Northern Ireland Ombudsman finds ‘systemic maladministration’ in further evidence use when assessing PIP

The Northern Ireland Public Services Ombudsman Margaret Kelly has recommended significant changes in how further evidence is used in assessing and awarding entitlement to PIP.

The recommendations came following publication of a very detailed investigation report which found that repeated opportunities were missed to make the right payment as early as possible in the process.

The report highlights that a failure by both the Department for Communities and Capita to seek and use further evidence, including that from medical professionals, meant claimants had to continually challenge the decision, often all the way to appeal, before the correct decision was made.

The repeated nature of these failures, the Ombudsman concludes, constitute “systemic maladministration”.

Overall the investigation found:

the most common reason for not requesting further evidence was that ‘it was unlikely evidence would be obtained within the timescale required’ – despite the fact that there were 6 weeks available within which to gain such evidence.
face to face assessments of claimants was often the primary and in some cases the only source of evidence relied upon by Disability Assessors.
Capita used information on the number of assessment reports completed and submission times to decide on bonuses for Disability Assessors; these had the potential to inhibit the appropriate use of further evidence in making assessments.
in the high number of cases where claimants had their PIP decision overturned at the last stage of the Department’s internal process, the investigation found numerous examples of where the evidence relied upon at appeal was either already available to the Disability Assessor or the contact details of those who could provide it were already available.
despite Capita and the Department’s contention that further evidence has a key role in the PIP process, it was often only at the last stage and following the submission of an appeal to the Tribunal that the role of further evidence was elevated.
too many vulnerable claimants may not have been identified for additional support at the very start of the PIP process because of the Department’s narrow interpretation of its own guidance.
many PIP claimants received correspondence from Capita that said all health professionals they had listed had been contacted, when in-fact this was not the case.
opportunities for the Department and Capita to systematically improve the quality of assessments and decision making were lost due to an incomplete analysis of the reasons for the overturn of benefit decisions.

In addition, the Ombudsman said:

“I also found that the Case Managers, who are the ultimate benefit decision makers, did not routinely request clarity from Capita Disability Assessors on assessment reports where advice was not properly explained.

There was a failure to examine further evidence opportunities where the reported impact and assessment advice conflicted, even though claimants had pointed to sources of relevant evidence.

Decision making on whether or not to request further evidence was overwhelmingly deferred to Capita, despite Case Managers having the ability to request it and the responsibility to ensure the benefit decision is robust”.

The Ombudsman makes no less than 33 recommendations including that:

the Department review Capita’s policy for requesting further evidence at the Initial Review and Assessment stages and address any processes, time or bonus incentives that may act as barriers to pursuing further evidence to improve the quality of assessment advice.
as well as improving the quality of the explanations provided in decision letters, the Department should provide claimants with a copy of their Assessment report along with the First Tier decision letter.
the Department should ensure Capita revises their information pack so that claimants are accurately informed as to whether further evidence requests have been made to the claimants’ health professionals and with whom contact has been made.
The Department should review its current method of recording reasons for the overturn of awards decisions at Mandatory Reconsideration and Lapsed Appeal. It should continuously review and analyse the reasons to inform learning and improvement and report publicly to increase understanding.

A summary or the full version of the Ombudsman's investigation report: PIP and the Value of Further Evidence is available from nipso.org.uk.

A short video overview from the Ombudsman is also available.