The CSP welcomes the opportunity to respond to the call for evidence for the fourth independent review of the work capability assessment (WCA).

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1 Fourth Independent Review of the Work Capability Assessment Chartered Society of Physiotherapy Submission of evidence To: By WCA Independent Review Team 2nd Floor Caxton House Tothill Street London SW1H 9NA The Chartered Society of Physiotherapy (CSP) is the professional, educational and trade union body for the UK s 51,000 chartered physiotherapists, physiotherapy students and support workers. The CSP welcomes the opportunity to respond to the call for evidence for the fourth independent review of the work capability assessment (WCA). Our response is focussed on the areas in which we feel we can most effectively contribute to the debate. We would be pleased to supply additional information on any of the points raised in our response at a later stage. The contribution of physiotherapy Physiotherapy enables people to move and function as well as they can, maximising quality of life, physical and mental health and well-being. With a focus on quality and productivity, it puts meeting patient and population needs, and optimising clinical outcomes and the patient experience, at the centre of all it does. As an adaptable, engaged workforce, physiotherapists have the skills to address healthcare priorities, meet individual needs, and to develop and deliver integrated services in clinically and cost-effective ways. Physiotherapists use manual therapy, therapeutic exercise and rehabilitative approaches to restore, maintain and improve movement and activity. Physiotherapists work with children, those of working age and older people; across sectors; and in hospital, community and workplace settings. Physiotherapists facilitate early intervention, support self management and promote independence, and help prevent episodes of ill health and disability developing into chronic conditions. Physiotherapy supports people across a wide range of areas including musculoskeletal disorders (MSD); many long-term conditions, such as stroke, MS and Parkinson s disease; cardiac and respiratory rehabilitation; children s disabilities; cancer; women s health; continence; mental health; falls prevention. 1

2 Physiotherapy delivers high-quality, innovative services in accessible, responsive, timely ways. It is founded on an increasingly strong evidence base, an evolving scope of practice, clinical leadership and person-centred professionalism. 1. The WCA seeks to identify and differentiate between claimants whose condition(s) means they are a) unable to undertake any form of work related activity (support group) b) currently unable to work due to illness or disability (work related activity group) c) fit for work. What evidence and examples can you provide as to the effectiveness of the WCA in doing this? In your opinion what are the strengths and weaknesses of the WCA identification process? 1.1 The CSP is concerned that arriving at a robust decision based on an individuals physical and mental function and work capability can be challenging given the absence of validated tools (1). There is a lack of clarity over how the elements of the WCA are weighed against each other to arrive at a robust decision. For example, claimants with chronic low back pain frequently report co-morbidities of anxiety and depression and without objective measure it is difficult to know how much their mental state impacts on their ability to undertake work if their physical condition allows this. 1.2 It is well recognised that the beliefs of the evaluating clinician can affect the interpretation of information therefore the CSP would recommend the inclusion of validated tools (see point 6.1) to ensure the rationale for decisions is clear and transparent. 1.3 The absence of any assessment of the claimants beliefs and attitudes to work is seen as a weakness in the decision making process. The CSP would recommend the inclusion of a validated tool to measure this (see point 6.1). 1.4 Physiotherapists on the expert review panels struggled with the concept of assessing a claimant in terms of their capability to do any work given that the WCA does not assess functional capability e.g. the ability to lift, carry, or manipulate objects and perform complex or repetitive tasks. The inclusion in the assessment of functional tasks would help to address this. 2. A number of changes have been made to the WCA since its introduction in Do you think these changes have made a difference to the effectiveness of the identification process and, if so, how? 2.1 Physiotherapists involved in the expert review panels found the additional information provided generally helpful, however there was concern expressed over the variability of the quality of client interview data provided. 2.2 There was frequently a lack of up to date reports from the individual s GP, medical consultants and other healthcare professionals (HCP) involved with the claimant which made decision making more subjective. There was a particular absence of mental health reports substantiating self reported diagnosis of anxiety and/or 2

3 depression when these were stated as primary reasons for absence from work. In some of the cases reviewed by the expert panels claimants were waiting for tests/ test results which would have provided helpful information in reaching the correct decision. 2.3 The CSP would recommend clear guidance as to the extent to which an interim report could be used in the event of pending or incomplete information or investigations which may change a work capability decision e.g. a claimant awaiting results of blood tests to confirm diagnosis. 3. There have been three Independent Reviews of the WCA since Do you have evidence that the WCA as a whole has changed as a result of the reviews? If so, please detail. 3.1 The CSP has no comment to make on this point. 4. A significant proportion of people applying for ESA have mental health conditions. What evidence do you have that mental health conditions are or are not given appropriate consideration during the WCA process? 4.1 The range and type of mental health conditions reported are extensive either as stand-alone conditions or co-morbidities to physical complaints e.g. low back pain. The use of relevant objective assessment tools would aid decision making as would up-to-date reports from appropriate mental health professionals. 4.2 The CSP believes it is vital that sufficient preparation and training to competently assess mental health problems is given to all assessors, including those who come from a non mental health background to ensure they are educated, trained and competent to fulfill their role. 5. There is a perception that the WCA is too heavily weighted towards a medical model. Do you believe this is the case? Do you think that the WCA takes suitable and sufficient account of the psycho-social factors that influence capability for work (this is not about the likelihood of finding work) - if not how do you think this should change? 5.1 The assessment of impairment follows a medical model and the expert review panels identified significant anomalies which did not make sense. For example: an individual with a fractured ankle where there was subjective evidence of functional limitation but the impairment assessment indicated no problem an individual with a impairment indicating no wrist movement but normal grip strength reported. 5.2 The instruction to claimants at the start of the assessment not to attempt any movement they might find uncomfortable may result in an unclear picture and reenforces potential fear avoidance behaviour. The CSP would recommend that this should be re-worded to encourage claimants to attempt all parts of the assessment and to inform the assessor should any movement become uncomfortable. 3

