Q&A: Sickness and disability benefits
Dr Jim Sherifi explains how far GPs should go in helping patients access benefits
This article aims to answer GPs’ common questions about benefits – the process of benefits being paid to patients, eligibility, and where GPs’ duty to help patients access benefits begins and ends.
One of the key points for any GP dealing with patients on benefits should be that the time spent filling in forms in the short term can save time and aggravation in the long term.
For more detailed information on benefits, eligibility, the definition of a disability and where to send patients who need more advice and support, see the full version of this article online at pulse-learning.co.uk.
What are the main benefits to which patients are entitled?
There are a number of disability-related benefits that patients can claim. The five key benefits GPs should be familiar with are:
• Employment and support allowance (ESA)
• Disability living allowance (DLA)
• Personal independence payments
(PIP), which replaced DLA for 16- to 64-
year-olds from April this year
• Attendance allowance (AA)
• Industrial injuries disablement benefit (IIDB).
Of these, ESA and DLA are the ones most likely to require GP input. ESA and PIP/DLA are independent of each other, since the former relates to the functional ability to work and the latter to care and mobility needs. Indeed, a patient can have the one without the other.
What are the recent changes to the benefits system that might provoke problems and lead to attendance at the GP surgery?
Recent changes that may have an impact on GP workload are:
• Reassessment of all previous DLA claims. Many of these were previously awarded for the ‘lifetime’ of the claimant but have since been downgraded or withdrawn on reassessment, with
a significant impact on claimants’ lives. Patients are likely to seek support from their GP if appealing the decision.
• ESA reassessments being undertaken more frequently. These may require additional information from a GP, such as a completed ESA 113 form.
• The change from DLA to PIP, which involves subtle differences between the two, including an increase from six months to nine months in the length of time the incapacity must persist before qualifying, and medical conditions only being assessed by how they affect the individual rather than by ‘labelling’ a patient with their disability. The period of the award will always be time limited and will be regularly reassessed for changes in circumstances. There are now two categories of benefit (daily living support and mobility) measured on two levels.
Can a GP charge for any extra work undertaken in support of a claim, for instance the provision of medical records?
Yes and no. Under the terms and conditions of service, NHS GPs are obliged to provide, free of charge:
• The Med 3
• The ESA/IB 113
• The statement on the back of the DLA/AA claim pack.
Factual reports (for instance, medical reports) requested by the claimant are not covered by NHS terms and conditions. GPs can either charge a fee to provide the report, provide one free of charge or refuse to provide one.
The Department for Work and Pensions or tribunals service can also request a factual report, in which case the GP can charge them a BMA-recommended fee of £33.50. The DWP may also request a DS 1500 if the patient is terminally ill in order to fast-track their benefits, for which the recommended fee is £17. Requests from the DWP or tribunals service should be addressed within four weeks.
How should a GP respond to a claimant whose benefits have been withdrawn following a tribunal appeal?
In short, sympathetically, since such a decision can have a profound effect on the way that person lives their life. A claimant whose appeal against withdrawal or downgrading of ESA/DLA has not been upheld may return to their GP to seek an explanation of the process or to ask for additional support in making a fresh claim.
The rules governing the issue of a further medical certificate state that such a certificate cannot be issued for the same condition within six months of the original decision following an ESA/DLA assessment. However, within that time a Med 3 can be issued if that medical condition has substantially deteriorated, or it can be issued for another medical condition that might impact on that person’s ability to work.
Note that while the appeals process is on-going, the DWP and Ministry of Justice do not require any additional medical certificates. Despite that, patients will often seek additional supporting evidence from their doctor when making an appeal. The GP is under no obligation to comply with these requests and can charge a fee if they do provide written evidence requested by patients. Further information can be found on the DWP website.
Some LMCs have advised GPs to refuse requests for information to support benefits appeals. Can I begin to do this, or should I wait for my LMC to sanction it?
There is currently an active debate taking place on the subject of the extra demands made on GPs when additional medical evidence is requested in the benefits claims and appeals process.
GPs are generally facing a rise in work related to benefits eligibility. For example, in June Pulse reported that there had been a 21% increase since January in formal requests from the DWP to GPs to verify work capacity assessments.
As a result, some LMCs (Lancashire and Cumbria, for instance) have advised GPs to refuse to carry out any unresourced work related to the benefits process.
There remains a statutory obligation for GPs to provide certain evidence requested through the DWP – such as the ESA 113 and medical records, for which they may be paid. But some LMCs have advised that any evidence requested by the claimant must be paid for by the claimant. Consultations between the BMA and DWP are on-going at the time of writing.
Additional workload can be reduced by providing detailed, objective evidence when the initial benefits claim is filled in. This is particularly the case with ESA/IB 113 forms, which have several sections asking the GP to provide information about the claimant’s ability to undertake specific tasks.
How should GPs respond when patients ask them to support a benefits appeal? What are our obligations?
Our obligations as set out by the GMC are to act in the best interests of our patients. As far as the benefits system is concerned, our input should be as objective as possible as this will assist the DWP in arriving at any decision in an informed and timely manner.
Undoubtedly this process can sometimes lead to misunderstanding between doctor and patient with regard to the latter’s ability to undertake certain functions.
Many patients who ‘fail’ an assessment immediately appeal and are told to see their GP to continue certification pending the appeal. In such a situation, is the GP obliged to give the patient a Med 3 certificate?
No. A further medical certificate need not be issued if it is not deemed to be in the patient’s interests for whatever reason. The old conflict between what a patient wants and what a patient needs still applies. To cut short any further debate on the subject, the patient should be referred back to the DWP.
Should the DWP feel that a further certificate is required, it can request one from the GP and be responsible for any fees incurred.
A patient can make an additional claim for ESA following an unsuccessful appeal. In order to do so they will need an additional Med 3 certificate but this must state either deterioration in the original condition or a different condition.
I recommend you record any incidence of such requests, as per GMC guidelines.
Should GPs sign people ‘off sick’ when their problem is specifically work-related stress, as this would seem to avoid rather than resolve the problem?
GPs should do what they feel is right for their patient. Med 3s can only be issued for a recognised medical condition, for example anxiety and depression. However, the current Med 3 forms allow for additional information to be written and this is useful for highlighting problems in the workplace that are impacting on that person’s mental or physical state.
But, as mentioned in a previous CPD module on the subject (pulsetoday.co.uk/med3-CPD) any additional information given is entirely advisory and the patient’s employer is under no obligation to act on it. The responsibility for good health in the workplace remains that of the manager.
Dr Jim Sherifi is a medical member of the Tribunals Judiciary and a GP in Sudbury, Suffolk