ESA regulations & ATOS interpretation/guidance

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ATOS guidance to healthcare professionals







ATOS - the key to whether you pass or fail the Work Capability Assessment...


In this article you can take a look at the guidance issued by Atos to their healthcare professionals. It's the guidance they are expected to following and taken from their latest 'Work Capability Assessment handbook' issued on the 5th July 2012. This encapsulates the more recently introduced Limited Capability for Work / Limited Capability for Work Related Activity amendments of 2011 (Harrington Review) and can be quoted at version 5 (Final) [MED-ESAAR2011HB~001]. Remember though that this is not binding legislation, it is only how the healthcare professional is guided into applying the various descriptors. At the time of writing the mental health & support group descriptors have not been added; - these will be added soon. It's helpful to have a look at the guidance if you are either completing an ESA or you are a welfare benefit specialist or advisor advising clients on how to complete the ESA 50 or in arguing a case at the reconsideration of appeal stage.


We will be taking a look at case and how this case be applied to the different descriptors. Here's an example of one which applies to walking & standing:

Attachments:

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General

benefits.tcell.org.uk/taxonomy/term/796/0

www.dls.org.uk/advice/factsheet/welfare_benefits/employment%20support%20allowance/Employment%20Support%20Allowance%20Appeal%20%20Decisions.pdf

www.dwp.gov.uk/docs/wca-handbook.pdf

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Activity 1:

Mobilising unaided by another person with or without a
walking stick, manual wheelchair or other aid if such aid can
reasonably be used.

Descriptors

W(a) Cannot either
(i) mobilise more than 50 metres on level ground without stopping in order to
avoid significant discomfort or exhaustion

or

(ii) repeatedly mobilise 50 metres within a reasonable timescale because of
significant discomfort or exhaustion.

W(b) Cannot mount or descend two steps unaided by another person even with the
support of a handrail.

W(c) Cannot either

(i) mobilise more than 100 metres on level ground without stopping in order to avoid
significant discomfort or exhaustion

or

(ii) repeatedly mobilise 100 metres within a reasonable timescale because
of significant discomfort or exhaustion.

W(d) Cannot either

(i) mobilise more than 200 metres on level ground without stopping in order to avoid
significant discomfort or exhaustion

or

(ii) repeatedly mobilise 200 metres within a reasonable timescale because of
significant discomfort or exhaustion.

W(e) None of the above apply


Scope

This activity relates primarily to lower limb function. It is intended to reflect the
level of mobility that a person would need in order to be able to move reasonably
within and around an indoor environment. It is not intended to take into account
transport to or from that environment.

The modern working environment should allow for the use of a wheelchair and
any other widely available aid and therefore the concept of mobilising within a
workplace is considered the critical issue – rather than just the individual’s ability
to walk around a workplace.

The descriptors should not be confused with the traditional concept of walking
(i.e. bipedal locomotion), that is, movement achieved by bearing weight first on
one leg and then the other. Those who are wheelchair dependant or can use
crutches or a stick to mobilise distances in excess of 200m would not be awarded
any points for their inability to walk.

When estimating the distances over which a claimant can mobilise you should
not take account of brief pauses made out of choice rather than necessity. The
end point is when the claimant can reasonably proceed no further because of
substantial pain, discomfort, fatigue or distress.

Descriptor W(b) also reflects a severe limitation of stair climbing. This may be
affected by severe lower limb pathology or breathlessness. It should be noted
that the descriptor indicates inability to perform this task even if holding on to a
handrail(s). Therefore the individual’s abilities must be considered within the
context of a handrail being present. This activity reflects a test of walking up or
down 2 steps, not of whether one hand or two hands is needed for support while
doing so. Therefore a person who can manage the two steps with support of two
handrails would be considered as capable of performing this activity.
Within the descriptors – the concept of repeatedly and reliably is explicit. If the
person could not repeat the activity within a reasonable time then they should be
considered incapable of this task. The effects of fatigue must be considered.

In considering the concept of repeatedly, the activity i.e. “mobilising unaided by
another person” must be kept in mind. Consider what would be expected of an
individual who did not have an impairment of their ability to mobilise. That is, a
‘normal’ individual would be able to perform this activity within a given time period
and repeat that activity again after a reasonable rest period. The duration of the
reasonable rest period can then serve as a basis for comparison to gauge
the range of what is 'reasonable'.

The ability to mobilise may also be restricted by limitation of exercise
tolerance as a result of respiratory or cardiovascular disease. Note any
restrictions due to breathlessness or angina, as well as any relevant
musculoskeletal problems. The choice of descriptor must be made very carefully.

If a particular descriptor activity could only be performed by inducing significant
breathlessness or distress, a higher descriptor must be chosen.
Walking may occasionally also be affected by disturbances of balance due, for
example, to dizziness or vertigo. The effects of any such condition should be
noted and full details given in your medical report.
When considering the issue of mobility, the ability to use an appropriate aid,
including a manual wheelchair must be considered. A manual wheelchair would
be considered any chair that is not electrically propelled. If the person does not
actually have a wheelchair, they should be considered in terms of whether they
could use one if provided, as manual wheelchairs are widely available. In terms
of considering whether or not the person could reasonable use a wheelchair, the
HCP must consider their upper limb function and cardiorespiratory status.

Details of activities of daily living

Consider the claimant's ability in relation to:

 Mobility around the home

 Shopping trips, exercising pets.

Include details of distances walked/mobilised and how long it takes the claimant
to walk any particular distance; whether the claimant needs to stop, and if so how
often, and for how long?

It may be useful to consider average walking speeds in this category.

Normal walking speed is 61-90m/min, a slow pace would be around 40-60m/min and a
very slow pace less than 40m/min.

The method of travel to the Examination Centre is relevant. You are likely, from
local knowledge, to know the distance from the bus station to the examination
centre. Record the distance, time taken, the number of rests required, and the
lengths of the rest periods.

Bear in mind that a person who can easily manage around the house and garden
is unlikely to be limited to mobility of less than 200 metres; a person who can
mobilise around a shopping centre/supermarket is unlikely to be limited to
mobility of less than 800 metres although consideration must be given to the
speed of walking, stops and pauses etc. Someone who is able only to move
around within their home is unlikely to manage 200m.

Observed behaviour

Observe the claimant walking from the waiting area to the examination room, and
note their gait, pace and any problem with balance. Look for evidence of
breathlessness precipitated by walking. If the claimant is in a wheelchair, note
the manner and ease with which they propel themselves. Claimants who are
clearly breathless on mobilising within the examination centre require very
careful assessment including consideration of whether a Support Group
criterion applies.
Note in general the appearance and use of the upper limbs in relation to their
ability to use walking aids/propel a wheelchair.
Note the use of any aids e.g. walking stick, and whether the use was appropriate.
Record any assistance needed from another person.

Clinical examination

Restricted ability to walk will commonly be due to disorders affecting the lumbar
spine or lower limbs. Restrictions may also be due to disease in the respiratory
or cardiovascular systems, with limitation of exercise tolerance as a result of
breathlessness, angina, or claudication. The effects of fatigue must also be
considered.

Where relevant, an appropriate assessment of the cardiorespiratory system must
be carried out, looking for cyanosis, dyspnoea at rest or on minimal exertion, the
presence of audible wheeze, signs of heart failure such as pitting dependant
oedema, and the state of peripheral blood vessels. Any respiratory or
cardiovascular factors affecting exercise tolerance must be taken into account
when choosing a descriptor.

Peak flow may be measured, if appropriate, and the recorded measurement
interpreted for the DM within the context of the other available information.

Comment on technique or effort may be appropriate. A note of whether an EU or
Wright Peak flow meter was used should be indicated when recording the peak
flow.

Where restriction of walking is apparent, the power/ co-ordination in the upper
limbs must be considered. Severe breathlessness and coronary artery disease,
for example may also impact on the people’s ability to both walk and propel a
wheelchair.

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Standing and sitting

Activity 2: Standing and sitting

Descriptors

S(a) Cannot move between one seated position and another seated position
located next to one another without receiving physical assistance from another
person

S(b) Cannot, for the majority of the time, remain at a work station, either:

(i) standing unassisted by another person (even if free to move around)

or;

(ii) sitting (even in an adjustable chair)
for more than 30 minutes, before needing to move away in order to avoid significant
discomfort or exhaustion.

