USE OF EMPLOYMENT AND SUPPORT ALLOWANCE INFORMATION IN CLAIMS FOR DISABILITY LIVING ALLOWANCE A Handbook for Decision Makers Forward This handbook has been prepared by the Department’s Health, Work and Wellbeing Directorate. It considers how Disability Living Allowance (DLA) Decision Makers (DMs) can use the information obtained in assessing Employment and Support Allowance in determining DLA benefit entitlement.

Employment and Support Allowance (ESA) has been introduced in October 2008, for new claimants, and will replace Incapacity Benefit and Income Support paid on grounds of incapacity. Analysis has shown that a large percentage of DLA claimants have a current or recent claim to incapacity benefit. Valuable information relating to the customer’s medical condition and functional limitations will be available in the documentation used to evaluate the ESA claim. Using this information may save the customer from having to undergo an examination in connection with their DLA claim, and reduce the need to obtain further clinical information from the customer’s doctor or another health care professional (HCP).

Section 1 – Background 1 The Employment and Support Allowance has been designed to enable people to achieve their full potential through work and to help them to gain independence from benefits. It will focus on what the person can do rather than what they cannot do. The overarching principle is that everyone should have the opportunity to work, and that people with an illness or disability should get the help and support needed for them to engage in appropriate work.

2 ESA requires all but those patients with the most severe illnesses or disabilities to engage in a programme of work focused interviews and develop a work related action plan as a condition of receiving the allowance.

3 The assessment process for deciding entitlement to benefit and rate of benefit paid is the Work Capability Assessment (WCA). The Work Capability Assessment replaces the Personal Capability Assessment (PCA) used to determine entitlement to Incapacity Benefit. Within the WCA, there are a number of assessments:

• Limited Capability for Work Related Activity (LCWRA) – This assessment aims to identify, through a series of descriptors, customers with the most severe illnesses or disabilities. These customers will identified as members of the Support Group of ESA and will not have to engage in work - focused interviews as a condition of receiving benefit.

• Limited Capability for Work Assessment (LCW) - This aims to identify those people who currently have a limited capability for work, but who would benefit from assistance and support with work and health related activity to maximise their full potential. This part resembles the PCA, but the descriptors have be reviewed and revised for both physical and mental functional capabilities. The report (ESA 85) generated from this part of the assessment will available to the DLA Decision Maker.

• Work Focused Health related Assessment (WFHRA) – This part comprises an interview with a healthcare professional to explore the customer’s views about moving into work and any health related interventions that would facilitate this.

Section 2 – The Work Capability Assessment 1 The Work Capability Assessment will be applied to all customers within the first thirteen weeks of claiming Employment and Support Allowance. It will assess, for the purposes of determining entitlement, whether a customer can be considered to have limited capability for work. It will also help determine the rate at which ESA is awarded from week fourteen.

2 The Work Capability Assessment looks at the effects of any illness or disability on the customer’s ability to carry out a range of everyday work related activities. The outcome of WCA determines if a person has limited capability for work. If a customer does not have limited capability for work they will be provided with advice about registering for employment and claiming other benefits.

3 The following Activities are evaluated in the assessment:

Physical assessment

4 There are eleven Activities relevant to the physical assessment:

• Walking with a walking stick or other aid if such aid is normally used; • Standing and sitting; • Bending or kneeling ; • Reaching; • Picking up and moving or transferring by the use of the upper body and

arms; • Manual dexterity; • Speech; • Hearing with a hearing aid or other aid if normally worn;

• Vision including visual activity and visual fields, in normal daylight or bright electric light, with glasses or other aid to vision if such aid is normally worn;

• Continence; and • Remaining conscious during waking moments.

Mental, cognitive and intellectual function assessment

5 There are ten Activities relevant to the mental, cognitive and intellectual function assessment:

• Learning or comprehension in the completion of tasks; • Awareness of hazards; • Memory and concentration; • Execution of tasks; • Initiating and sustaining personal action; • Coping with change; • Getting about; • Coping with social situations; • Propriety of behaviour with other people; and • Dealing with other people.

6 For each of the Physical and Mental Health Activities there is a set of statements ranked in order of functional restrictions known as the descriptors. They describe different levels of functional limitation.

7 Each descriptor that is relevant to a customer’s illness or disability has a score.

For example, Walking is defined as ‘Walking with a stick or other aid if such aid is normally used’ and there are six descriptors:-

• Cannot walk at all (score 15) • Cannot walk more than 50 metres on level ground without repeatedly

stopping or severe discomfort (score 15) • Cannot walk up or down two steps even with the support of a handrail

(score 15) • Cannot walk more than 100 metres on level ground without stopping or

severe discomfort (score 9) • Cannot walk more than 200 metres on level ground without stopping or

severe discomfort (score 5) • None of the above apply (score 0).

8 Getting about is an example of one of the Mental function Activities, and there are five descriptors:-

• Cannot get to any specified place with which the customer is, or • would be, familiar (score 15) • Is unable to get to a specified place with which the customer is

• familiar, without being accompanied by another person on each occasion (score15)

• For the majority of the time is unable to get to a specified place with • which the customer is familiar without being accompanied by another • person (score 9) • Is frequently unable to get to a specified place with which the • customer is familiar without being accompanied by another person

(score 6) • None of the above apply ( score 0)

Combinations of disabilities

9 Many people may have more than one disability. The assessment therefore includes a means of taking into account the combined effects of different disabilities. For example, if a customer could walk 50 metres or more but could not walk 200 metres without stopping or severe discomfort, this by itself would score 6. However, if they also had difficulties with ‘Manual dexterity’ such as cannot physically use a pen or pencil, this would score an additional 9. Any further score awarded in respect of functional limitation caused by a mental health disorder is added to reach the total. If a customer is awarded a score of 15 or more, they will be entitled to Employment and Support Allowance and be considered as having limited capability for work.

Section 3 - Overview of the Claim Process 1 In the majority of cases the initial claim for ESA is made via Jobcentre Plus by telephone. When someone becomes entitled to ESA they enter a thirteen week assessment phase. If it is apparent at this initial stage that the customer is terminally ill (Special Rules), benefit is paid without the need to undergo further assessment. Some other customers, for example, people receiving chemotherapy or regular haemodialysis, will also be considered as having limited capability for work without taking part in the full Work Capability Assessment.

2 If a customer is not identified as having limited capability for work or limited capability for work-related activity at the preliminary stage, they are asked to complete questionnaire ESA 50 providing details of their illnesses and functional limitations. The claim is assessed by Medical Services using evidence in the ESA 50 questionnaire, medical certification and any further medical evidence requested by Medical Services. Medical Services will determine if the person fulfills the criteria as having limited capability for work or entry into the Support Group of ESA (see below) without having to undergo further assessment including medical examination.

3 People eligible for inclusion in the Support Group are those who have the most severe illnesses and disabilities, including terminal illnesses. Customers fulfilling the criteria for the Support Group are treated as having limited capability for work and for work related activity. They are assessed in respect of eleven Activities, and Medical Services will advise the ESA DM on report

ESA 85A if at least one of the descriptors applies to the customer. The eleven Activities are:

• Walking or moving on level ground; • Rising from sitting and transferring from one seated position to another; • Picking up and moving or transferring by the use of the upper body and

arms; • Reaching; • Manual dexterity; • Continence; • Maintaining personal hygiene; • Eating and drinking • Personal action; and • Communication.

Full details of the Activities and the descriptors can be found in Appendix A.

4 Customers not in the Support Group or having LCW/LCWRA are called for assessment, when the medical examination is recorded on form ESA 85, and a WFHRA is carried out. The medical report ESA85 provides medical evidence and information that is likely to be useful to the DLA DM. It may, however, become apparent at this assessment that the customer has a severe illness or disability such that they fulfill the criteria for the Support Group, and the ESA DM is advised accordingly.

5 On the basis of the information in report ESA85 the Decision Maker determines whether the customer has limited capability for work. The customer is considered as having limited capability for work if he:

• scores 15 points in respect of the physical descriptors; or • 15 points in respect of the Mental Function descriptors; or • 15 points in respect of the descriptors in a combination of mental

function and physical descriptors).

In both the physical and mental function categories, the highest descriptors in any functional area attract 15 points and the lowest descriptors have a 6 point value. A customer may reach the prescribed degree of disability to be considered as having limited capability for work, if they are awarded the highest descriptor in any one physical or mental function category or through a combination of lower scoring descriptors in a number of functional areas.

6 Customers reaching the threshold for limited capability for work will be required to attend a series of six Work Focussed Interviews with their Personal Adviser at Jobcentre Plus. During these sessions an agreed action plan of activity will be drawn up to help the customer with a potential return to work.

Section 4 – Overview of how the Work Capability Assessment can be used in DLA

1 The medical report form ESA85 is completed as part of the assessment of the customer at the Medical Examination Centre. It contains valuable information including factual information about the medical condition and the customer’s functional limitations.

2 These include:

• Diagnoses; • Medication and any side effects; • History of condition; • Recent hospital treatment; • Description of daily activities and how these relate to function (typical

day interview); • Clinical findings; • Observed behaviour; and • Advice regarding functional limitations in the prescribed Activities.

The specific features of the ESA 85 report that are of greatest use to the DLA DM are described in detail in subsequent sections.

