8.
Prognosis
8.1
Overview
As part of the filework process, HCPs are required to give advice on when a return to work / work related activity could be considered in all cases in which acceptance, Treat as LCW or Support Group inclusion is advised.
The key messages are:
- For the majority of claimants, provision of ESA should be regarded as a temporary measure, until the claimant has recovered from an illness or adapted to disability (following appropriate interventions if necessary)
- ESA is an active benefit (with Work Focussed Interviews and appropriate interventions) and so prognosis does not only consider when / if a claimant’s disability would be expected to improve, but also considers the provision of appropriate interventions or adaptations that could be made.
Note the following:
- Under the LCW/LCWRA medical procedures, approved HCPs are required to give advice on prognosis without reference to the outcome of the decision making process
- When the claimant satisfies the LCW/LCWRA medical examination, the medical advice on prognosis provided by approved HCPs to Job Centre Plus is often used by the Decision Maker to determine when subsequent re-referral to Atos Healthcare is appropriate
- The DWP will wish to refer a claimant for reassessment of LCW/LCWRA at the point where there is a reasonable expectation that their prospects of a return to work have improved. Whether the outcome of the case is inclusion in the Support Group, application of Exceptional Circumstances or advice on a functional condition, the Decision Maker will require a reasonable prognosis for a return to work. In assessing when a return to work may be possible, the approved HCP should provide this advice based upon their assessment of the claimant, their knowledge of the natural progression of the identified medical conditions, and the time they feel a claimant may need to adapt to their condition
- Note that the prognosis is not just about improvement in function. This is obviously one part of the prognosis issue, however; there are conditions that will be permanent with no expectation of functional improvement but this does not mean the claimant will be unable to work. Consideration of reasonable time scales to allow time for possible retraining, support, time to adapt to disability and provision of work place adaptations should allow many claimants, even with significant functional restriction to enter into work.
- For those deemed to be in the terminally ill group there is no requirement to include a prognosis
- If there is more than one relevant functional condition, the HCP should aim to provide an opinion on the likely timescale for return to work, taking account of the effects of all conditions
- If an early improvement is expected, a short prognosis should be given in all cases your opinion on when a return to work could be considered must be fully and comprehensively justified. It is important to consider each case individually and to choose and justify the appropriate time period (3, 6, 12 or 18 months), or to justify why a return to work is unlikely within 2 years or in the longer term.
8.2
How to formulate prognosis advice
Improvement Likely
The main question the HCP must consider is:
When would you expect significant improvement in the disability or in cases where improvement in the level of function is not anticipated, with adaptation/re-training/aids when could a return to work be considered?
The HCP’s response will depend on whether the key functional problems will improve and over what timescale:
- With further treatment
- With time
- With the natural progress of the underlying disease
- Or whether adjustments will result in a reasonable expectation of the claimant being engaged in some form of work
The duration of prognosis must be based around the medical knowledge of the condition and consideration of rehabilitation and workplace adaptations. This will determine the duration of prognosis.
It is difficult to give specific guidance as each case must be considered on its own merits. Some cases with the same functional loss may have different prognosis.
For example:
Registration as severely sight impaired. Those who have had a gradual process of visual loss and have continued to work and have now become unemployed are more likely to be able to re-enter the workplace in a shorter time than a person who perhaps through trauma has become severely sight impaired. The person with acute visual loss is likely to need more time to adapt to their condition to allow safe navigation and is likely to need retraining or significant workplace adaptations to re-enter a workplace.
In some cases, functional recovery cannot be expected, for example, where there is complete paraplegia following spinal cord transaction. This, however, does not mean that a long term prognosis is appropriate. With ongoing rehabilitation, perhaps retraining and workplace adaptations, the person may be able to return to work.
In musculoskeletal cases, with advances in medicine and with adaptations in the work place, most cases should have some expectation of recovery of function and with additional support should be able to re-enter the workplace in the short to medium term. Again, this is not an absolute as complex rheumatoid cases with multiple joint involvement may require longer for their medical management of the condition to be optimised and they may need multiple adaptations to allow them to work. Therefore overall, each case must be considered carefully and prognosis advice fully justified to the Decision Maker.
In Mental Function cases, consideration of the diagnosis, current treatment and medication should be considered. Guidance from the EBM Mental Health protocols should be followed. In mild to moderate anxiety and depression, in most cases, with support, a fairly short prognosis would be expected. In more major conditions such as first onset of a psychotic episode, the treatment and recovery time may be more prolonged.
With some conditions, prognosis may be more straightforward, for example where LCW is accepted due to pregnancy around dates of confinement.