4 5.3 Psycho-social factors are not explicitly addressed in the current assessment. The CSP would recommend the inclusion of a validated tool to assess this aspect of the claimant s condition. Suggested tools are included in point Changes have already been made to the WCA face-to-face assessment since its introduction. Do you believe that further changes would improve the faceto-face part of the WCA? If so, please detail what changes you would suggest and provide supporting evidence that they would be effective. 6.1 The CSP recommends the inclusion of objective validated tools to assess mental and physical function. Examples include the 36-Item Short Form Health Survey (SF36) (2), Hospital Anxiety and Depression Score (HAD), Fear Avoidance Beliefs Questionnaire (FABQ) (3). Test results would aid robust decision making by providing objective markers. 6.2 The CSP supports the assessment of potentially modifiable risk factors known to affect work capacity including beliefs and attitudes to work (yellow flags) and workplace issues (blue flags) which are not currently included. Results would indicate areas where support was needed to move the individual into work. 6.3 The CSP suggests consideration is given to the inclusion of questions to assess a claimant s readiness to work either as a standalone questionnaire or as selected questions incorporated into the assessment process (4). This would help identify discrepancies between a claimants beliefs and work capability and indicate areas where support to facilitate return to work was required. An example of best practice is the Working towards Wellbeing questionnaire produced by the Bury Physio Wellbeing Centre i. 6.4 The CSP would support the inclusion of simple functional tasks (lift, carry, turn, push) to replace/supplement the current impairment test (range of movement, muscle power). We do not consider the current physical assessment fit for purpose because the ability (or inability) to perform any single movement does not give sufficient information to enable a decision to be made as to an individual s capacity to undertake work related functional activities. 6.5 Physiotherapists taking part in the expert panels expressed some concern over the variability in assessment duration. Are assessors given guidance as to the recommended time allowed? 7. Assessment processes can be criterion-based, points-based or (as in the case of the WCA) a combination of these. What evidence do you have of the effectiveness of these different approaches in identifying the capability of claimants consistently? 7.1 The physiotherapists on the expert review panels generally found the additional information provided on the cases reviewed was helpful in making a decision. We would recommend that this additional interview incorporates questions on beliefs, attitudes and readiness to work. i 4

5 7.2 There is a lack of robust evaluation of the relative merits of a criterion verses points system in the literature. Based on the limited evidence available, the CSP would support a combination of approaches as a pragmatic choice. 8. Thinking about the overall WCA process, do you think the system needs further improvement, and if so what changes do you think are required? Please provide supporting evidence that the changes would be effective. 8.1 The CSP believes it is vital to ensure that relevant tests, investigations and specialist appointments pertinent to the decision over work capability are completed prior to decision making, however an interim report could be completed based on the information available. For example, a client presented during the expert review process awaiting the results of tests for Rheumatoid Arthritis which may have resulted in different recommendations around the work adaptations required. 8.2 The CSP believes that the inclusion of letters/reports from HCPs working with the claimant should be a standard requirement to provide a comprehensive picture and facilitate robust decision making. 8.3 Physiotherapists participating in the expert review panels were concerned about the variability in the quality of the reports. Some were comprehensive and easy to read, others were poorly drafted, contradictory and contained typing errors. We would recommend that the training given to assessors is reviewed to ensure that reports are completed in a more standardised and professional manner. 9. Please give us any further information and evidence about the effectiveness of the WCA, particularly thinking about the effect on claimants, that you consider to be helpful. 9.1 The CSP would recommend the use of a claimant reported experience measure of the WCA in line with current best practice in other public sector organisations. 9.2 The AHP Advisory Fitness for Work Report is attached for information as an example of the contribution physiotherapists and other allied health professionals can make in supporting people to return to work. Natalie Beswetherick Director of Practice and Development Chartered Society of Physiotherapy 21 August ends - 5

6 References: 1. Schult ML, Ekholm J. Agreement of a work-capacity assessment with the World Health Organisation International Classification of Functioning, Disability and Health pain sets and back-to-work predictors. Int J Rehabil Res Sep;29(3): Brazier JE, Harper R, Jones NM, et al. Validating the SF-36 health survey questionnaire: new outcome measure for primary care. Bmj Jul 18;305(6846): Waddell G, Newton M, Henderson I, et al. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain Feb;52(2): Franche RL, Corbiere M, Lee H, et al. The Readiness for Return-To-Work (RRTW) scale: development and validation of a self-report staging scale in lost-time claimants with musculoskeletal disorders. J Occup Rehabil Sep;17(3): For further information on anything contained in this response or any aspect of the Chartered Society of Physiotherapy s work, please contact: Donna Castle Head of Public Affairs and Policy The Chartered Society of Physiotherapy 14 Bedford Row London WC1R 4ED Telephone: castled@csp.org.uk Website: 6