S(c) Cannot, for the majority of the time, remain at a work station, either:

(i) standing unassisted by another person (even if free to move around)

or;

(ii) sitting (even in an adjustable chair)
for more than an hour before needing to move away in order to avoid significant
discomfort or exhaustion.

S(d) None of the above apply.


Scope

This activity relates to lower limb and back function. It is intended to reflect the
need to be able to remain in one place, through either sitting or standing. When
standing, a person would not be expected to need to stand absolutely still, but
would have freedom to move around at the workstation or shift position whilst
standing. Similarly, it is considered reasonable that a person would be able to
move around when sitting. The reference to an “adjustable chair” reflects the
advances in ergonomics over the years. Those with some difficulty/ discomfort on
sitting can often be significantly aided by provision of an adjustable chair. This
type of adaptation is likely to be considered a reasonable adjustment under the
Equality Act.

S(a) “Moving between adjacent seated positions” is intended to reflect a
wheelchair user who is unable to transfer, without help, from the wheelchair. It
reflects a substantial restriction of function important within the workplace and
therefore the inability to transfer without assistance from another person implies
the person has LCWRA. In considering their ability to transfer the use of
reasonable aids such as a transfer board should be taken into account. Use of
situation specific aids such as a hoist should not be considered.

In Sb and Sc, the person does not have to stand or sit for the whole 30 or 60
minutes. They can alternate between the two. For example, a person may only
be able to sit for 30 minutes, but then stand for 10 or 15 and then sit for another
30 minutes. In this case they would not attract a scoring descriptor as they are
able to remain at the workplace for in excess of 60 minutes. N.B – the person
must be able to stand with one hand free to make this effective standing in the
workplace, so for example a person who needs 2 crutches to stand would not be
considered as “effectively standing”.

Sitting

When considering sitting, the following should be taken into account.
Sitting involves the ability to maintain the position of the trunk without support
from another person.
Sitting need not be entirely comfortable. The duration of sitting is limited by the
need to move from the chair because the degree of discomfort makes it
impossible to continue sitting and therefore any activity being undertaken in a
seated position would have to cease.
Inability to remain seated in comfort is only very rarely due to disabilities other
than those involving the lumbar spine, hip joints and related musculature.
Reported limitations for reasons other than these require thorough exploration
and strongly supported evidence. Often, a suitably adjusted chair will overcome
many of these issues.

Details of daily living

Consider the claimant's ability in relation to:-

 Watching television (for how long at a time and type of chair).

 Other leisure or social activities, e.g. listening to the radio, using a
computer, sitting in a friend's house, pub or restaurant, cinema, reading,
knitting.

 Sitting at meal times (which may involve sitting in an upright chair with no
arms).

 Time spent travelling in cars or buses.

Observed behaviour

Record the claimant's ability to sit without apparent discomfort within the
examination centre where this has been observed. Take great care not to give
the impression in your report that the observed behaviour is the maximum that
can be achieved.

Standing

When considering standing, it should be noted that descriptors S(b) & S(c)
reflects the ability to stand without the support of another person. This
suggests a very significant level of disability in relation to standing.
Standing can be achieved with the use of aids. The ESA regulations specify that
“the person is to be assessed as if wearing any prosthesis with which [he] is
fitted, or wearing or using any aid or appliance which is normally worn or used”.
When standing, the person must be capable of some activity at the workstation,
therefore someone who can only stand with the aid of 2 sticks would not be
considered capable of “standing” in this context as they could not perform any
useful function at the workstation. In such a case, their ability to sit must be taken
into account as if they are able to remain seated for in excess of 60 minutes, they
will not attract a scoring descriptor. You need to think carefully about why the
person needs 2 sticks when standing. There needs to be a medical reason for
this. Severely arthritic knee or hip joints might cause such a problem, but back
pain should not do so

Details of activities of daily living

Relevant activities are:

 Standing to do household chores such as washing up or cooking.

 Standing at queues in supermarkets or waiting for public transport,
standing and waiting when collecting a child from school.

 Standing to watch sporting activities.

You should comment on the length of time the claimant stands during any such
activities.

Observed behaviour

It is usually only possible to observe the claimant standing for short periods of
time but even these are of value in your report, e.g.
"I observed him standing for 3 minutes only during my examination of his spine
but he exhibited no distress and this, in conjunction with my clinical examination
recorded below, would not be consistent with his stated inability to stand for less
than 30 minutes. He may need to move around to ease spinal discomfort but
would not need to sit down." As always, this opinion should be reinforced by
typical day examples of standing ability.
Some claimants prefer to stand throughout the interview and this should be
suitably recorded.

Transferring

The inability to transfer between one seated position and another suggests
significant disability. It reflects those who are wheelchair dependant and unable
to transfer independently. Upper limb function may be relevant in this activity. For
example, a rehabilitated paraplegic who is able to transfer by use of his upper
limbs would not satisfy the transferring descriptor.

Details of activities of daily living

Relevant activities may include:

 Getting on and off the toilet unaided, without the assistance of another
person.

 The use of public transport in the absence of a companion

 The use of an adapted car by a wheelchair dependant person

 Getting in and out of a car; and

 Getting out of chairs or off the bed

 Aids used such as a board or hoist

Observed behaviour

Observe the claimant's ability to rise from sitting and note the type of chair when
they are collected from the waiting area. There is a further opportunity to observe
this function following the interview. This will provide some information on their
likely ability to transfer.

Clinical examination

Restricted ability to sit and stand will commonly be due to disorders affecting the
lumbar spine or lower limbs. The level of restriction required for sitting or standing
descriptors to apply would suggest that there should be evidence of positive
clinical findings in the majority of cases. Evidence of muscle wasting and testing
of power in the lower limbs will be important clinical findings. Neurological
examination may be important in some cases to clarify likely level of disability.

Upper limb function may have to be reviewed when considering ability to transfer.
A paraplegic who has suffered a complete spinal cord transaction but who has
good upper limb power may be able to transfer, however a quadriplegic with an
incomplete spinal cord injury who has limited power in both upper and lower
limbs may be unable to transfer without assistance.

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Reaching

Activity 3: Reaching

Descriptors

R(a) Cannot raise either arm as if to put something in the top pocket of a coat
or jacket.

R(b) Cannot raise either arm to top of head as if to put on a hat.

R(c) Cannot raise either arm above head height as if to reach for something.

R(d) None of the above apply.



Scope

This activity relates to shoulder function and/or elbow function. It is intended to
reflect the ability to raise the upper limbs to a level above waist height.
The functional category considers the claimant's ability to reach mainly in an
upward direction through movement at the shoulder joint through forward flexion
or abduction. The descriptors also reflect internal rotation of the shoulder. It is an
evaluation of power, co-ordination and joint mobility in the upper limbs.
It reflects a bilateral problem.

Consider only the ability to achieve the described reaching posture and do not
measure hand function, i.e. it is not necessary for the claimant to adjust the hat if
he can achieve the reaching movement defined in Descriptor R(b) "Cannot raise
either arm to top of head as if to put on a hat".

Details of activity of daily living

Consider details of self-care which involve reaching e.g.:

 Dressing and undressing (including reaching for clothes on shelves/in
wardrobes)

 Hair washing and brushing

 Shaving.

 Household activities such as reaching up to shelves; putting shopping
away at home; household chores such as dusting; hanging laundry on a
washing line.

 Leisure activities such as aerobics, golf, painting and decorating.

Observed behaviour

Record any spontaneous movements of the upper limbs, particularly if these are
in excess of those elicited by formal examination.
Consider the speed and efficiency of dressing/undressing. Apart from the
removal of outdoor clothes there will usually be no direct observation of the
claimant dressing or undressing. However you should look for evidence of
protecting a painful shoulder during any observed activity.

The claimant may hang up a coat or a jacket allowing observation of shoulder
and upper limb action.

Examination

Ensure that the examination clarifies whether the disability is unilateral or
bilateral. If unilateral, state which side is affected and chart the normality in the
opposite limb. The MSO should identify any requirement for a more focussed
regional examination – especially of the shoulder joint if restriction is apparent.

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Picking up and moving

Activity 4: Picking up and moving or transferring by use of the upper
body and arms

Descriptors

P(a) Cannot pick up and move a 0.5 litre carton full of liquid.

P(b) Cannot pick up and move a one litre carton full of liquid.

P(c) Cannot transfer a light but bulky object such as an empty cardboard box.
.
P(d) None of the above apply.