Where the claimant is in the Support Group because they are having chemotherapy, prognosis may initially seem fairly straightforward since in most cases the duration of treatment will be known. However, you must also assess a “reasonable recovery periodâ€. This may vary from one case to the next. A person who was otherwise fit and well may have a shorter recovery period than a person who has had significant weight loss, post operative complications or complications of chemotherapy. You must base your advice on your medical knowledge and skills as a disability analyst to provide reasonable advice to the DM. Where the advice provided seems to be out with that normally expected clear and comprehensive justification must be given.
The timescales for improvement are:
- 3 months
- 6 months
- 12 months
- 18 months
Change unlikely:
In some cases the HCP may consider change is unlikely.
The timescales for advice in these cases are:
- Within the next 2 years:
If significant change is unlikely within two years but nevertheless there is still some possibility that improvement may occur with time or with further therapy, then the HCP should indicate that a return to work is unlikely for at least 2 years.
For example, you might be considering a claimant with rheumatoid arthritis with a significant degree of functional disability, where you would not expect much improvement within 2 years but where surgery or other treatment in the medium term might change the clinical picture. You might reasonably advise that a return to work is unlikely within 2 years.
Or
A claimant has significant learning difficulties needing significant support on a daily basis; however is attending life skills at college and with some degree of further maturity may functionally improve, a 2 year prognosis may be suitable.
Change unlikely:
- In the longer term:
If in your opinion there is a substantial degree of functional impairment due to a serious medical problem which is chronic or will inevitably deteriorate further, even with optimal treatment/ maximal input and adaptations, you should indicate that a return to work is unlikely for in the longer term.
For example, you might reasonably advise an “in the longer term†prognosis for a claimant with a clearly progressive neurological condition.
Or, in the case of a young adult with a very significant degree of learning disability, who has a disability in a number of functional areas because of cognitive impairment and a requirement for a high level of support, you may feel that all management and support strategies have been exhausted and that further adaptation is unlikely to occur. You might then reasonably advise an “in the longer term†prognosis.
Other factors:
Age:
This is not a medical cause of incapacity but may indicate the stage of the disease.
Duration of incapacity:
- It is undesirable to frequently review claimants with a confirmed chronic or progressive disability whose capability is unlikely to improve.
Fluctuating conditions:
- It may be reasonable to give a finite prognosis if the natural history of the condition suggests that the periodicity and duration of exacerbations of the condition will be significant.
Multiple conditions:
- If there is more than one relevant functional problem, your prognosis should be based on the overall functional prognosis.
HCPs should remember the repository and the EBM Protocols. These will be helpful when considering prognosis.
(See Appendix F for a Prognosis Matrix)
8.3
The Work Programme
The Work Programme is a major new payment for results welfare to work programme launched throughout Great Britain in June 2011. It replaces previous programmes such as the New Deals, Employment Zones and Flexible New Deal. It is delivered by a range of private and voluntary sector organisations providing support for people who are at long-term risk of unemployment. It represents a significant investment by the Government and its partners in seeking to help millions of people into lasting jobs.
The design of the Work Programme seeks to address weaknesses of previous programmes, and brings together and simplifies the range of contracted provision and support. The programme supports a wide range of participants, from those who are at risk of long-term unemployment, to others with limited capability for work and who may have been out of work for several years.
Individuals can access the Work Programme at different times dependent on a number of characteristics. These include: the type of benefit they are receiving, their age, their distance from the labour market and, for individuals placed in the Work-related Activity Group (WRAG) of ESA, their WCA prognosis. Some will be required to attend the Work Programme, whilst others will be able to volunteer with the agreement of their Jobcentre Plus adviser. Whilst not on the Work Programme claimants will be supported by Jobcentre Plus.
Individuals who are placed in the WRAG and given a 3 or 6 month prognosis will be required to join the Work Programme. These individuals will be expected to recover or adapt to their condition within a relatively short period of time, so they will be provided with immediate support to help them back to work. They will be reassessed respectively at the 3 or 6 month point and if found fit for work can claim Jobseekers Allowance and continue to receive support through the Work Programme. This will place them in the best possible position to return to work once they are well enough to do so. Individuals placed in the WRAG and given a prognosis of greater than 6 months will not be required to join the Work Programme. They will be able to access the Work Programme on a voluntary basis or receive support through Jobcentre Plus.
Once on the Work Programme, claimants will be expected to stay on the programme for two years. During this time, some people’s circumstances and the nature of their participation in the programme may change. If, for example, they are found to be in the Support Group at reassessment, then they will no longer be mandated to remain in the Work Programme, but could still access the support on a voluntary basis.
Work Programme providers are able to require participants in the WRAG to undertake work related activity. However, this activity must always be reasonable given the claimant’s circumstances. ESA claimants cannot be required to look for, apply or undertake work, nor undergo medical treatment.
Claimants in the WRAG who are not on the Work Programme will be expected to prepare for a return to work with support from Jobcentre Plus, undertaking work-related activity as required by their adviser.
