into the Department from August. We are also trying to in-house many of the assessments for which further medical evidence is not needed; indeed, we have already started to in-house 25 per cent of them. We need to go much further, and working with health will be critical over the next period.”
In June 2021, it was announced that Capita will also have a role in carrying out medical assessments for awards made under the new Troubles-related-incident Victims’ Payment Scheme.