Scope


This activity relates mainly to upper limb power; however joint movement and
coordination may also have to be considered. It is intended to reflect the ability to
pick up and transfer articles at waist level, i.e. at a level that requires neither
bending down and lifting, nor reaching upwards. It does not include the ability to
carry out any activity other than picking up and transferring, i.e. it does not
include ability to pour from a carton or jug.
All the loads are light and are therefore unlikely to have much impact on spinal
problems. However, due consideration should be give to neck pain and the
associated problems arising from cervical disc prolapse and marked cervical
spondylitis. These conditions may be aggravated by lifting weights in exceptional
circumstances.

Within the descriptors, the concept of adaptation exists. There is no requirement
to have two hands to achieve the tasks outlined in the descriptors. For example in
P(c), a person could reasonable manage this by using one hand and supporting
the box against another part of their body.
In descriptors P(a) and P(b), if the person could move the weight by using both
hands together, they should be considered capable of performing the task.
The ability to carry out these functions should be considered with the use of any
prosthesis, aid or appliance.

Details of activities of Daily Living

In order to get a measure of what the claimant is able to do consider domestic
activities such as:

 Cooking (lifting and carrying saucepans, crockery)

 Shopping (lifting goods out of shopping trolley or from the supermarket
shelves).

 Dealing with laundry/carrying the laundry

 Lifting a pillow

 Making tea and coffee

 Removing a pizza from the oven/ carrying a pizza box

Observed behaviour

Watch for hand, arm and head gestures. Note the ease (or otherwise) with which
any coat or jacket is removed and replaced.
The claimant may hang up a coat or a jacket allowing observation of shoulder
joint and arm action.
The claimant may lift their handbag or shopping bag several times during the
interview process.
They may use a hand to open a door.

Where there is a lack of co-operation in carrying out active neck and shoulder
movements then informal observations, coupled with examination of the upper
limbs, may allow an estimate of the usual mobility of the shoulder girdle. This
may well be confirmed by evidence from the typical day.

Examination

Consideration should be given to joint movement and power. Reduced coordination or other neurological problems such as tremor may have to be
assessed when considering these activities.

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Manual Dexterity

Activity 5: Manual Dexterity

Descriptors

M(a) Cannot either:

(i) press a button, such as a telephone keypad or;

(ii) turn the pages of a book
with either hand.

M(b) Cannot pick up a £1 coin or equivalent with either hand.

M(c) Cannot use a pen or pencil to make a meaningful mark.

M(d) Cannot use a suitable keyboard or mouse.

M(e) None of the above apply.


Scope


This activity relates to hand and wrist function. It is intended to reflect the level of
ability to manipulate objects that a person would need in order to carry out workrelated tasks. Ability to use a pen or pencil is intended to reflect the ability to use
a pen or pencil in order to make a purposeful mark such as a cross or a tick. It
does not reflect a person’s level of literacy. The same concept applies to use of a
computer keyboard. When considering the use of a keyboard, ergonomic
advances in equipment should be considered. The actual familiarity with the use
of a PC in technical terms is not considered in Md.

The descriptors reflect that those with effective function of one hand have very
little restriction of function in the workplace. The descriptor scoring in these areas
is weighted quite highly as bilateral restriction of hand function is disabling even
in the modern workplace. The ability to turn pages in a book is considered
essential in the workplace, therefore a person meeting the criteria in M(a) would
be considered to have limited capability for work related activity.

Details of Activities of daily living

Consider activities such as:

 Filling in forms (e.g. ESA50, national lottery ticket)

 Use of phones, mobile phones, setting house alarms, light switches

 Paying for things with either cards or cash

 Coping with buttons, zips, and hooks on clothing

 Cooking (opening jars and bottles; washing and peeling vegetables).

 Leisure activities such as reading books and newspapers; doing
crosswords; knitting; manipulating the petrol cap to refuel a car, using keys
to open locks etc.

Observed behaviour

You may have the opportunity to observe how the claimant handles tablet bottles,
their expenses sheet or a repeat prescription. You may also observe them lifting
objects such as a pen or handling a newspaper. Fine movements may be
observed if the claimant adjusts their hair or scratches their head. They may also
adjust their watch or unbutton a shirt cuff for examination.

Examination

In addition to the examination of the upper limbs as subsequently described,
always inspect the hands carefully and document any evidence of ingrained dirt
or callosities, indicating the possibility of some heavy domestic/manual work at
some point in time (but be careful to consider that the callosities may not
necessarily represent recent manual work).
Test grip and the ability to perform pincer movements and opposition of the
thumb.

Indicate whether the problem is unilateral or bilateral.
Where the problem is unilateral, record which side has the disability and report
succinctly on the normality of the "good" limb.

In view of the complexity of a hand/wrist examination provide a simply worded
summary particularly if your descriptor choice is at variance with that of the
claimed level of disability.

EXAMPLE

Consider the case of a man with mild, bilateral Dupuytren's contracture where the
disability claimed is in excess of your descriptor choice. The following summary
of your clinical findings would assist the Decision Maker:

"He has thickening of the tissues in the palms of both hands which is beginning to pull the ring and little fingers in towards the palm. However, he retains an effective range of fine finger movements and has unimpaired grip in both hands."

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Making self understood

Activity 6: Making self understood through speaking, writing, typing, or other means normally used; unaided by another person.

Descriptors

SP(a) Cannot convey a simple message, such as the presence of a
hazard

SP(b) Has significant difficulty conveying a simple message to strangers

SP(c) Has some difficulty conveying a simple message to strangers.

SP(d) None of the above apply


Scope


This activity relates to ability to express yourself rather than simply speech. It
assumes use of the same language as the person with whom communication is
being attempted. Where speech is considered, local or regional accents are not
taken into consideration.

The scope of the descriptor includes impediment to communication due physical
causes, for example due to expressive dysphasia (inability to express ones
thoughts) resulting from brain injury or generalised neurological conditions
causing problems with speech and manual dexterity such as Motor Neurone
Disease and advanced Parkinsons Disease. In considering expressive
dysphasia, the person’s ability to write or type would also have to be considered.

People who have had a CVA may have both speech and upper limb problems
such that they have significant problems with communication through speech or
writing.

Speech is an extremely complex activity, involving intellectual, neurological and
musculoskeletal components. It may, therefore, be affected by any condition
involving these areas. In rare cases, it may be that both psychological and
physical factors play a part in the causation of speech difficulties. In every case,
alternative methods of communication must be considered. It should be noted
that the descriptors in this area infer a reduction in function due to physical
limitations.

Occasionally people whose principle diagnosis is Panic Disorder claim that they
have difficulty making themselves understood during an episode of acute anxiety.
Similarly those with severe Chronic Fatigue Syndrome may claim that speech
becomes unclear when they are tired. Consider carefully whether such claimants
should be assessed under the Mental Function Assessment. You should consider
their ability to make themselves understood most of the time by any means.

Some claimants who suffer from breathlessness due to physical causes will
describe difficulty with speech. However, in many of these cases, the problem is
transitory and only occurs during extra physical effort, for example walking
quickly or climbing stairs.

Therefore, for the majority of the time, they will have normal speech. If the
claimant is breathless at rest, you should consider advising that they fall within
the support group criteria.

The level of communication in the descriptors represents a very basic level of
communication and this can be achieved by writing or typing if speech is not
possible. The concept of communicating a message such as a hazard is
hypothetical and the immediate availability of a PC/Pen and paper to write a
message would not be considered. Those with significant communication
problems are likely to carry items such as a pen/paper to ensure they can
communicate.

Details of activities of daily living

Consider:

 The ability to socialise with family and friends

 The ability to ask for items e.g. order drinks at a bar or ask for items in a
shop where self –service is not available – do they use speech or do they
write a list and hand it over.

 Ability to use public transport/ taxis.

 Ability to use a telephone.

 Ability to use text/e-mail.

 Ability to deal with correspondence, complete ESA 50 may give
information about written communication.

Observed behaviour

Describe the quality of speech at interview and any difficulty you have in
understanding the claimant. Note any abnormalities of the mouth and larynx and
their effects on speech. Hand function may have to be considered where speech
is a significant issue. Upper limb function may have to be assessed to ascertain
whether then person could communicate a simple message through the written
means.

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Understanding Communication

Activity 7: Understanding communication by both verbal means (such as hearing or lip reading) and non-verbal means (such as reading 16
point print) using any aid it is reasonable to expect them to use;
unaided by another person.