2 As explained in Section 3 above some customers with the most severe illnesses and disabilities that fulfil the criteria for inclusion in the Support Group may be identified at the medical examination. The ESA DM will be advised of this in an additional report ESA 85A, and this report may also be available to the DLA DM in a small number of cases. Its potential use to the DLA DM will be described later in this guidance.

Section 5 – What happens at the Medical Assessment Approved disability analyst

1 The medical assessment process as a whole differs in many respects from traditional history taking and examination that occurs in the general practice or hospital setting. It entails bringing together information gained from observation, questionnaire, medical evidence and examination in order to reach an accurate assessment of the customer’s functional restrictions. The assessment is carried out by an Approved Disability Analyst.

2 All health care professionals who give advice relating to Employment and Support Allowance must be approved by the Secretary of State for Work and Pensions. The approved disability analyst may be a registered medical practitioner, registered nurse, registered occupational therapist or registered physiotherapist. Approval involves attendance at a prescribed training course, written assessment of medical knowledge, successful completion of the stages of the approval process, and ongoing demonstration that the work being carried out meets a satisfactory standard including attendance at future professional educational events.

3 Examining Medical Practitioners who carry out DLA/AA assessments undergo a similar process of training and monitoring, and are approved as disability analysts by the DWP Secretary of State.

4 The approved disability analysts who undertake the WCA are employed by Medical Services. Their role is different from the clinical role of the GP or hospital specialist, which is to diagnose and treat the patient. The clinician is an expert in arriving at a diagnosis, using physical examination and special investigations in combination with detailed knowledge of treatments. Clinicians are not experts in assessment of disability, since they have not received training in determining the disabling effects of medical conditions on a person’s every day life and activities. See table at Appendix D.

5 The medical disability analyst provides the Decision Maker with justified advice that takes into account the clinical history, examination, observed behaviour and their knowledge of the disabling effects of the medical condition(s). The advice is consistent, evidence based and in accordance with the legislative criteria of the benefit.

6 There are four stages in the ESA LCW/LCWRA Assessment. These are:

• Reading the documents; • Interviewing the customer; • Examining the customer; and • Completing the medical report.

Reading the Documents

7 In preparation for the interview the disability analyst reads the documents in the file. All the medical evidence is considered, including medical certificates, factual reports, any previous examination and other documents, including Tribunal documents. Particular attention is paid to the current customer questionnaire (ESA 5O).

8 When the disability analyst has read the documents, he or she usually goes to meet the customer in the waiting room, and accompanies them from the waiting room to the interview/examination room. In addition to being a natural courtesy it helps to put the customer at ease, and allows the disability analyst to observe the customer’s activities outside the examination room. The disability analyst will observe how the customer rises from the chair, walks etc.

Interviewing the Customer

9 The nature of the interview differs materially from the traditional consultation in clinical practice. The aim of the traditional interview is to arrive at a diagnosis and treat the patient. In the LCW/LCWRA interview, the disability analyst gathers information to assess the claimant’s abilities in all of the relevant functional areas. A concise and relevant medical history is included.

10 One of the most important aspects of the interview is the Typical Day enquiry. This is a record of the customer’s everyday life including a factual description of how the medical condition affects their day-to-day activities. The disability analyst records the account in note form; it is not a statement. Experience shows that Decision Makers find this section of the report particularly helpful.

The examination

11 When the interview has been completed, the disability analyst seeks the customer‘s consent for physical examination of the relevant functional areas. The granting of this consent is noted in the report. Mental state examination and completion of the Mental Function assessment is carried out where there is evidence of mental disease or disablement (mental illness, learning disabilities, cognitive impairment or sedative medication).

12 Informal observations of the customer are also made during the entire period of customer contact and incorporated into the report. The disability analyst looks for consistency when evaluating the informal observations, the clinical examination findings, the clinical history, and the analyst’s knowledge of the disabling effects of the customer’s medical condition(s).

Completing the medical report form ESA 85

13 The disability analyst completes the medical report ESA 85 choosing and justifying the relevant descriptors. In the majority of claims a computerised version of the report using Logic integrated Medical Assessment (LiMA) is provided for the Decision Maker.

14 Where the disability analyst’s choice of descriptor differs from the customer's stated level of disability, the disability analyst provides justified advice to the Decision Maker supported by the evidence to explain why their opinion, rather than the customer's, should be accepted.

15 If the customer has a severe illness or disability such that they fulfil the criteria for inclusion in the Support Group both the examination and the report completion may be curtailed. Additional information is then provided on form ESA 85A – see Section 16.

16 Report completion may also be curtailed if the customer has high levels of functional restriction in a number of areas i.e. the highest-ranking descriptors are applicable for a number of Activities. Under these circumstances LiMA invites the author to provide the most detailed justification in the most highly scoring activities, and less information is provided about other Activities.

17 The time spent with the customer is recorded on the report, and includes the time from greeting the customer in the waiting room until the end of the interview and examination. The additional time that it takes to complete the report is recorded. The time spent on the medical assessment will depend on

the complexity of the case. It is estimated that the overall time to complete the WCA will be between 75 and 90 minutes.

Section 6 - Choosing descriptors 1 The disability analyst selects their choice of descriptor in each of 11 physical functional areas (Activities), and if relevant to the case, in each of 10 mental function areas.

2 The choice of the most appropriate descriptor in the relevant functional areas depends upon consideration of all the medical evidence, the customer interview, the medical examination, and the disability analyst’s medical knowledge of the likely effects of the disabling condition.

3 For each of the mental, physical and sensory functional areas (Activities) the disability analyst chooses only one descriptor, and this is the descriptor, which reflects the customer's level of functioning most of the time, taking into account such factors as pain, stiffness, response to treatment and variability of symptoms. This ensures that the opinion is not just a "snapshot" of the customer on the day of examination, but reflects their functional ability over a period of time. See below for more detail.

4 In certain functional areas, the descriptors do not conform to a simple hierarchical progression. In these areas the descriptor chosen is that which most accurately reflects the highest level of disability experienced by the claimant. For example, in the functional area of Continence, when a customer loses control of bladder so that the person cannot control the full voiding of the bladder at least once a month and loses control of bowels so that the person cannot control the full evacuation of the bowel occasionally, the latter is selected, as it is the “higher” descriptor.

5 If the disability analyst‘s opinion on the level of functional restriction in any Activity differs from that of the customer, as indicated on the ESA 50 questionnaire or as described at interview, the disability analyst provides a full justification for their opinion. The justification of descriptor choice is supported by information from the clinical history, activities of daily living, observation of the customer, and clinical examination findings.

6 A number of functional activity areas on the ESA 85 are linked e.g. walking, standing and sitting, and bending and kneeling, and justification for these group of functional areas are entered together in the appropriate boxes. Clinical details may be cross-referred to other relevant linked groups. Evidence should be consistent so that contradictions do not in different sections of the report. Any apparent contradictions are explained such that the Decision Maker is able to understand that two pieces of evidence, which at first sight appear contradictory, are in fact compatible with one another.

7 On occasions the disability analyst will choose a "None of the above apply” descriptor, even though some disability has been identified. In these

circumstances the level of functional restriction is not severe enough to reach the lower threshold; i.e. the penultimate descriptor. For example, the customer may have indicated that they have difficulty with walking, but the evidence from the assessment shows they only experience significant discomfort after walking at a reasonable pace for 20 minutes (i.e. they can manage over 800 m).

Section 7 - Variable and fluctuating conditions 1 The disability analyst is required to provide the Decision Maker with medical advice on the most appropriate level of functional ability in each Activity. In doing so they must take into account a number of factors including:

• Any fluctuations in the medical condition i.e. how the condition changes with time.

• The variation of functional ability i.e. how the person's functional ability changes over time and in relation to changes in the underlying medical condition.

• Any pain that results from performing the activity. • The ability to repeat the activity. • The ability to perform the activity safely.

2 The disability analyst’s choice of descriptors reflects what the person is capable of doing for most of the time. In other words, could the person normally carry out the stated activity when called upon to do so?

3 For conditions that vary from day to day a reasonable approach would be to choose the functional descriptors, which apply, for the majority of the days. (N.B some of the Mental Function descriptors specify frequency of limitation and are considered individually).

4 In some cases the disability analyst has to consider whether the claimed level of disability on 'good' and 'bad' days is likely to be consistent with the clinical picture presented, the diagnosis and the overall pattern of daily activity. The disability analyst provides the DM with advice on:

• The customer's functional limitations on the majority of the days. • The limitations found on the remaining days where the customer’s

condition is worse or better, with an indication of the frequency with which these days arise.

5 For conditions that vary through the day the choice of descriptor should reflect that level of activity, which can be performed for a reasonable continuous period within the day.

6 If a person cannot repeat an Activity with a reasonable degree of regularity, and certainly if they can perform the Activity only once, then they are considered unable to perform that Activity.

7 The customer must be able to undertake the Activity safely. If a person with vertigo is physically able to bend to touch his knees but in so doing falls over due to giddiness, then he is considered incapable of performing that Activity.

8 The Activities do not have to be performed without any discomfort or pain. However if the customer cannot perform an Activity effectively because of pain they are considered incapable of performing that Activity.

9 When considering the effects of pain, the predictability of onset and the effectiveness of treatment are taken into account. Pain that starts without warning and requires analgesia is very different from predictable angina of effort that can be forestalled, or rapidly relieved, with appropriate treatment (e.g. GTN spray).

10 Breathlessness is an important symptom, because it is not specifically reflected in many of the descriptors, but it may contribute significantly to disability, for example, in relation to walking. Therefore, a customer who experiences significant breathlessness when carrying out an activity should be scored as if the activity cannot be undertaken.

