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Copies of new medical information vital for DLA claims & appeals

3 July 2007
New medical information produced by the DWP should be consulted by any claimant or adviser making a DLA or AA claim or appeal.

The new medical information forms part of a system introduced by the DWP to try to standardise decision making and reduce the number of successful appeals. Some of the information has now been published on the internet, but Benefits and Work is concerned that much of it remains hidden.

Customer Case Management
The new system, Customer Case Management (CCM), is being gradually introduced over time. The new DLA claim packs form part of CCM, as does the medical information now replacing the Disability Handbook previously used by decision makers.

The DWP have so far published the following items of CCM medical information:

Abridged Schizophrenia guidance

Ankylosing Spondylitis helpscreen

Mechanical back pain and non-specific back pain helpscreen

Osteoarthritis hip guidance

Osteoarthritis knee guidance

Rheumatoid arthritis helpscreen

The information is particularly important because it tells claimants and advisers what signs, symptoms, aids and adaptations the decision maker will look for when deciding whether the condition is mild, moderate or severe. This in turn will affect what level of award is made.

Hip and back problems
So, for example, for osteoarthritis of the hip, decision makers are told that the following factors should be looked for when deciding whether a claimant's condition is severe:

Awaiting hip surgery, usually total hip replacement.
Continuous pain or pain wakes them at night.
Gross restriction of movements
Morning stiffness lasts more than 60 minutes.
Always limps.
On NSAID's.
Uses crutches and wheelchair.
Has stairlift plus chair raise, toilet raise, bath modifications, access rails, (prescribed by Physio/Occupational Therapist).
Under Consultant care.
Xrays may show severe OA changes.
Examination reveals muscle wasting around the joint

Decision makers are told that 'Not all these factors need to be present to indicate severe disease. The most important are the first three.'

The guidance tells decision makers that claimants with mild or moderate osteoarthritis of the hip will have no care or mobility needs that would entitle them to DLA or AA. Only claimants with severe osteoarthritis of the hip will be considered for an award.

For mechanical and non-specific back pain, it appears from the guidance that no matter how severe the condition, it will never give rise to an award of DLA or AA, except in a small percentage of cases where 'psychological and psychosocial factors lead to the development of a disabled lifestyle'.

Claim pack completion
It is important to be aware that this is merely guidance given to decision makers: it has no legal standing. However, where a claimant can show in their claim pack that they have the elements which indicate a severe condition, this will clearly improve their chances of getting the appropriate award without needing to appeal.

So, anyone with one of the conditions listed above would be well advised to consult them when completing a DLA or AA claim pack. In addition, more detailed guidance for decision makers is available in the members are of the Benefits and Work website, though at this point it is not clear whether decision makers see this guidance or abridged versions of it. What is certain however, is that decision makers have access to guidance on a much wider range of conditions than has yet been made public.

Appeals
Anyone appealing against a DLA or AA decision should definitely ask the DWP to disclose what guidance was made available to, or consulted by, the decision maker in the course of reaching their decision, including any Helpscreens associated with the Customer Case Management system.

Where it appears that the new guidance has been used, claimants may wish to argue that the decision maker has based their decision on generalized guidance rather than simply considering how the condition affects you as an individual. In particular, the division of conditions into mild, moderate and severe based largely on externally verifiable factors is largely an administrative convenience intended to standardize, rather than make more accurate, the decision making process.

The future
It's likely that much more medical information will be made available over the coming months. We'll inform members as this occurs and, once a sufficient body of material is available, aim to produce some more detailed arguments to use in challenging refusals based on CCM information.