Descriptors

H(a) Cannot understand a simple message due to sensory impairment, such
as the location of a fire escape.

H(b) Has significant difficulty understanding a simple message from a stranger due
to sensory impairment.

H(c) Has some difficulty understanding a simple message from a stranger due to
sensory impairment.

H(d) None of the above apply


Scope


This activity relates to the ability to understand communication sufficiently clearly
to be able to comprehend a simple message. It does not relate to being able to
follow a complex conversation, the level of communication is basic. It is intended
to take into account hearing aids if normally worn, ability to lip read and ability to
read large size print or Braille to understand a basic message.

It should be noted that in this activity, a person must be able to understand
communication through both the written and spoken word. A restriction of
understanding in either of these communication modalities may result in a scoring
descriptor. For example this means a person with normal hearing ability who
understands the spoken word without difficulty but has visual impairment to the
extent they cannot read 16 point print nor read Braille would meet Support Group
criteria in this activity.

Considering Hearing

The methods used to assess the ability to understand communication involve
considering a person’s ability to hear a shout at one metre and their ability to lip
read. The descriptors are intended to take into account hearing aids if normally
worn. A “shout” is equivalent to 80dB of noise and therefore inability to hear a
shout suggests a significant loss of hearing.

State the claimant's ability to wear a hearing aid. If the claimant has rejected the
prescribed hearing aid then state the reason why. Bear in mind that a claimant
who has been inconvenienced by a hearing aid and has abandoned it should be
assessed without aids.

People with bilateral hearing loss with an average loss of less than 30Db do not
usually gain from any form of hearing aid as the small amplification needed
creates distortion of sound. Hearing aids function by amplifying sounds, but they
cannot help with the processing of sound.

For this reason conductive hearing loss is more likely to be helped with an aid
than sensorineural hearing loss.

For the same reason, hearing loss which is evenly distributed throughout the
frequencies is more amenable to hearing aid use. Where the hearing loss varies
over the frequencies an aid can create sound distortion and discomfort.
Older claimants can have difficulties adapting to hearing aid use.
The level of lip reading required is very basic as it involves understanding only a
simple message and it would be expected that the vast majority of people would
meet this level of proficiency in lip reading. It is however important to be mindful
that some people may not be able to lip read a simple message, for example
those with severe profound pre-lingual deafness who have no experience of the
spoken word. Also people with a visual impairment may be unable to lip read as
they cannot adequately see the persons face to lip read.

When considering the descriptors, the HCP must comment on lip reading ability
which will be apparent from the assessment in most cases and document hearing
ability.

Details of activities of daily living

 Consider any restrictions reported in the typical day with communication
such as difficulty socialising, shopping and engaging in hobbies.

 Note the use of any accessory aids such as headphones or loop system
amplification for TV, radio, or video; amplification for telephone handset;
loud front door bells or door lights.

 Consider their visual abilities, such as reading a newspaper, e-mails, use
of the internet, watching TV, using subtitles on the television etc.

 Consider day to day tasks where contact with other people is likely such as
in the supermarket, using public transport etc.

Observed behaviour

The claimant's response to a normal conversational or quiet voice during
interview is a good measure of their ability to hear.

Very deaf claimants often fail to respond to their call in the waiting area; bring a
companion with them to assist them with communication; or function poorly at the
interview requiring you to raise your voice and repeat questions.

A person who relies on lip reading may have problems understanding questions if
you are not facing the person directly when you speak to them.

It may be helpful to asses the level of restriction (some vs. significant) by
considering whether they understand the main context of questions, just missing
an occasional word, or whether their restriction is more significant in that they
struggle to follow a conversation.

The person may read/look at their tablets, repeat prescription to give you some
information about visual acuity. Where a BSL interpreter is used, it is essential
that the HCP assesses lip reading ability.

Examination

The most relevant examination technique to assess any restriction in hearing is
the conversational voice test. One ear is masked with the claimant's hand and
the claimant looks away from the examiner. The claimant is asked to repeat
numbers or words or answer simple questions which are posed in a normal
conversational voice. The furthest distance away from the ear that the words can
be heard is recorded.

The normal ear can detect a conversational voice at 9 metres which is impractical
in most examination centres. A distance of 3 metres is acceptable proof of
hearing for the purposes of reasonable functional hearing ability.

Conversational Voice Testing

Free field speech testing, also referred to as the Conversational Voice (CV) test
will give a rough guide to hearing loss. It requires the person’s response to quiet
voice, and conversational voice. (Testing by whisper is not recommended). The
person being tested should not be able to pick up visual clues, by lip-reading.
The following is a very rough guide to the noise level of speech:

 It is normal to hear a quiet voice at 60 cms from the ear.

 Conversational voice not heard over 4 metres – loss approximates to 30dB
in both ears.

 Conversational voice not heard over 3 metres - loss approximates to less
than 40dB in both ears.

 Conversational voice not heard over 2 metres - loss approximates to 50 –
53 dB in both ears.

 Conversational voice not heard over 1 metre - loss approximates to 61-66
dB in both ears.

 Conversational voice not heard over 30cms – loss approximates to 73-79
dB in both ears.

 Shout from not beyond 1 metre away- loss approximates to 80dB.
In unilateral hearing loss the normal ear generally compensates for the deaf one,
so the overall hearing loss in such a case is unlikely to be significant.

However, checking the hearing in each ear separately and then both ears
together provides the opportunity to detect unreliable responses suggestive of
non-organic hearing loss.

Near vision testing should be performed where a problem is identified with regard
to hearing ability.

Tinnitus

Claimants may refer to tinnitus when discussing hearing.
This is the perception of sound where there is no external stimulus. In rare
instances, such sound is transmitted from vascular sources such as aortic or
carotid murmurs.

Much more commonly, however, tinnitus is non-pulsatile and is linked to high
frequency sensorineural deafness, which may be so slight or at such high
frequency that it cannot be evaluated in a functional assessment.
The use of hearing aids can, by recruitment of background noises, help to mask
tinnitus. Claimants may also have developed their own masking techniques, for
example by the use of background music.

Tinnitus maskers may also be prescribed in severe cases.

Severe and/or resistant tinnitus can be very disabling and may result in sleep
disturbance, anxiety and depression. The following factors will give indication of
disabling tinnitus:

 Referral to a specialist unit

 The prescription of maskers/hearing aids

 The need for night sedation

 The prescription of anti-depressant medication.
Tinnitus on its own is unlikely to cause functional hearing loss, however can
significantly impact on concentration therefore consider applying the Mental
Function test in cases of tinnitus where there is cognitive impairment or
other mental disablement, such as anxiety.

Tinnitus is unlikely to impact to such a degree in itself tto amount to
substantial problems in understanding simple communication.

Considering Visual Restriction

The main assessment measures are the ability to read 16 point print using
reasonable aids and for those who cannot read 16 point print, an
assessment of their ability to read Braille to understand a simple message
must be considered.

Again, as in hearing, the level of reading 16 point print or Braille is only to a level
where a simple message can be understood. The HCP must therefore make
specific enquiry into ability to read Braille where restriction of reading print is
identified

Details of activities of daily living

 Consider any restrictions reported in the typical day with communication or
reading such as difficulty socialising, shopping and engaging in hobbies.

 Note the use of any accessory aids such as reading glasses, large print
books, magnifying glasses, talking books etc.

 Consider their visual abilities, such as reading a newspaper, e-mails, use
of the internet, watching TV etc, using subtitles on the television, reading
numbers on buses, packaging in supermarkets etc.

 Consider day to day tasks where contact with other people is likely or there
is a need to understand the written word such as in the supermarket, using
public transport etc.

 If the person uses Braille, enquiry should be made about their level of
training they have had and what types of material they read in Braille – e.g.
newspapers, any forms they complete that are provided in large print/Braille

Observed behaviour

Observation of ability to navigate, read prescription labels etc should be
recorded.

If a person has combined visual and hearing impairment where a BSL interpreter
is used, the HCP should consider whether\ the claimant uses lip reading in
addition to “sign” and how well they can see the sign language being used.
It may be useful to consider level of restriction in the context of how easily a
person reads a paragraph in large print – for example if they struggle with some
text but can still manage to understand the main content of the paragraph, vs. a
person who struggles to such a degree that they may misunderstand the key
concepts in the text.

Examination

Distance and near vision should be recorded as detailed in section 3.2.7

Summary

Thus overall, you must make an assessment of a person’s ability in both sensory
modalities. Where a restriction is identified in one area, it is likely they will be
awarded a scoring descriptor.