11 The disability analyst will advise on the consistency of the variable factors with the diagnosis and with the stage reached by the disease, and with the customer’s lifestyle. For example, the medical certification says the customer has mechanical back pain, and on examination there is no lumbar spine abnormality. The customer says that on one day a week his back is so bad that he has to stay in bed. This degree of variability is very unlikely; mechanical back pain does not normally vary to this extent.

Section 8 - Physical and Sensory Activities Eleven specified physical Activities are assessed. These are grouped together as follows:

Lower Limb – Activities 1, 2 and 3

• Walking; • Standing and sitting; and • Bending and kneeling.

Upper Limb - Activities 4, 5 and 6

• Reaching; • Picking up and moving or transferring by the use of the upper body and

arms; and • Manual dexterity.

Special functions – Activities 7, 8 and 9

• Vision; • Speech; and • Hearing.

Continence – Activities 10 (a), 10 (b) and 10 (c)

Remaining conscious – Activity 11

Section 9 - Mental Health Activities 1 This part of the ESA 85 report is completed when a specific mental disorder has been diagnosed, or where there is any condition, that could be mental, physical or sensory, that results in the cognitive or intellectual impairment. In addition the assessment is undertaken in the following circumstances:

• where the customer is taking any medication which affects cognitive abilities to a degree that causes mental impairment;

• where there is evidence of an alcohol /drug dependency problem which has resulted in mental impairment;

• where there is evidence of a physical or sensory disability such as tinnitus or chronic fatigue that may impact on mental function;

• where there is evidence of learning disability; • where there is evidence of acquired brain injury; and • where there is a previously unidentified mild or moderate mental

function problem identified during the LCW/LCWRA assessment.

2 If the disability analyst does not consider that it is necessary to apply the mental function assessment, they are required to justify this. This is likely to be the case where there is no recent history of diagnosis or treatment of mental illness, and where there is no evidence at the assessment of any condition, diagnosed or apparent, that is likely to impair mental function.

3 There are ten Activities (functional categories) that are addressed in the ESA LCW/LCWRA mental assessment. These categories cover a number of areas relevant to those with a specific mental illness, or cognitive or intellectual impairment. These categories are grouped together in the ESA 85 report as follows:-

Understanding and focus (Activities 12, 13, 14, 15 and 16)

• Learning or comprehension in the completion of tasks; • Awareness of hazard; • Memory and concentration; • Execution of tasks; and • Initiating and sustaining personal action.

Adapting to change (Activities 17, 18 and 19)

• Coping with change;

• Getting about; and • Coping with social situations.

Social Interaction (Activities 20 and 21)

• Propriety of behaviour with other people; and • Dealing with other people.

4 In the ESA 85 report a structured Mental State Examination is provided by the disability analyst from which he or she draws evidence to support their choice of descriptors. Information is recorded under the following headings:

• Appearance; • Behaviour/volition; • Conversation; • Cognition – general; • Cognitive tests – informal; • Cognitive tests – formal; • Insight; • Addictions; and • Involuntary movements.

Section 10 – Differences between IB 85 and ESA 85 1 As described at the beginning of this guidance the WCA has been designed to focus on a person’s capabilities with an emphasis on what they can do rather than what they cannot. Both the physical and mental Activities have modified so that they reflect the type of work related activities relevant to the modern work place. The physical Activities recorded in the IB 85 have been extensively revised for ESA. Changes include removal of some Activities, amalgamation of others, inclusion of new descriptors and revision and deletion of existing descriptors. The descriptor scores have also been revised to reflect the aims of the new assessment and benefit.

2The table at Appendix B summarises the main differences in the physical assessment between the ESA 85 report and the IB 85.

3 The mental health questionnaire found in the IB 85 has been replaced by the new ESA mental function assessment. There are no longer 25 descriptors presented as a series of questions requiring a yes or no answer. In the ESA 85 there are 10 new mental function Activities, each of which has a number of ranked descriptors. This mirrors the format of the physical assessment, and the disability analyst chooses a descriptor for each Activity, and the descriptor is scored.

Section 11 –The ESA 85 report and its relevance to the DLA Decision Maker

The information in the ESA 85 presented under the following headings:

1 A list of medical conditions, previously diagnosed, found at the medical assessment or reported by the customer.

2 Medication, dosage and the reasons for its use.

3 Side effects of the medication as reported by the customer with the disability analyst’s comment on their functional relevance.

4 History of the medical conditions and how they affect function.

5 Record of any hospital treatment and tests within the last yea.r

6 History of any specific therapy for mental health problems with the past 3 months.

7 Social and occupational history including the reason for leaving work.

8 Description of a typical day.

9 Medical opinion – Physical. This section records the disability analyst’s choice of descriptors for the eleven physical functional areas (Activities). The Activities are grouped together under a number of headings i.e. Lower limb, Upper limb, Special senses, Continence and Remaining Conscious. Within each of these groupings the medical evidence used to justify the choice of descriptor for each Activity is presented under four sub-headings:

• Prominent features of functional activity relevant to daily living; • Behaviour observed during assessment; • Relevant features of clinical examination; and • Summary of functional ability.

10 Mental Function - the disability analyst indicates if the mental function assessment has been applied. If not, an explanation why it has not been applied is recorded.

11 Medical opinion – Mental function. This section records the disability analyst’s choice of descriptors for the ten mental functional areas (Activities). The Activities are grouped together under three headings i.e. Understanding and focus, Adapting to change and Social Interaction. Within each of these groupings the medical evidence used to justify the choice of descriptor for each Activity is presented under three sub-headings:

• Prominent features of functional activity relevant to daily living; • Relevant features of clinical examination and • Summary of functional ability.

12 Advice on Exceptional Circumstances (also known as non-functional descriptors). These relate to a small number of severe medical conditions that

do not result in a score that is sufficient to reach the benefit threshold of 15, but would render the customer unfit for work. Since such cases do not usually have significant functional restrictions, it is unlikely that the information pertaining to this category will be of direct relevance to the DLA DM.

13 Limited Capability for Work Related Activities. In this section the disability analyst gives an opinion as to why the customer does not meet any of the descriptors for the Limited Capability for Work- Related Activity. i.e. fulfill the Support Group criteria. This is the most likely outcome in the majority of cases, and this information is not likely to be of direct use to the DLA DM.

14 In a small number of cases additional information will be available on report ESA 85A for customers who meet the criteria for the Support Group. This information may be useful to the DLA DM and this is discussed below in section 16.

15 Advice on prognosis (when likely to be a significant improvement in function)

16 Summary of medical examination findings (physical and/or mental).

Section 12 – The Physical Assessment and its use in DLA In this section detailed information about each of the Physical Activities and the ranked descriptors is provided. An explanation of the scope of each Activity is combined with notes about the type of specific evidence that the disability analyst takes into account in making their descriptor choice. For each Activity additional guidance on how the ESA 85 report may be used to evaluate care and mobility (DLA considerations) is provided.

Lower Limb function

• walking

• standing and sitting

• bending and kneeling

Upper Limb

• reaching

• picking up

• manual dexterity

Sensory

• speech

• hearing

• vision

Continence

Remaining conscious

Walking - Activity 1

Walking with a walking stick or other aid if such aid is normally used.

Descriptors

W (a) Cannot walk at all

.

W (b) Cannot walk more than 50 metres on level ground without repeatedly stopping or severe discomfort.

W(c) Cannot walk up or down two steps even with the support of a handrail

W (d) Cannot walk more than 100 metres on level ground without stopping or severe discomfort.

W (e) Cannot walk more than 200 metres on level ground without stopping or severe discomfort.

W (f) None of the above apply.

Scope

1 This Activity 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 intended mainly to apply to lower limbs impairments; however walking ability may also be restricted by limited exercise tolerance due to respiratory or cardiovascular disease. Conditions affecting upper limb function i.e. ability to use a stick, are not taken into consideration.

2 Walking is bipedal locomotion, that is, movement achieved by bearing weight first on one leg and then the other. Those who are wheelchair dependant or can only swing through on crutches do not fulfil this definition, and therefore fall within descriptor W (a).

3 When estimating the distances over which a customer can walk, the disability analyst takes account of brief pauses made out of choice rather than

necessity. The end point is when the customer cannot reasonably proceed further because of substantial pain, discomfort, or distress.

4 Descriptor W(c) also reflects a severe limitation of stair climbing. This may be caused by severe lower limb impairments 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 are 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

5 The disability analyst notes any restrictions due to breathlessness or angina, as well as any relevant musculoskeletal problems. If a particular descriptor activity could only be performed by inducing significant breathlessness or distress, a higher descriptor is chosen.

6 Walking may occasionally also be affected by disturbances of balance due to for example, dizziness or vertigo. The effects of any such condition will be noted and full details given in the medical report.

Details of daily living

7 The disability analyst considers the customer's walking ability in relation to:

• Mobility around the home; and • Shopping trips, exercising pets.

8 The report may include details of distances walked and how long it takes the customer to walk any particular distance; whether the customer needs to stop, and if so how often, and for how long? 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.

9 The method of travel to the examination centre is relevant. The disability analyst is likely, from local knowledge, to be aware of the distance from the bus station to the examination centre and may record the distance, time taken, the number of rests required, and the lengths of the rest periods.

Observed behaviour

10 The disability analyst observes the customer walking from the waiting area to the examination room, and notes their gait, pace and any problem with balance. They will look for evidence of breathlessness caused by walking.

11 The disability analyst notes the use of any aids e.g. walking stick, and whether their use was appropriate. They also record any assistance needed from another person.

Clinical examination

12 Restricted ability to walk will commonly be due to musculoskeletal and neurological disorders affecting the lower limbs, and sometimes the lumbar spine. Restrictions may also be due to diseases of the respiratory or cardiovascular systems, with limitation of exercise tolerance as a result of breathlessness, angina or claudication.

13 Where relevant, an appropriate assessment of the heart and lungs is carried out, with a record of any cyanosis, dyspnoea at rest or on minimal exertion, the presence of audible wheeze, signs of heart failure such as ankle oedema, and the state of peripheral blood vessels. Any respiratory or cardiovascular factors affecting exercise tolerance are taken into account when choosing the descriptor.

14 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 also be made.

DLA considerations

15 If one of the first three descriptors is chosen i.e.

W (a) Cannot walk at all.

W (b) Cannot walk more than 50 metres on level ground without repeatedly stopping or severe discomfort.

W(c) Cannot walk up or down two steps even with the support of a handrail

it is likely that there is significant walking restriction. This will also indicate that the person has difficulty in using stairs.

16 If descriptor W (d) is chosen Cannot walk more than 100 metres on level ground without stopping or severe discomfort, it is unlikely that the person is restricted in their walking to a lesser distance. If the disability analyst judged that the person could only walk 75 metres, they would chose the higher descriptor W(b)

17 Note that in evaluating this Activity the disability analyst takes into account factors such as pain, fatigue, balance, gait, ability to walk at a reasonable speed and breathlessness. If the person has severe breathlessness due to cardiac or respiratory diseases this will be reflected in the descriptor choice, even if lower limb function is normal.

18 The descriptor choice will be supported by the disability analyst’s own observation of the person walking at the examination centre, and the account of their daily activities. It is worth noting that a person who can easily manage around the house and garden is unlikely to be limited to walking less than 200

metres; a person who can walk around a shopping centre/supermarket is unlikely to be limited to walking less than 800 metres.

Standing and sitting – Activity 2

Descriptors

S (a) Cannot stand for more than 10 minutes, unassisted by another person, even if free to move around, before needing to sit down.

S (b) Cannot sit in a chair with a high back and no arms for more than 10 minutes before needing to move from the chair because the degree of discomfort experienced makes it impossible to continue sitting.

S(c) Cannot rise to standing from sitting in an upright chair without physical assistance from another person.

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

S (e) Cannot stand for more than 30 minutes, even if free to move around, before needing to sit down.

S (f) Cannot sit in a chair with a high back and no arms for more than 30 minutes without needing to move from the chair because the degree of discomfort experienced makes it impossible to continue sitting.

S (g) None of the above apply.

Scope

1 This Activity relates to lower limb and back function. It is intended to reflect the need to be able to remain in one place, either sitting or standing. When standing, a person would not be expected to have a need to stand absolutely still, but would have freedom to move around or shift position whilst standing.

S (d) “Moving between adjacent seated positions” is intended to reflect a wheelchair user who is unable to transfer, without help, from the wheelchair.

Sitting

2 When considering sitting the following are taken into account:

• Sitting involves the ability to maintain the position of the trunk without support from the arms of a chair or 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 their related musculature.

Details of daily living

3 The disability analyst considers the customer’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

4 The disability analyst records the customer's ability to sit without apparent discomfort within the examination centre, both in the waiting area and during the interview, where this has been observed. The record should state the type of chair.

Standing

5 When considering standing, it should be noted that descriptor S(a) reflects the ability to stand without the support of another person. This reflects a very significant level of disability in relation to standing.

6 S (e) reflects the ability to stand even with the use of aids. The ESA regulations specify “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”. So a person who can stand with the aid of two sticks is, for the purpose of descriptor choice, able to stand.

7 The requirement to sit down suggests a greater degree of disability than simple discomfort resulting in a need to move around. It would normally be expected that significant lower limb problems and muscle weakness would be present

Details of activities of daily living

8 The disability analyst considers the customer’s ability in relation to:

• 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.

The report should include comments on the length of time the customer stands during any such activities.

Observed behaviour

9 It is usually only possible to observe the customer standing for short periods of time during the assessment and the report should reflect this, 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 the clinical examination recorded, 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."

10 Some customers prefer to stand throughout the interview and this should be recorded.

Rising and Transferring

11 When considering the ability to rise from sitting to standing, the descriptor only applies when the customer is unable to rise from sitting without the assistance of another person. If they could rise using the arms of the chair or other appropriate aid this descriptor would not apply. The descriptor would be consistent with severe lower limb problems and muscle wasting. The functions of the major leg joints have more relevance than lower spinal function to this activity, since rising can be achieved without spinal flexion.

12 Similarly, the inability to transfer between one seated position and another indicates 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 (however they may well satisfy the higher standing descriptor depending on degree of lower limb weakness).

Details of activities of daily living

13 The disability analyst considers the customer's ability in relation to:

• 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.

Observed behaviour

14 The disability analyst observes the customer’s ability to rise from sitting and notes the type of chair, when the person is collected from the waiting area. There is a further opportunity to observe this function during and at the end of the interview.

Clinical examination

15 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 indicate that there should be evidence of positive clinical findings in the majority of cases. Normal functional ranges of movement for rising are considered. Evidence of muscle wasting and reduced power in the lower limbs are important clinical findings.

16 Upper limb function is 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.

DLA Considerations

17 The Activity provides information about the ability to stand, to rise from a chair, to transfer and to sit comfortably. Consideration of the descriptor chosen will be useful to the DM when determining the help needed with getting in and out of bed, use of bath/shower, rising from a chair, using the toilet and preparing a meal.

18 The ability to stand is covered by the two descriptors:-

S (a) Cannot stand for more than 10 minutes, unassisted by another person, even if free to move around, before needing to sit down.

S (e) Cannot stand for more than 30 minutes, even if free to move around, before needing to sit down.

19 Musculoskeletal and neurological conditions affecting the lower limbs may limit the ability to stand. Someone who cannot stand unassisted for more than 10 minutes S (a) is likely to need help with bathing, getting in and out of bed, the toilet and may need with help with cooking. People who cannot stand for more than 30 minutes are likely to more independent in respect of these care needs. Corroboration of a person’s ability to stand will be found in the record of daily activities e.g. waiting for the bus, queuing at the supermarket check out, waiting for children outside school.

20 Descriptor S (d) Cannot move between one seated position and another seated position located next to one another without receiving

physical assistance from another person is relevant to a wheelchair user who cannot transfer unaided.

21 People who require assistance to rise from a chair will be covered in the report

by descriptor S (c) Cannot rise to standing from sitting in an upright chair without physical assistance from another person. Note that this refers to an upright chair without arms. At the medical assessment the disability analyst will have had the opportunity to observe the person getting up from a chair in the waiting room and examination room. In the typical day account there may also be reference to the person’s ability to get in and out of a car, to use the toilet and the bath.

22 The ability to sit comfortably (descriptors S (b) and S (e)) are of less relevance to the need for care, and are more applicable to the person’s ability to perform work related activities.

Bending and kneeling - Activity 3

Descriptors

B (a) Cannot bend to touch knees and straighten up again.

B(b) Cannot bend, kneel or squat, as if to pick a light object, such as a piece of paper, situated 15cm from the floor on a low shelf, and to move it and straighten up again without the help of another person.

B(c) Cannot bend, kneel or squat, as if to pick a light object off the floor and straighten up again without the help of another person.

B (d) None of the above apply

Scope

1 This Activity relates to lower limb and back function. It is intended to reflect ability to reach a low level such as a low shelf, or the floor, using supports such as furniture if needed, but without dependence on another person for support to straighten up again.

2 “As if to pick up an object” does not include the ability to manipulate the object or the ability to lift weights (these capabilities are covered in other areas relating to upper limb function).

3 Descriptor B (a) implies a very severe condition, with both lumbar spine and hip movements severely reduced, or restricted by pain. This activity is very different from the one involved in descriptors B (b) and B(c). These descriptors consider the activity of bending and/or kneeling as if to pick something off the floor or a low shelf which involves a combination of flexing

the lumbar spine, flexing the hip joints, and bending the knees to a squatting position.

Details of activities of daily living

4 The disability analyst considers the customer’s ability in relation to:

• Dressing and undressing especially footwear; • Getting in and out of the bath; • Bending to reach the oven, front loading washing machine, low

cupboards or shelves; • Hanging laundry to dry; and • Carrying out household cleaning chores.

Bending to tend to babies and toddlers may also be relevant as may leisure and recreational activities involving bending e.g. gardening, tending to pets.

Observed behaviour

5 The record should obtain observations about general mobility. Functional knee and hip movement are important for this task and may be observed while the customer is seated at interview. While it is not appropriate to directly observe the claimant undressing/dressing the record may note the time taken and any help requested with certain items of clothing particularly shoes.

6 The disability analyst will observe the customer’s ability to climb on and off the couch.

7 It may be possible to observe the customer pick up an item such as a handbag or shopping bag from the floor of the examination room.

Clinical examination

8 Restriction of spinal movement to the degree indicated by B (a) suggests a severe spinal problem. Clinical examination should be consistent with this. There may be evidence of muscle wasting. For B (b) or B(c) to apply, examination would confirm the presence of significant pathology in both knees and hips. In some neurological conditions an assessment of balance including tests of cerebellar or proprioceptive function may be recorded. Assessment of power in the lower limbs is essential.