The following table may help in considering the level of restriction likely.

See page (90)

For example,
A person who has no restriction of hearing but has some restriction of reading 16
point print with no ability to read Braille is likely to attract descriptor H(c).
A person who has some restriction of hearing and struggles to hear a shout at 1
metre but in addition has some reduction of vision who can still read 16 point print
but struggles with lip reading, may be awarded H(c) or H(b) depending on the
level of their difficulty in understanding the spoken word, despite being able to
read 16 point print.

A person who cannot see16 point print but can read Braille and hears normally,
would be likely to be awarded H(d)

A person who has normal vision and can easily understand the written word, but
who cannot hear at all and is unable to lip read will be likely to be awarded H(a).

A person who has normal hearing but very poor sight to the extent of being
unable to read 16 point print with no ability to read Braille will be likely to be
awarded H(a).

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Navigation and maintaining safety

Activity 8: Navigation and maintaining safety, using a guide dog or other aid if normally used (Activity 8 is detailed at this point to reflect the structure of the ESA 85 and LiMA application)

Descriptors

V(a) Unable to navigate around familiar surroundings, without being accompanied
by another person, due to sensory impairment.

V(b) Cannot safely complete a potentially hazardous task such as crossing the
road, without being accompanied by another person, due to sensory impairment.

V(c) Unable to navigate around unfamiliar surroundings, without being
accompanied by another person, due to sensory impairment.

V (d) None of the above apply

Scope

This activity not only relates to visual acuity (central vision and focus) and visual
fields (peripheral vision) but takes into account the persons ability to adapt to
their condition. The person’s confidence and training must be taken into account.
Within the modern workplace, many adaptations can be made to accommodate
those with visual impairment.

Within the workplace, the key issue is the individual’s ability to navigate
and maintain safety in their environment.
The environment must be taken into account. Those who are able to navigate in
familiar surroundings but need the support of another person in an unfamiliar
environment, will have a greater level of disability than those who have adapted
to navigating in any area, whether familiar or unfamiliar.

The concept of safety awareness and the person’s ability to safely negotiate
hazards must be considered. This is an important issue in a workplace as
provision of a companion throughout the working day to ensure safety may be
considered an excessive adaptation for an employer to make.

The clinical history must be considered. The duration and speed of progression of
visual loss is likely to impact on an individual’s ability to adapt to navigation and
safely negotiate hazards. For example, someone who has had sudden complete
loss of vision very recently, perhaps as a result of trauma, is less likely to have
adapted quickly than someone with congenital visual restriction or a slower
progression of visual loss. Other medical conditions may have to be considered
to asses the individuals likely ability to adapt – e.g. those with cognitive
impairment may have more difficulty adapting to a visual impairment.

The person’s ability must be considered in the context of using any aids such as
spectacles, a white stick or guide dog they normally use. As a guide dog is not
universally available/suitable for every person, the use of a guide dog must only
be considered if the person has a guide dog. The use of GPS devices would not
be considered in this area.

The level of visual restriction is likely to impact on the person’s ability to navigate.
Visual field restriction is also important in maintaining awareness of hazard, but
again, the ability to adapt should be considered – e.g. turning the head to look for
traffic/other hazards.

Any restriction identified must relate primarily to a sensory problem, and not
cognitive issues as these are considered elsewhere.

Normal vision is taken as visual acuity of 6/6 at a distance of 6 metres from the
Snellen chart. To hold a class 1 driving licence in the UK, acuity of 6/10 on the
Snellen chart is required. To have problems in navigation, it would be expected
that the person would have a severe level of sight impairment. It is likely the
person will be registered as sight impaired or severely sight impaired .A person
registered as sight impaired or severely sight impaired will be given a certificate
of visual impairment (CVI). If the claimant brings a CVI with them to the
examination, the HCP must review the information on this and take it into
account in their justification. A copy should be made with the claimant’s
permission for inclusion in the file for the DM. Registration of a person as
severely sight impaired or sight impaired is the role of the consultant
ophthalmologist. This can be a complex procedure but some examples are
provided below.

People with acuity below 3/60 on the Snellen chart would be considered as
severely sight impaired. People with acuity of 3/60 but less than 6/60 with
significant visual field restriction may also be registered as severely sight
impaired. For sight impairment there is no formal definition, however those with
acuity of 3/60 to 6/60 with a full visual field may be registered as sight impaired.
Those who have a gross contraction of the visual field and vision of 6/18 or even
better may also be registered as sight impaired. Further details of sight/severe
sight impairment registration can be found at:

www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digita
lasset/dh_078294.pdf

Copies of the CVI can be reviewed at:
www.rcophth.ac.uk/standards/cvi

It may be useful to consider DVLA driving requirements in relation to functional
ability. In order to have a class 2 driving licence in the UK, a full binocular field of
vision is required. For a normal class 1 driving licence in the UK, specific
standards are also required and, for example, someone with a homonymous
hemianopia or bitemporal defect would not be allowed to hold a licence. Further
information on driving standards can be obtained on the DVLA website:
www.dvla.gov.uk. The LiMA repository contains extensive useful information on
assessment of vision and visual fields and may be referred to.

Details of Activities of daily living

Consider activities such as:

 Driving – both from the visual acuity and visual field point of view

 Ability to get around indoors

 History of falls or accidents

 Ability to use public transport- get on and off buses unassisted and read
the bus name and number

 Mobilising independently outdoors

 Going to a supermarket

 Reading newspapers or magazines

 Maintaining safety in the kitchen, ability to cook meals

 Getting in and out of a bath

 Caring for children
Observed behaviour

Ask the claimant how they got to the examination centre, and how they found
their way around the centre. Note whether the claimant needed to be
accompanied by another person.

Observe movement when navigating obstacles- do they rotate their neck more to
adjust for reduced visual fields?

Note any observed ability to manipulate belts and buttons.
Observe whether the claimant manages to read their medication labels or repeat
prescription sheet.

Examination

Record the aided binocular vision, and explain the significance of this to the
Decision Maker.

If the claimant forgets their spectacles but there is evidence from the typical day
activities and behaviour observed that there is no significant disability with vision,
then this should be reflected in your descriptor choice. In these cases or in cases
where the VA is poor but you think it could improve with correction measure it
using a pinhole. Only in exceptional circumstances should a claimant be recalled
to have their eyesight tested with spectacles worn.

Near vision should be recorded using a near vision chart. N8 print is the
equivalent of normal newsprint. HCPs should ensure that they use a near vision
testing chart with N16 print to accurately assess ability to read 16 point print.

Visual field testing

Where there is a history of any visual field problem or where the practitioner at
assessment feels there may be a visual field problem, visual fields must be
tested.

Visual field testing can be a complex procedure requiring sophisticated
equipment to aid diagnosis or to assess minor defects in the visual fields.
Minor defects in visual fields will rarely result in significant functional problems.

Therefore for the purposes of disability analysis, the traditional method of visual
field examination by the “confrontation method” detailed below is adequate to
detect gross defects in the visual fields that may be of functional relevance. If the
person has a CVI, details of visual field restriction may also be detailed there.
A structured approach for performing visual field testing by the “confrontation
method” is outlined below:

 Ensure you have a piece of card for the claimant to cover up one eye

 Sit 60cm from the claimant and ask them to look directly into your eyes
and keep looking straight at your face

 Ask the claimant to cover one eye with the card provided

 Check there is no central defect by ensuring they can see your full face

 Stretch both arms out in a plane equidistant between you and the claimant
and at the outermost periphery of your vision

 Move the index and middle fingers on one hand and confirm the claimant
can see your fingers moving and ask the claimant which hand is moving

 Move your hands to different positions to check the superior, inferior, nasal
and temporal fields in order. You may wish to change the fingers being
moved to ensure accuracy of response.

For the purposes of the LCW/LCWRA, you should consider any visual field
loss in the context of whether or not it is likely to impact on the person’s ability
to safely navigate. This should be in considered with visual acuity and the
typical day and any information obtained from a CVI brought by the claimant.
You must provide the DM with a detailed justification of your choice of
descriptor.

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Continence

Activity 9: Absence or loss of control leading to extensive evacuation of the bowel and/or bladder, other than enuresis (bed-wetting) despite the presence of any aids or adaptations normally used.