DLA Considerations

9 Consideration of the descriptor chosen will be useful to the DM in determining the help needed with dressing, getting in and out of bed, bathing, rising from chair. The customer whose restriction in bending and kneeling is described by B (a) or B (b) is likely to need assistance with personal care.

10 A person with lumbar back pain who has good hip and knee function would be expected to be able to bend to an oven safely, since they would not rely solely on bending their lower back to reach the oven.

Reaching - Activity 4

Descriptors

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

R (b) Cannot put either arm behind back as if to put on a coat or jacket.

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

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

R (e) None of the above apply.

Scope

1 Ability to undertake these activities is determined by shoulder function and/or elbow function. It is intended to reflect the ability to raise the upper limbs to a level above waist height.

2This functional category considers the customer’s ability to reach upwards. It is an evaluation of power, co-ordination, and joint mobility in the upper limbs.

3 All the descriptors apply to people who have functional restriction affecting both upper limbs i.e. they must have bilateral impairment.

4 It takes into account the ability to achieve the described reaching posture and does not measure hand function, i.e. it is not necessary for the customer to adjust the hat if he can achieve the reaching movement defined in Descriptor R(c) "Cannot raise either arm to top of head as if to put on a hat".

Details of activity of daily living

5 The disability analyst considers the customer’s ability in relation to:

• 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

6 The disability analyst records any spontaneous movements of the upper limbs, particularly if these are in excess of those elicited by formal examination.

7 The ease (or otherwise) with which a coat or jacket is removed and subsequently replaced may be observed. It may be apparent that a stiff or painful shoulder restricts function.

8 The customer may also hang up a coat or a jacket allowing observation of spontaneous shoulder and arm action.

Examination

9 The examination shows whether the restriction in reaching is unilateral or bilateral. If unilateral, the report will state which side is affected and record normal function in the opposite limb.

DLA considerations

10 Cases in which any of the descriptors R (a) to R (d) have been chosen are likely to have severe bilateral joint conditions or neurological disorders affecting function e.g. rheumatoid arthritis, tetraplegia, muscular dystrophy. This information will be useful to the DM when considering the need for help with dressing, washing, feeding etc., and will be supported by observations of upper limb use in the examination centre, and an account of relevant daily living activities such as ability to dress, wash hair, shave, do household tasks, drive etc.

11 The Activity does not apply to someone who can reach with one arm only, whether the dominant arm or not. However if a person has a condition that affects reaching in one upper limb only, this will be documented in the report. Clinical findings will be recorded for both the impaired and the normal limb, and the disability analyst’s opinion in respect of the function in each will be supported in the usual manner by the observations and the person’s ability to perform daily tasks. The information is likely to be of value to the DM when considering the need for help with personal care.

Picking up or moving or transferring objects by use of the upper body and arms – Activity 5

Descriptors

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

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

P(c) Cannot pick up and move a light but bulky object, such as an empty cardboard box, requiring the use of both hands together.

P (d) None of the above apply.

Scope

1 This Activity relates mainly to upper limb power, however joint function and co-ordination of movement are also 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 (these capabilities are covered in other areas). 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. Note that the descriptors apply to people who have functional restriction affecting both upper limbs.

2 All the loads are light and are therefore unlikely to have much impact on spinal problems. However, consideration is given to neck pain and the associated problems arising from cervical disc prolapse and marked cervical spondylitis (arthritis). These conditions may be aggravated by lifting weights in exceptional circumstances.

3 The ability to carry out these functions is considered with the use of any prosthesis, aid or appliance.

Details of activities of Daily Living

4 The disability analyst considers the customer’s ability in relation to:

• 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; and • Removing a pizza from the oven/ carrying a pizza box.

Observed behaviour

5 The disability analyst observes hand, arm and head gestures. They note the ease (or otherwise) with which any coat or jacket is removed and replaced.

6 The customer may hang up a coat or a jacket allowing observation of upper limb function.

7 The customer may lift their handbag or shopping bag several times during the interview process.

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

Examination

9 The report contains information about joint movement and power in the limbs. Reduced co-ordination or other neurological problems such as tremor e.g. Parkinson’s disease, is assessed when considering these activities.

DLA Considerations

10 The information in the report will applicable to care needs in respect of dressing, washing, feeding, preparing a meal etc. The choice of descriptors P (a) to P(c) is likely to be made in customers who have severe bilateral joint conditions such as rheumatoid arthritis or neurological disorders such as multiple sclerosis, Parkinson’s disease.

11 The Activity does not apply to someone who can pick up or transfer with one arm only, whether the dominant arm or not. However if a person has a condition that affects one upper limb only e.g. stroke, this will be documented in the report. Clinical findings will be recorded for both the impaired and the normal limb, and the disability analyst’s opinion in respect of the function in each will be supported in the usual manner by the observations and the person’s ability to perform daily tasks. The information about the impaired limb is likely to be of value to the DM when evaluating the need for help with personal care.

Manual Dexterity - Activity 6

Descriptors

M (a) Cannot turn a “star-headed” sink tap with either hand.

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

M(c) Cannot turn the pages of a book with either hand.

M (d) Cannot physically use a pen or pencil

M (e) Cannot physically use a conventional keyboard or mouse

M (f) Cannot do up / undo small buttons, such as shirt or blouse buttons.

M (g) Cannot turn a “star-headed” sink tap with one hand but can with the other.

M (h) Cannot pick up a £1 coin or equivalent with one hand but can with the other

M (i) Cannot pour from an open 0.5 litre carton full of liquid

M (j) None of the above apply

Scope

1 This Activity relates to hand and wrist functions. It is intended to reflect the level of ability to manipulate objects that a person would need in order to carry out work-related 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. It does not reflect a person’s level of literacy. The same concept applies to use of a computer keyboard/mouse.

2 The efficiency of hand function is considered in relation to the other limb, i.e., it should not be accepted that one limb can complete a task when this can only be accomplished with the support of the other limb. For example, the customer whose right-arm is in a plaster cast where they can only complete tasks by supporting it with the left arm.

3 "Either" hand in M (a), M (b) or M(c) means they cannot carry out the action with their right hand and they cannot do it with their left hand.

4 An individual in a forearm plaster may still have good movements of their hands but the level of pain experienced should be taken into account when choosing a descriptor, e.g. an individual with a fractured wrist may have good fine movements of their hand but turning a star headed sink tap would cause severe pain in their wrist.

Details of Activities of daily living

5 The disability analyst considers the customer's ability in relation to:

• Filling in forms (e.g. ESA50, national lottery ticket); • Coping with buttons, zips, and hooks on clothing; • Cooking (opening jars and bottles; washing and peeling vegetables);

and • Leisure activities such as reading books and newspapers, doing

crosswords, knitting, manipulating the petrol cap to refuel a car.

Observed behaviour

6 The disability analyst may have the opportunity to observe how the customer handles tablet bottles, their expenses sheet or a repeat prescription sheet. They may also be observed lifting objects such as a pen or handling a newspaper. Fine movements may be seen if the person adjusts their hair,

scratches their head or removes spectacles. They may also adjust their watch or unbutton a shirt cuff for examination.

Examination

7 The disability analyst tests grip and the ability to perform pincer movements and opposition of the thumb.

8 The report will show whether the problem is unilateral or bilateral. Where the problem is unilateral, the record will state which side is impaired and comment on the normal function of the other limb.

DLA Considerations

9 Descriptors M(a), M(b) and M(c) relate to impairment affecting both limbs and are likely to reflect severe functional limitation in conditions such as rheumatoid arthritis, multiple sclerosis, motor neurone disease. Information about manual dexterity is valuable to the DM in respect of dressing, washing, managing at the toilet, feeding, preparing food. How the person manages these types of activities on a daily basis will be included in the typical day account. For example, the ability to prepare a snack or to load a dishwasher mirrors the tasks undertaken in preparing a meal.

10 Descriptors M (d) to M (i) relate to unilateral impairment only and cover a much wider range of medical conditions including arthritis, stroke, chronic regional pain syndrome etc.

Speech - Activity 7

Descriptors

Sp (a) Cannot speak at all

Sp (b) Speech cannot be understood by strangers

Sp(c) Strangers have great difficulty understanding speech

Sp (d) Strangers have some difficulty understanding speech

Sp (e) None of the above apply.

Scope

1 This Activity relates to ability to communicate through speech. It assumes use of the same language as the person with whom communication is being attempted. The intention is that it would include impediment to communication resulting from a severe stammer, but not impediment from speaking with a local or regional accent. It includes impediment to communication due to

expressive dysphasia (inability to express one’s thoughts) resulting from brain injury.

2 Note that the term "strangers" means persons who do not know the claimant, but speak in the same language using a similar accent.

3 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.

4 Speech problems may occasionally be claimed such that speech is affected in cases of Chronic Fatigue Syndrome, where the customer asserts that speech becomes unclear when they are tired. A similar claim may be made by customers suffering from panic attacks, who describe difficulty in making themselves understood during an episode of acute anxiety. It may be the case that such customers should be assessed under the mental function Activities. The disability analyst considers their ability to make themselves understood most of the time.

5 Some customers 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, like walking quickly or climbing stairs. Therefore, for the majority of the time, they will have normal speech.

Details of activities of daily living

6 The disability analyst considers the customer's ability in relation to:

• socialising with family and friends; • activities such as shopping, or travelling on public transport; and • use of the telephone.

Observed behaviour

7 The disability analyst describes the quality of speech at interview and any difficulty they have in understanding the customer. The report will detail any abnormalities of the mouth and larynx and their effects on speech.

Hearing – Activity 8

Hearing is assessed with a hearing aid or other aid if normally worn

Descriptors

H (a) Cannot hear at all

H (b) Cannot hear well enough to be able to hear someone talking in a loud voice in a quiet room, sufficiently clearly to distinguish the words being spoken

H(c) Cannot hear someone talking in a normal voice in a quiet room, sufficiently clearly to distinguish the words being spoken

H (d) Cannot hear someone talking in a loud voice in a busy street, sufficiently clearly to distinguish the words being spoken

H (e) None of the above apply

Scope

1 This Activity relates to the ability to hear speech sufficiently clearly to be able to follow a conversation. It is intended to take into account hearing aids if normally worn, but not non-verbal means of communication such as lip reading or use of sign language.

2 Descriptor H(a) is intended for the person who cannot hear sound even when maximum volume is used, implying a very severe degree of hearing loss, which will only apply in exceptional cases e.g. with a binaural hearing threshold above 90db.

3 A "busy street" does not mean one rendered intolerably noisy by exceptional machinery such as a juggernaut or earth-moving equipment. None of us would be able to hold a conversation under such circumstances. It is however commonplace for pedestrians to talk to each other while busy traffic passes by. The assessment will consider whether the customer could hold such a conversation under these circumstances, or whether hearing is so diminished that background traffic noise would render conversation impossible.

4 The report will show whether deafness is unilateral or bilateral as stated by the customer, and how it affects them.

5 The report will describe the person’s ability to wear a hearing aid. If the person is unable to use the prescribed hearing aid, the report will show the state the reason why. A customer who has been inconvenienced by a hearing aid and has abandoned its use should be assessed without aids.

6 It should be remembered that hearing aids can cause distortion of sound and do not restore ‘normal’ hearing to people with hearing impairments. Older people may have difficulties adapting to hearing aid use.

7 The report will provide examples of how a person with hearing impairment communicate in day to day life with family, out shopping, travelling by public transport etc. People with severe hearing impairment who use British Sign Language may attend for assessment. In these circumstances the disability analyst is asked to enquire, via their interpreter, about their ability to

communicate when out e.g. by writing a request such where do I catch the bus to X?

8 For further information on associated problems such as tinnitus, and Meniere's disease, see the end of this section.

Details of activities of daily living

9 Significant deafness is such a disadvantage that the customer would be expected to readily impart details of social isolation and domestic difficulties, such as problems encountered in communication in shops or on family occasions, inability to continue particular hobbies e.g. going to the cinema or theatre, playing bridge or bingo.

10 The report will describe 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.

11 In claimants with profound deafness who communicate through British Sign Language (BSL), enquiries should have been made via the interpreter with regard to the standard of BSL that they achieve and how they communicate in shops, pubs; for example, whether they write a list to hand to the bar tender.

Observed behaviour

12 The customer’s response to an ordinary or quiet voice during interview is a good measure of their ability to hear.

13 Very deaf customers 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 the examiner to raise their voice and repeat questions.

Examination

14 The most relevant examination technique is the conversational voice test. One ear is masked with the customer’s hand and the customer looks away from the examiner. The customer 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.

15 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.

16 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 provide opportunity to detect unreliable responses suggestive of non-organic hearing loss.

Tinnitus

17 Tinnitus the perception of sound where there is no external stimulus. It is often described as a high-pitched buzzing noise in one or both ears.

18 The use of hearing aids can, by recruitment of background noises, help to mask tinnitus. Customers 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.

19 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 aid; • The need for night sedation; and • The prescription of anti-depressant medication.

20 Tinnitus on its own is unlikely to cause functional hearing loss, however it can significantly impact on concentration. The Mental Function test is carried out in cases of tinnitus where there is anxiety/depression or other mental disablement.

Meniere’s disease

21 Meniere’s disease is characterised by recurring bouts of profound, prostrating vertigo, nausea and vomiting with deafness and tinnitus. Such attacks can last for anything up to 24 hours, but unsteadiness and loss of confidence can persist for several further days. Sensorineural low/mid-frequency hearing loss and tinnitus may persist between bouts and if the condition is chronic the deafness may be progressive. The occurrence of attacks is variable and unpredictable. Management involves symptomatic treatment of the acute episode and prescription of prophylactic medication.

22 For the purpose of the LCW/LCWRA, the disability analyst records the frequency and duration of the attacks, and also the therapeutic measures being taken to control the condition, and the effectiveness of the measures.

23 The effects of the Meniere’s disease should be fully taken into account when choosing physical descriptors (i.e. the activity must be performed safely, reliably and repeatedly).

DLA Considerations

24 People with significant degrees of hearing loss represented by descriptors H(a) to H(c) will be assessed at the WCA with a view to facilitating a return to work, or entry into work for those who have not worked previously e.g. people with congenital deafness. The report will provide information on how they communicate on a day to day to basis including use of BSL, and whether they have any additional learning disabilities or mental health problems that might increase their level of disability. The information will be of use to the DM both in determining care needs and their ability to get around on their own

Vision – Activity 9

Vision including visual acuity and visual fields, in normal daylight or bright electric light, with glasses or other aid to vision if such aid is normally worn

Descriptors

V (a) Cannot see at all

V (b) Cannot see well enough to read 16 point print at a distance of greater than 20cm

V(c) Has 50% or greater reduction of visual fields

V (d) Cannot see well enough to recognise a friend at a distance of at least 5 metres

V (e) Has 25% or more but less than 50% reduction of visual fields

V (f) Cannot see well enough to recognise a friend at a distance of at least 15 metres

V (g) None of the above apply

Scope

1 The Activity is vision in normal daylight or bright electric light, with glasses or other visual aids, which would normally be worn. It relates to visual acuity (central vision and focus) and to visual fields (peripheral vision). It is intended to reflect the activity of seeing clearly without taking literacy into account.

2 16-point print is intended to reflect central vision, and should be enough to allow a person to read a reasonable amount of text at a time, not just individual letters. However it does not include ability to sustain concentration while reading or literacy.

3 "Recognising a friend" implies the ability to recognise a friend's features, not to recognise them, for example, from the clothes they are wearing.

4 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 (permits driving of a private car) in the UK, acuity of 6/10 on the Snellen chart is required.

5 Vision has to be useful vision in the context of a normal environment. A condition causing severe tunnel vision where, despite reasonable visual acuity, an individual cannot read whole sentences or scan a page, causes significant disability. An appropriate descriptor in this situation would be V(b)

6 Visual field loss is considered in the LCW/LCWRA. Visual field loss may result in significant functional limitations and can be caused by a number of conditions such as glaucoma, retinopathy or homonymous hemianopia. It may reduce safety awareness in situations such as traffic or cause a tendency to falls.

Details of Activities of daily living

7 The disability analyst considers the customer’s ability in relation to:

• Filling in forms; • Driving – both from the visual acuity and visual field point of view; • History of falls or accidents; • Use of public transport - getting on and off buses unassisted, reading

the bus name and number; • Mobilising independently outdoors; • Reading newspapers or magazines, watching television; • Helping children with homework or reading bedtime stories; and • Leisure activities, in particular participatory sports such as snooker or

darts and activities that require good vision such as knitting or sewing.

Observed behaviour

8 The disability analyst records how the customer got to the examination centre, and how they found their way around the centre, and whether they needed to be accompanied by another person.

9 The disability analyst observes their actions when navigating obstacles, for example, do they rotate their neck more to adjust for reduced visual fields?

10 They will also observe their ability to manipulate belts and buttons, and whether the claimant is able to read their medication labels or repeat prescription sheet.

Examination

11 The report includes the aided binocular vision, and explains its significance to the Decision Maker.

12 If the customer 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 will be reflected in the descriptor choice. In these cases or in cases where the VA is poor but the examiner thinks that it could improve with correction, it can be measured it using a pinhole, (in effect this replaces a spectacle lens as in a pin hole camera).

13 Near vision is recorded using a near vision chart. N8 print is the equivalent of normal newsprint.

14 Where there is a history of any visual field problem or where the analyst at assessment thinks that there may be a visual field problem, visual fields are tested by clinical examination.

15 For the purposes of the LCW/LCWRA, the examiner will provide an opinion of visual field loss of 50% or greater (descriptor Vc) or loss of 25% or more but less than 50 % (descriptor Ve) than normal.

DLA considerations

16 For people with visual impairment the report contains a record of their visual acuities. In addition it will also contain information about any reduction in visual fields. The latter is expressed as a percentage reduction.

17 A person should be able to dress themselves if vision meets the descriptor V(b) or better i.e. V(b) Cannot see well enough to read 16 point print at a distance of greater than 20cm.

18 A person should be able to find their way around if their vision is V (f) or better i.e. - Cannot see well enough to recognise a friend at a distance of at least 15 metre.

19 The disability analyst will have observed the ease with which the customer moves around the examination centre, their ability to read documentation, to manage personal possessions such as a handbag and to make eye contact during interaction. Their ability to watch TV, go shopping, to drive and partake in leisure activities will have been explored in the typical day interview.