Descriptors

C(a) At least once a month experiences

(i) loss of control leading to extensive evacuation of the bowel and/or voiding
of the bladder; or

(ii) substantial leakage of the contents of a collecting device;
sufficient to require cleaning and a change in clothing.

C(b) At risk of loss of control leading to extensive evacuation of the bowel
and/or voiding of the bladder, sufficient to require cleaning and a change in
clothing, if not able to reach a toilet quickly.

C(c) None of the above apply

Scope

This functional area relates to the ability to maintain continence of bladder or
bowel, or prevent leakage from a collecting device.

When considering these descriptors, the review group considered social
acceptability and personal dignity to be of paramount importance. Therefore
someone who has loss of continence monthly will be considered to have LCW. It
should be noted that to be considered as having LCWRA, the loss of control
should be weekly. It is therefore essential to ensure the history contains adequate
detail to make this distinction.

These descriptors take into consideration loss of continence while the claimant is
awake. Incontinence which occurs only while asleep is not regarded as
incontinence in terms of the legislation as, with the appropriate personal hygiene,
this will not affect the person's functioning whilst awake.

Similarly, incontinence occurring during a fit happens during a period when there
is a period of altered consciousness, so incontinence will not of itself affect
functioning. Seizures should be considered under the appropriate functional area.
If a person has episodes of incontinence while under the influence of alcohol or
drugs in the absence of other pathology would not be considered in this area as
the descriptors refer to ability to maintain continence when fully alert/awake.
Poor mobility (i.e. continence problems are as a result of time taken to get to
toilet facilities because of mobility issues) is not taken into account in this area as
this is covered elsewhere.

The descriptors relate to a substantial leakage of urine or faeces – such that
there would be a requirement for the person to have to wash and change their
clothing. The descriptors do dot refer to minor degrees of leakage that could be
managed by the use of pads and not necessitate a full change of clothing. If a
person is not using pads, they should be considered as if using pads as these
are a widely available aid.

Urgency, as typically associated with prostatism, will not usually meet the criteria
for `incontinence' or `loss of control', as it can be controlled by regular voiding.
Detrusor instability can cause significant symptoms, however the condition is
likely to be controllable with the use of aids and pads in which case the scoring
descriptors would not apply. Claimants with gastro-intestinal problems such as
dumping syndrome should be considered as possibly meeting the criteria for C(b)
when their problem is unpredictable to the extent that they would become
incontinent if they did not leave their work place immediately or within a very
short space of time. Irritable bowel syndrome can usually be controlled with
medication and/or lifestyle changes and is not often associated with such urgency
that a scoring descriptor is likely to apply. NICE guidelines indicate that diarrhoea
prominent IBS can usually be managed with medication such as loperamide,
however, all the evidence such as use of pads and restriction of lifestyle must be
considered when providing advice in IBS cases. In every case, the diagnosis
history/nature of the condition must be carefully considered and the true risk of
loss of control considered on the balance of medical probability and evidence.
Medication, specialist input and aids used must be documented.

Details of activities of daily living

Consider the frequency and length of any journeys or outings undertaken, e.g.

 Shopping trips

 Visits to friends or relatives

 Other social outings
and any problems encountered in undertaking these activities.

[nickd]

Consciousness

Activity 10: Consciousness during waking moments.

Descriptors

F(a) At least once a week, has an involuntary episode of lost or altered
consciousness resulting in significantly disrupted awareness or concentration.

F(b) At least once a month, has an involuntary episode of lost or altered
consciousness resulting in significantly disrupted awareness or concentration.

F(c) None of the above apply


Scope


This function covers any involuntary loss or alteration of consciousness
resulting in significantly disrupted awareness or concentration occurring
during the hours when the claimant is normally awake and which prevents the
claimant from safely continuing with any activity. Such events occurring when the
claimant is normally asleep should not be taken into consideration. The
descriptors relate to the frequency with which such episodes of lost or altered
consciousness occur. The working group reviewing the descriptors considered
that seizures occurring on less than a monthly basis are unlikely to significantly
impact on an individual’s ability to work. It should be noted that the descriptors
indicate that awareness must be significantly disrupted. This means the nature of
the episodes and their effects on function must be explored to see if they fulfil the
criterion of the descriptor.

In the context of disability assessments, the most likely causes of episodes of
“lost consciousness” are:

 Generalised seizures (previously referred to as grand mal, tonic clonic and
myoclonic seizures.

 Seizures which are secondary to impairment of cerebral circulation (e.g. as
a result of cardiac dysrhythmias).

 Cardiac arrhythmia.
"Altered consciousness" implies that, although the person is not fully
unconscious, there is a definite clouding of mental faculties resulting in loss of
control of thoughts and actions. The causes most likely to be encountered are:

 Partial seizures which may simple or complex partial (previously known as
Temporal Lobe epilepsy) or

 Absence seizures which may be typical (petit mal) or atypical

 Dissociative disorders, fugues and narcolepsy should be considered.
Sleep apnoea is unlikely to meet the criteria for loss of consciousness as
the person is in a state of sleep at the time and could be roused by noise or
another person.

 Significant hypoglycaemia where the person requires the intervention of
another person to manage the episode.

For both lost and altered consciousness, establishing an exact diagnosis is less
important than establishing whether or not any disability is present.

Any disability due to side effects of medication taken to control seizures needs to
be taken into account. A mental function assessment should be performed if the
side effects of medication are sufficient to interfere with cognitive ability or
produce other mental disablement.

Giddiness, dizziness, and vertigo, in the absence of an epileptic or similar
seizure, do not amount to a state of "altered consciousness". These conditions
are therefore not taken into account when assessing the functional area of
remaining conscious. If they affect functional ability in other categories, they
should be taken into account when considering the relevant activity categories.

Migraine

Migraine is classified by the International Headache classification ICDH-2 in
terms of “Migraine without aura” and “Migraine with aura”. Migraine without aura
is the commonest subtype.

The symptoms relating to migraine are wide ranging but do not usually result in a
significant loss of consciousness in most cases.

One notable exception is Basilar Type Migraine. Basilar type migraine is a rare
condition associated with aura. The symptoms relate to disruption at the
brainstem and /or involvement of both hemispheres at one time without motor
weakness. As a result of these headaches, a number of symptoms may occur.
These include vertigo, tinnitus, hyperacusis, diplopia, ataxia, a variety of visual
symptoms and decreased level of consciousness (ICDH – 2).

Thus in cases where basilar type migraine has been formally established, the
HCP must carefully take note of symptoms to ascertain whether consciousness is
disrupted to the degree described in the descriptors. The HCP must carefully
enquire into frequency of episodes and the effect of treatment. (For example,
verapamil has been shown to improve symptoms in some cases). Note, it is not
the role of the HCP to attempt to diagnose basilar type migraine.

The effect of migraine headache on any other functional category should be
assessed in the same way as the effect of any other pain, bearing in mind the
frequency and severity of the attacks.

Further information on migraine classification and symptoms can be found at:
ihs-classification.org/en/02_klassifikation/02_teil1/01.00.00_migraine.html

Variability

It may be necessary to consider whether a claimant's claimed frequency of
seizures is medically reasonable. For example, if there is no corroborative
evidence from the GP and the claimant is not on any appropriate medication, this
would raise doubts as to a claim of frequent episodes of lost or altered
consciousness.

Details of activities of daily living

Consider:

 Whether the person drives - the DVLA will refuse to issue a licence to
anyone who has had a daytime fit in the past year.

 Potentially hazardous domestic activities such as cooking.

 Recreational activities e.g. swimming, contact sports

[nickd]

MH test

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Learning tasks (Understanding and focus)

Activity 11: Learning tasks

Descriptors

LT(a) Cannot learn how to complete a simple task, such as setting an
alarm clock

LT(b) Cannot learn anything beyond a simple task, such as setting an alarm
clock.

LT(c) Cannot learn anything beyond a moderately complex task, such as
the steps involved in operating a washing machine to clean clothes.

LT (d) None of the above apply


Scope


This activity reflects ability to learn a task. “Learning” assesses the ability to learn
and retain information. The method that people learn by is not relevant - what is
important is the ability to learn to do a task. It is therefore of no relevance
whether a person learns a task by watching a visual demonstration, learns by
reading or through verbal instruction. Within the workplace, the ability to learn
tasks is vital. If the person needs to be shown how to do a task again, they have
not learned it.

This activity may be relevant to conditions including learning disability and
organic brain disorders including acquired brain injury or stroke. People with
severe and profound learning disability are unlikely to be able to learn how to
complete a simple task and people with moderate learning disability are unlikely
to be able to complete a moderately complex task.