Continence – Activity 10

This Activity is subdivided under 3 sets of descriptors – 10(a), 10(b), and 10(c)

Activity 10 (a) Continence other than enuresis (bed-wetting) where the person does not have an artificial stoma or urinary collecting device.

Descriptors

C (a) Has no voluntary control of the evacuation of the bowel

C (b) Has no voluntary control of the voiding of the bladder.

C(c) At least once a month loses control of bowels so that the person cannot control the full evacuation of the bowel.

C (d) At least once a week loses control of bladder so that the person cannot control the full voiding of the bladder.

C (e) Occasionally loses control of bowels so that the person cannot control the full evacuation of the bowel.

C (f) At least once a month loses control of bladder so that the person cannot control the full voiding of the bladder.

C (g) Risks losing control of bowels or bladder so that the person cannot control the full evacuation of the bowel or the full voiding of the bladder if not able to reach a toilet quickly

C (h) None of the above apply

Scope

1 This functional area describes total involuntary voiding of bowel or bladder, not just minor leakage as might occur with minor degrees of stress incontinence.

2 The descriptors cover an assessment of continence while the customer is awake. Incontinence which occurs only while asleep (enuresis) 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 e.g. at work.

3 Similarly, incontinence occurring during a seizure 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.

4 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. Customers with gastro-intestinal problems or frequency of micturition should be considered as possibly meeting the criteria for C (g), 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.

5 In situations where a customer has problems of control with both the bladder and the bowels the highest descriptor should be applied, e.g. in a customer who loses control of bladder function at least once a month (C (f)) and who also loses control of their bowels occasionally (C (e)) the higher of the two descriptors (C (e)) should be chosen.

6 `Occasionally' implies less than once a month or, happening irregularly with an overall frequency of less than once a month.

7 ‘No voluntary control’ - means that the person is unable to determine, by conscious effort, when the bladder or bowels discharge.

8 Mild stress related incontinence, where the person has voluntary control over the bladder for most of the time but such control is lost at certain times, would not amount to 'no voluntary control over the bladder'.

Details of activities of daily living

9 The disability analyst considers the customer's ability in relation to:

• the frequency and length of any journeys or outings undertaken, e.g. shopping trips, car journeys ;

• Visits to friends or relatives; • Other social outings;

and any problems encountered in undertaking these activities. The clinical diagnosis, medication and previous investigations or specialist input are taken into account.

Activity 10 (b) Continence where client uses a urinary collecting device, worn for the majority of the time including an indwelling urethral or suprapubic catheter.

Descriptors

CU (a) Is unable to affix, remove or empty the catheter bag or other collecting device without receiving physical assistance from another person

CU (b) Is unable to affix, remove or empty the catheter bag or other collecting device without causing leakage of contents.

CU(c) Has no voluntary control over the evacuation of the bowel

CU (d) At least once a month loses control of bowels so that the person cannot control the full evacuation of the bowel.

CU (e) Occasionally loses control of the bowel so that the person cannot control the full evacuation of the bowel.

CU (f) Risks losing control of bowels so that the person cannot control the full evacuation of the bowel if not able to reach a toilet quickly

CU (g) None of the above apply

Scope

10 This functional category reflects the ability of an individual to manage their urinary continence by use of a urinary collecting device. It should be noted that for the purposes of the legislation, a urostomy is considered as a urinary collecting device.

11 Therefore, a person who has no bowel continence issues and can successfully manage to maintain their urinary collecting device without spillage, would not score in this category.

12 In this area, a stoma that is poorly functioning, or has a fistula or is poorly fashioned such that leakage is a common occurrence should be considered as CU (b).

13 Upper limb function and mental abilities must be considered in this activity in relation to the person’s ability to cope with the collecting device.

Activity 10(c) Continence other than enuresis (bed wetting) where the person has an artificial stoma.

Descriptors

CB (a) Is unable to affix, remove or empty stoma appliance without receiving physical assistance from another person.

CB (b) Is unable to affix, remove or empty stoma appliance without causing leakage of contents.

CB(c) Where the person’s artificial stoma relates solely to the evacuation of the bowel, at least once a week, loses control of bladder so that the person cannot control the full voiding of the bladder.

CB (d) Where the person’s artificial stoma relates solely to the evacuation of the bowel, at least once a month, loses control of bladder so that the person cannot control the full voiding of the bladder.

CB(e) Where the person’s artificial stoma relates solely to the evacuation of the bowel, risks losing control of the bladder so that the person cannot control the full voiding of the bladder if not able to reach a toilet quickly.

CB (f) None of the above apply

Scope

14 This functional category reflects the ability of an individual to manage their artificial stoma.

15 Therefore, a person who has no problem with urinary continence and can successfully manage to maintain their stoma without leakage would not score in this category.

16 In this area a stoma that is poorly functioning, or has a fistula or is poorly fashioned such that leakage is a common occurrence should be considered as CB (b).

17 Upper limb function and mental abilities must be considered in this activity in relation to the person’s ability to cope with the artificial stoma.

DLA Considerations

18 Activity 10(a) relates to urinary and/or bowel continence where the person does not have a stoma or urinary collecting device. It reflects the amount of voluntary control that the person has over micturition or defaecation, and how often incontinence occurs. The report provided useful information regarding the diagnosis of the underlying medical condition causing the incontinence, any special investigations undertaken and medication taken.

19 Activity 10(b) applies to people who wear for the majority of the time a urinary collecting device such as a urinary catheter, urethral sheath, suprapubic catheter or urostomy. It provides information as to whether the person needs physical assistance from another person to manage the catheter bag or who cannot manage the bag without causing leakage. This could be because the person lacks manual dexterity e.g. rheumatoid arthritis, or because they have learning disabilities.

20 Activity 10 (c) applies to people who have artificial stomas. It identifies people who need physical assistance from another person to manage the stoma bag, or who cannot mange the bag without causing leakage.

21 Although information in the Continence section of the report appears complex, it will be very helpful to the DLA DM in identifying individuals who have medical conditions causing urinary and/or bowel incontinence of a substantial nature, and in recording how often the incontinence occurs. For people who have artificial stomas or long-term urinary catheters (or other urinary collecting devices), the report contains information on those who need help from others to manage on a day-to-day basis.

Remaining conscious during waking moments – Activity 11

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) At least twice in the six months immediately preceding the assessment,

has an involuntary episode of lost or altered consciousness, resulting in significantly disrupted awareness or concentration

F (d) None of the above apply

Scope

1 This Activity covers any involuntary loss or alteration of consciousness resulting in significantly disrupted awareness or concentration occurring during the hours when the customer is normally awake, and which prevents the customer from safely continuing what they are doing. Such events occurring when the customer is normally asleep are not taken into consideration. The descriptors relate to the frequency with which such episodes of lost or altered consciousness occur. It should be noted that the descriptor indicates 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 criteria.

2 In the context of WCA, the most likely causes of episodes of “lost consciousness” are:

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

• A seizure which is secondary to impairment of cerebral circulation. • 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:

i. Partial seizures which may simple or complex partial (previously known temporal lobe epilepsy); or

ii. Absence seizures which may be typical (petit mal) or atypical; or

iii. Hypoglycaemia.

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

3 Any functional limitations due to side effects of medication taken to control seizures are 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.

4 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 Activities.

5 The disability analyst considers whether a customer's claimed frequency of seizures is medically reasonable. For example, if there is no corroborative evidence from the GP and the person 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

6 The disability analyst considers the customer’s ability in relation to:

• driving - the DVLA does not issue a licence to anyone who has had a daytime seizure in the past year.

• potentially hazardous domestic activities such as cooking. • recreational activities e.g. swimming, contact sports.

DLA considerations

7 This section of the report relates to people with epilepsy including grand mal seizures, temporal lobe epilepsy and absence seizures such as petit mal. It also includes alterations in consciousness due to cardiac arrhythmias and hypoglycaemia. It does not include giddiness, dizziness, and vertigo.

8 The frequency of the episodes of lost or altered consciousness determines the descriptor that is chosen. The disability analyst takes into account the diagnosis, hospital investigations and medication prescribed when evaluating this Activity. If there is no corroborative evidence of the medical condition from the general practitioner and the customer is not on any appropriate medication, it is unlikely that functional limitation due to lost or altered consciousness will be credited.

9 Information in this section of the ESA 85 is useful to the DM in establishing the diagnosis, investigation and treatment of the medical condition affecting consciousness, and the frequency of episodes. It is less helpful in establishing whether the person has useful warning of the episode, if preventative measures could be taken and the amount of supervision that the person might require.

Section 13 - Summary of ESA 85 physical function information for DLA

Care needs Functional

Activity groups

Main ESA Activity

to consider

Notes Other Activities to consider

Getting in and out of bed

Lower limbs, lumbar spine, upper limbs

Standing & sitting, Bending or kneeling

Walking, Picking up and transferring

(ability to push up)

Getting up from chair

Lower limbs, lumbar spine, upper limbs

Standing & sitting

Refers to an upright chair with no arms. Includes wheelchair transfer

Walking, Bending or Kneeling

Washing, Bathing/use of shower

Lower limbs, lumbar spine, upper limbs

Standing & sitting

Walking, Bending or Kneeling, Picking up and transferring

Dressing Upper limbs, Vision

Manual dexterity, Vision

Should be able to dress if vision is Vb or better

Reaching, Bending or Kneeling

Feeding Upper limbs Manual dexterity

Reaching, Vision

Preparing a meal

Upper limbs

Cognition

Manual dexterity

Mental function

Picking up and transferring, Vision

Continence Urinary and bowel (not nocturnal enuresis)

Continence Includes ability to manage catheters and artificial stomas

Manual dexterity, Vision, Mental Function

Walking (Mobility)

Lower limbs Walking With aids if used. Includes stairs

Getting around

Vision, Hearing, Mental function

Vision, Mental Function

Should be able to find way around if vision is Vf or better

Section 14 - The Mental Function Assessment and its use in DLA In this section detailed information about each of the Mental Function Activities and the ranked descriptors is provided. An explanation of the scope of each Activity is combined with notes about the type of specific evidence that the disability analyst takes into account in making their descriptor choice. For each Activity additional guidance on how the ESA 85 report may be used to evaluate attention, supervision and getting around (DLA considerations) is provided.