It also may reflect difficulties in understanding language, such as receptive
dysphasia.


Issues to consider


• The length of time taken to learn a task and the ability to retain the
information must be taken into account.

• If a person learns a task on one day but is unable to repeat it the next day,
they have not learned this task.

• If a person takes a very long time to learn a task, for example takes 2
years to learn how to wash and dress themselves, this would not be
considered reasonable and that person would not be considered to have
the ability to learn this task. The inability to learn a very simple task
represents a very high level of disability such that they would also be
considered to have limited capability for work related activity.

• A simple task may only involve one or two steps while a moderately
complex task may involve 3 or 4 steps.


Details of activities of daily living


Consider basic functions of personal care and leisure activities.

Simple tasks may include:

• Brushing teeth. This would involve remembering to put toothpaste onto a
brush and brushing all areas of teeth.

• Washing. This would involve the ability to use soap/shower gel and wash
their body

• Brushing hair

• Turning on the television/ using basic functions on the TV remote control

• Getting a glass of water

Moderately complex tasks may include:

• Using a microwave oven

• Making a cup of tea including filling kettle, putting tea bags in teapot,
pouring into cup and adding milk and sugar

• Playing CDs on a stereo

• Using a Playstation

• Using a computer for basic activities such as playing a game
More complex tasks should also be considered such as driving should be
detailed and any previous tasks learned in training and employment should
be considered.

Careful enquiry must be made during the history to ascertain the individual’s true
capacity to learn tasks. For example, using a mobile phone may be considered to
be a moderately complex task if the person can text, set up speed dials, change
ring tones etc, however, if a person can only use the phone in a limited way to
dial a number pre-set by a carer, this may be considered a simple task. Similarly
use of a television/ remote control etc must be carefully considered. If the person
has simply learned to use the “on” button on the TV control and digital box this
does not necessarily mean they have an ability to learn very complex tasks.
Enquiry should be made into what other things they can do. If someone can set
up a TV/DVD player, programme channels, rearrange leads at the back of the TV
it suggests a much greater capacity to learn more complex tasks.


Mental State Examination


Relevant findings may be general memory and concentration, general decision
making ability at assessment, their ability to cope at interview, general
intelligence and requirement for prompting. It may be appropriate when
considering this functional area to consider and document more specific tests of
memory and concentration.

[nickd]

Awareness of Hazard (Understanding and focus)

Activity 12: Awareness of everyday hazards (such as boiling water or
sharp objects).

Descriptors

AH(a) Reduced awareness of everyday hazards leads to a significant
risk of:

(i) injury to self or others; or

(ii) damage to property or possessions,
such that they require supervision for the majority of the time to maintain
safety.

AH (b) Reduced awareness of everyday hazards leads to a significant risk of

(i) injury to self or others; or

(ii) damage to property or possessions,
such that they frequently require supervision to maintain safety.

AH (c) Reduced awareness of everyday hazards leads to a significant risk of:

(i) injury to self or others; or

(ii) damage to property or possessions,
such that they occasionally require supervision to maintain safety.

AH(d) None of the above apply


Scope


This activity is intended to reflect the ability to recognise risks from common
hazards that may be encountered by people with reduced awareness of danger
through learning difficulties, or conditions affecting concentration, including
detrimental effects of medication; or from brain injury or other neurological
conditions affecting self awareness. It may also apply to people with severe
depressive illness and psychotic disorders as a result of a significant reduction in
attention and concentration, but is unlikely to apply to people with anxiety
disorders.


Issues to consider


• The activity reflects a lack of understanding and insight that something is
dangerous or that there is an impaired ability to recognise that a situation
will present a potential hazard. For example a person with dementia may
lack the insight to recognise why it may be dangerous for them to cook -
they lack the ability to recognise that they are at risk of forgetting that the
cooker is on.

• The descriptors do not reflect simple accidents that may occur through
lapses in concentration/distraction such as cutting a finger when chopping
vegetables when the phone goes. If a person knows that there is a risk and
therefore avoids the situation, they would not score in this category. There
must be evidence that they do not realise there is a risk.

• The level of severity of the descriptors reflects the amount of supervision
that would be required to ensure the safety of the person and others.

• The “majority of the time” would represent a need for daily supervision.
Frequently would represent several times a week.

• As substantial supervision in the workplace may pose problems, the level
of supervision required has been taken into consideration when
determining the LCW threshold. Thus those who require supervision for the
majority of the time should be considered for the Support Group.

• If AH(b) is suggested, the HCP must consider whether the issues
presented may present “risk” to the safety of the person or others and they
must carefully consider whether the “substantial risk” NFD is appropriate.


Details of activities of daily living


When considering this functional category details you should ask about ability to
cope with potential hazards. These may include:

• Ability to cope with road safety

• How they manage if they live alone

• Driving

• Ability in the kitchen

• Awareness of electrical safety

• Responsibility for children/pets

It may be useful to consider the concept of whether the person could be safely
left alone to manage basic daily life when you consider this functional category.


Mental State Examination


Cognitive issues will be important in assessing this issue.
Insight will also be an important factor. You should consider whether the claimant
has adequate insight into their problems to recognise the risks present and
therefore whether they are able to avoid potential hazardous situations.
.

[nickd]

Initiating and completing personal action (Understanding
and Focus)


Activity 13: Initiating and completing personal action (which means
planning, organisation, problem solving, prioritising or switching
tasks).

Descriptors

IA(a) Cannot, due to impaired mental function, reliably initiate or
complete at least 2 sequential personal actions.

IA(b) Cannot, due to impaired mental function, reliably initiate or complete
at least 2 personal actions for the majority of the time.

IA(c) Frequently cannot, due to impaired mental function, reliably initiate or
complete at least 2 personal actions.

IA(d) None of the above apply


Scope


This activity reflects the ability to initiate and successfully complete tasks
without need for external prompting. This Support Group describes a severe
restriction of an individual’s ability to understand how to co-ordinate actions in the
correct sequence such that they successfully complete any personal actions in a
logical order for example washing before dressing
It is intended to reflect difficulties that may be encountered by people with
conditions such as psychosis, OCD, autism and learning disability. A very severe
depressive illness that results in apathy, or abnormal levels of fatigue experience
problems in this area. It may be compounded by the effects of medication.
Issues to consider

• The intention of the activity is to assess whether a person has the
capability to carry out routine day to day activities or activities that may
normally be associated with work. The concept of 2 sequential tasks could
include showering, and getting dressed to go out.

• The issue of whether a person can repeatedly and reliably complete tasks
must also be considered.

• There must be evidence of effective personal action. For example,
someone with OCD may initiate many actions, but due to rituals they may
not actually be able to complete them and therefore should be considered
not capable of personal action. Similarly, if a person perhaps with bipolar
illness manages to wash and dress but then goes out and spends all their
money on non essential activities, giving no consideration to issues such as
bills, rent, food etc, they would not be considered to be initiating effective
personal action.

“Personal action” may include:

• ability to plan and organise a simple meal

• ability to get up, washed, dressed and ready for work in the morning

• ability to cope with simple household tasks e.g. sorting laundry and
using a washing machine

• dealing with finances

• arranging GP appointments, picking up prescriptions, taking medication
Details of activities of daily living
Areas to consider should include any behaviour that involves a decision to plan
or organise a personal action to enable them to perform it.

Activities may include:

• Making travel arrangements

• Writing shopping lists

• Organising finances

• Planning a simple meal

• Getting washed and dressed

• Ironing clothes for the next day

• Caring for children: preparing clothing, lunches etc.


Mental State Examination


General memory and concentration will be important areas to consider.
Intelligence and severity of depression should be considered. It would be
expected that the Mental State Examination findings should be consistent with
significant impairment of mental function if choosing a descriptor in this
functional category. Where depression is present, evidence of psychomotor
retardation would be likely if these descriptors were applicable.

[nickd]

Coping with change (Adapting to change)


Activity 14: Coping with change


Descriptors

CC(a) Cannot cope with any change to the extent that day to day life
cannot be managed

CC(b) Cannot cope with minor planned change (such as a pre-arranged
change to the routine time scheduled for a lunch break), to the extent that
overall day to day life is made significantly more difficult.

CC(c) Cannot cope with minor unplanned change (such as the timing of an
appointment on the day it is due to occur), to the extent that overall, day to
day life is made significantly more difficult.

CC(d) None of the above apply


Scope


This activity reflects the flexibility needed to cope with changes in normal routine.
It is intended to include difficulties that may be encountered by people with
moderate/severe learning disability, autistic spectrum disorder, brain injury, OCD,
severe anxiety or psychotic illness. It is not intended to reflect simple dislike of
changes to routine, but rather the inability to cope with them. The permanence of
the change is not relevant to the descriptors.


Issues to consider


• This activity reflects a significant level of disability where small changes
result in the individual’s day to day life being significantly affected i.e. day to
day life is made significantly more difficult or cannot be managed.

• The highest descriptor represents a level such that a change to routine
would mean that life would stop for everyone involved and basic activities
could not continue.

• More specific short lived episodes such as leaving the supermarket as it is
too crowded would not be considered if this was the only change to their
planned day. Similarly a person who has a panic attack but manages to do
most usual tasks in a day after the episode of panic would not attract a
scoring descriptor in this area.

• It is important to obtain examples of when change occurred and what
happened to the person when this occurred.


Activities of daily living


In this functional area you should consider the person’s ability to cope in
situations where some change is possible. Areas to consider may include:

• Use of public transport

• Shopping

• Dealing with appointments at hospital, GP or Jobcentre Plus

• Coping with children and their out of school activities
It may be useful to consider some of these activities in terms of the level of
disability intended, for example:

• A claimant with a severe form of mental disablement who may become so
distressed by the supermarket being out of stock of their usual brand of
breakfast cereal that they cannot continue with other activities or complete
the rest of their shopping.

• A claimant who would be unable to cope with the train being cancelled and
would return home rather than wait for the next train.


Mental State Examination


It is expected that the Mental State Examination findings would be consistent with
the type of conditions this descriptor is intended to reflect. They may have poor
rapport and be extremely anxious at interview.

It may be that they have been completely unable to attend the MEC for
assessment. It would seem unlikely that a claimant who manages to attend the
MEC alone would meet the level of severity of functional restriction for anything
other than CC(d) to apply.

[nickd]

Getting about (Adapting to change)


Activity 15: Getting about


Descriptors

GA(a) Cannot get to any specified place with which the claimant is familiar

GA(b) Is unable to get to a specified place with which the claimant is familiar,
without being accompanied by another person

GA(c) Is unable to get to a specified place with which the claimant is
unfamiliar without being accompanied by another person.

GA(d) None of the above apply


Scope


This activity is intended to reflect inability to travel without support from another
person, as a result of disorientation; or of agoraphobia causing fear of travelling
unaccompanied by another person. People with a learning disability may have
significant problems in this activity. The highest descriptor represents a complete
inability to leave the home.


Issues to consider


• When considering this activity, the means that the person arrives at their
destination is not considered. For example, individuals who are unable to
use public transport but are able to arrive at their destination by other
means will not score on this activity.

• The descriptors do not reflect lesser degrees of anxiety about going out.
Nor do they reflect planning and timekeeping.

• For people with anxiety, panic disorder and agoraphobia there should be
supporting evidence that corroborates the severity of the condition, for
example, level of medication / psychiatric input.

• Specified places with which the claimant is familiar would be locations in
their local area such as the GP surgery, dentist, bank, post office, local
shops etc. If a person simply avoids the large supermarket in the town but
manages to go to other local shops etc, they would not score in this area.

• A person who has been unable to leave the confines of their own village
for many years may attract GA(c).


Activities of daily living


General level of function should be considered in this category with regard to
level of anxiety and ability to leave the house. Activities to consider may be:

• Shopping

• Attending the chemist

• Attending hospital or GP appointments

• Walking the dog

• Supervising children outdoors

• General safety awareness and abilities in kitchen may support significant
cognitive disruption resulting in safety issues if going out unaccompanied.


Mental State Examination


Intelligence and cognitive function must be carefully considered. It would be
expected that evidence of severe anxiety would be apparent to support the
level of functional restriction in this area. Lesser degrees of anxiety would not
fulfil the criteria. The descriptors reflect true panic disorder or severe
agoraphobia.

[nickd]

Coping with social engagement (Social Interaction)


Activity 16: Coping with social engagement due to cognitive
impairment or mental disorder


Descriptors

CS(a) Engagement in social contact is always precluded due to
difficulty relating to others or significant distress experienced by the
individual.

CS(b) Engagement in social contact with someone unfamiliar to the claimant
is always precluded due to difficulty relating to others or significant distress
experienced by the individual.

CS(c) Engagement in social contact with someone unfamiliar to the claimant
is not possible for the majority of the time due to difficulty relating to others or
significant distress experienced by the individual.

CS(d) None of the above apply.


Scope


This activity is intended to reflect a significant lack of self-confidence in face to
face social situations that is greater in its nature and its functional effects than
mere shyness or reticence. Those with severe anxiety, autism, psychosis or
learning disability may have problems in this area. It reflects levels of anxiety that
are much more severe than fleeting moments of anxiety such as any person
might experience from time to time.


Issues to consider


• The level of anxiety referred to suggests a specific and overwhelming
experience of fear, resulting in physical symptoms or a racing pulse, and
often in feelings of impending death such as may occur in a panic attack.

• There must be evidence that the social engagement results in significant
distress to the individual. CSa represents almost total social isolation.

• For people with anxiety, panic disorder and agoraphobia there should be
supporting evidence that corroborates the severity of the condition, for
example, level of medication / psychiatric input.


Activities of daily living


Consider any form of social contact such as:

• Use of public transport

• Shopping

• Talking to neighbours

• Use of phone

• Hobbies and interests

• Social interaction with family


Mental State Examination


The Mental State Examination findings would be expected to reflect severe
anxiety or communication problems. Rapport is likely to be poor with lack of eye
contact. The claimant may be sweating and finding the consultation difficult. They
may be somewhat timid in demeanour at interview. It would seem likely the
person would require a companion to attend at the MEC due to the level of
anxiety/communication restriction that this descriptor would normally be expected
to reflect.

[nickd]

Appropriateness of Behaviour with other people (Social
Interaction)


Activity 17: Appropriateness of behaviour with other people, due to
cognitive impairment or mental disorder


Descriptors

IB(a) Has, on a daily basis, uncontrollable episodes of aggressive or
disinhibited behaviour that would be unreasonable in any workplace.

IB(b) Frequently has uncontrollable episodes of aggressive or disinhibited
behaviour that would be unreasonable in any workplace.

IB(c) Occasionally has uncontrollable episodes of aggressive or disinhibited
behaviour that would be unreasonable in any workplace.

IB(d) None of the above apply


Scope


This activity is intended to reflect difficulties in social behaviour which might for
example, be encountered by people with psychotic illness or other conditions
such as brain injury that result in lack of insight. The activity also includes the
difficulties people with autistic spectrum disorder may have in social behaviour. It
is intended to reflect the effects of episodic relapsing conditions such as some
types of psychotic illness, as well as conditions resulting in consistently abnormal
behaviour.


Issues to consider


• There should be evidence of a disorder of mental function for this
descriptor to apply. This may be as a result of a specific mental illness or a
condition, whether mental, physical, or sensory resulting in cognitive or
intellectual impairment of mental function. The descriptors do not simply
relate to aggressive behaviour/anger management issues where there is no
underlying mental health issue.

• The descriptors relate to behaviour that would be considered in an
average workplace such as a call centre as this provides a more general
concept rather than applying “reasonable” to one person’s standards as this
may be subject to considerable variability. It is likely that the behaviour
would extend beyond verbal aggression for the descriptors to apply.

• There must be evidence that the individual is unable to control their
behaviour for the descriptors to apply.

• The history and nature of the events should be detailed along with the
frequency in which they occur.

• Where the episodes occur frequently and the episodes are major, the “risk”
NFD must be carefully considered and whether or no it is applied fully
justified.


Activities of daily living


Consider any activity involving interaction with others:

• Previous occupational history

• Shopping

• Childcare

• Parents nights at school

• Relationships with neighbours

• Ability to cope at appointments: GP/ Hospital etc

• Ability to cope with bills and on the phone

• Dealing with finances and bills at the post office

• Appointments with official persons such as the Bank Manager/ Social
Worker/ Benefits Personnel


Mental State Examination


There is likely to be evidence of reduced insight. Cognitive function should be
carefully addressed. Evidence of addiction or thought disorder should be carefully
assessed. Rapport may be poor and communication difficult.