Note that the Mental Function Activities are grouped together:-

Understanding and focus (Activities 12, 13, 14, 15 and 16)

• Learning or comprehension in the completion of tasks; • Awareness of hazard; • Memory and concentration; • Execution of tasks; and • Initiating and sustaining personal action.

Adapting to change (Activities 17, 18 and 19)

• Coping with change; • Getting about; and • Coping with social situations.

Social Interaction (Activities 20 and 21)

• Propriety of behaviour with other people; and • Dealing with other people.

Learning or comprehension in the completion of tasks – Activity 12

Descriptors

LT (a) Cannot learn or understand how to successfully complete a simple task, such as setting an alarm clock, at all.

LT (b) Needs to witness a demonstration, given more than once on the same occasion of how to carry out a simple task before the person is able to learn or understand how to complete the task successfully, but would be unable to successfully complete the task the following day without receiving a further demonstration of how to complete it.

LT(c) Needs to witness a demonstration of how to carry out a simple task, before the person is able to learn or understand how to complete the task successfully, but would be unable to successfully complete the task the following day without receiving a verbal prompt from another person.

LT (d) Needs to witness a demonstration of how to carry out a moderately complex task, such as the steps involved in operating a washing machine to correctly clean clothes, before the person is able to learn or understand how to complete the task successfully, but would be unable to successfully complete the task the following day without receiving a verbal prompt from another person.

LT (e) Needs verbal instructions as to how to carry out a simple task before the person is able to learn or understand how to complete the task successfully, but would be unable, within a period of less than one week, to successfully complete the task without receiving a verbal prompt from another person.

LT (f) None of the above apply.

Scope

1 This Activity reflects ability to learn and understand information. “Learning” assesses the ability to learn and retain information; while “understanding” is about comprehension of information. This activity is intended to be relevant to learning disability of whatever cause, including the result of acquired brain injury. It also reflects difficulties in understanding language, such as receptive dysphasia.

2 It should be noted that some of the descriptors refer to a demonstration rather than a prompt. This reflects a higher level of disability in that the person would be unable to remember how to do the task. For example in LT(b), the person would need to be shown how to push the buttons on the alarm clock, but in LT(d), being reminded how to do the task would suffice – i.e. they would not need to be shown physically how to push the button.

3 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

4 The disability analyst considers basic functions of personal care such as brushing teeth. This would involve remembering to put toothpaste onto a brush and brushing all areas of teeth. This may be regarded as a simple task. Other aspects of personal care may be the ability to be able to get up, showered, shave, clean teeth, select clothing items and get dressed appropriately for the weather outside. This may represent an ability to understand and retain information.

5 Other leisure activities that may be considered include using a TV remote control, using a stereo by loading the CD into the CD player and selecting the appropriate function on the stereo to allow the CD to play. Ability to use a Play station or computer might be relevant in this functional category.

6 Ability to drive, previous employment or tasks learned in training may also be relevant.

Mental State Examination

7 Clinical findings include record of memory and concentration, general decision-making ability at assessment, ability to cope at interview, general intelligence, requirement for prompting etc. The disability analyst may undertake specific tests of memory and concentration.

DLA Considerations

8 This Activity is intended to be relevant to people with learning disabilities, brain injury and dementia. The highest level descriptors LT (a) & LT (b) will be applied to those with the most severe learning disabilities, and the DM should consider the need for prompting in respect of self-care, and also the requirement for supervision in some cases. The lower level descriptors LT (c), LT (d) and LT (e) are also likely to be applicable to people who need prompting and help with main meal preparation.

Awareness of hazards – Activity 13

Descriptors

AH (a) Reduced awareness of the risks of everyday hazards (such as boiling water or sharp objects) would lead to daily instances of or to near-avoidance of:

(i) injury to self or others; or

(ii) significant damage to property or possessions,to such an extent that overall day to day life cannot successfully be managed.

AH (b) Reduced awareness of the risks of everyday hazards would lead for the majority of the time to instances of or to near-avoidance of:

(i) injury to self or others; or

(ii) significant damage to property or possessions, to such an extent that overall day to day life cannot successfully be managed without supervision from another person.

AH (c) Reduced awareness of the risks of everyday hazards has led or would lead to frequent instances of or to near-avoidance of:

(i) injury to self or others; or

(ii) significant damage to property or possessions, but not to such an extent that overall day to day life cannot be managed when such incidents occur.

AH (d) None of the above apply

Scope

1 This Activity is intended to reflect 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.

2 The Activity reflects a lack of understanding that something is dangerous or that there is an impaired recognition that a situation will present a potential hazard. For example a person with dementia may lack insight with regard to the reason 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.

Details of activities of daily living

3 When considering this functional category the disability analyst will ask about ability to cope with potential hazards, and whether the person could be safely left alone to manage basic daily life. Potential scenarios include:

• Ability to cope with road safety awareness; • Driving; • Ability in the kitchen; • Awareness of electrical safety; and • Responsibility for children/pets.

Mental State Examination

4 Cognitive issues are important in assessing this functional activity.

5 Insight will also be an important factor and consideration will be given as to whether the customer has adequate insight into their problems to recognise the risks present, and therefore whether they are able to avoid potentially hazardous situations.

DLA Considerations

6 Descriptors AH (a) and AH (b) would be relevant to a need for supervision in customers with learning disabilities, brain injury etc., and also may be helpful in considering whether they need guidance when getting around out of doors. It is not envisaged that the descriptors apply to people with suicidal intent who

have clear mental faculties and understand the implications of such an attempt.

Memory and concentration - Activity 14

Descriptors

7 MC (a) On a daily basis, forgets or loses concentration to such an extent that overall day to day life cannot be successfully managed without receiving verbal prompting, given by someone else in the person’s presence.

MC (b) For the majority of the time, forgets or loses concentration to such an extent that overall day to day life cannot be successfully managed without receiving verbal prompting, given by someone else in the person’s presence

MC(c) Frequently forgets or loses concentration to such an extent that overall day to day life can only be successfully managed with pre-planning, such as making a daily written list of all tasks forming part of daily life that are to be completed

MC (d) None of the above apply

Scope

1 This activity is intended to be relevant to lapses in memory or concentration due to fatigue, anxiety, depression, delusions, hallucinations, memory loss, brain injury or dementia. It also reflects difficulties with memory or concentration that result from detrimental effects of medication, such as drowsiness or sedation.

2 It should be noted that in MC (a) and MC (b) that the prompting must be given in the presence of another person. Prompting via telephone would not reflect the severity of disability in MC (a) or MC (b). These descriptors reflect a very severe level of functional restriction.

3 In MC(c) the lists do not reflect the type of lists that could reasonably be expected to be utilised by those with normal cognitive function such as shopping lists. The descriptor reflects a need to have additional input to manage all tasks involved in daily life such as remembering to get washed and dressed.

Details of activities of daily living

4 When considering this activity, the customer’s ability to live alone or attend appointments alone should be considered. It would seem unlikely that those who live alone without substantial input from a carer would have the level of disability reflected in these descriptors.

5 Abilities that are considered by the disability analyst include:

• Attending to personal care; • Coping with medication; • Significant accidents at home; • Shopping; • Reading/TV; • Driving; • Attending to nutrition; and • Dealing with finances and bills.

Mental State Examination

6 On examination, it would be expected that a severe level of cognitive impairment would be evident for any of the above descriptors to apply. Mild impairment of concentration or memory would not normally be consistent with the level of disability reflected in the descriptors MC (a), MC (b) or MC(c).

DLA Considerations

7 Descriptors MC (a), MC (b) and MH (c) will applicable to people with learning disabilities, brain injury and dementia. Only those with the most severe levels of functional restriction due to depression, schizophrenia and generalised anxiety disorder requiring long-term medication and care from the mental health team are likely to be covered by these descriptors. Consideration should be given to the need for prompting or supervision.

Execution of tasks – Activity 15

Descriptors

ET (a) Is unable to successfully complete any everyday task.

ET (b) Takes more than twice the length of time it would take a person without any form of mental disablement, to successfully complete an everyday task with which the claimant is familiar.

ET(c) Takes more than one and a half times but no more than twice the length of time it would take a person without any form of mental disablement to successfully complete an everyday task with which the claimant is familiar.

ET(d) Takes one and a half times the length of time it would take a person without any form of mental disablement to successfully complete an everyday task with which the claimant is familiar.

ET (e) None of the above apply.

Scope

1 This Activity reflects the ability to carry out a task within a reasonable time. It is intended to reflect difficulties that may be encountered by people with

obsessive-compulsive disorder (OCD), learning disability or brain injury. It includes the effect on a person of experiencing a panic attack – a specific and overwhelming experience of fear, precluding any form of normal activity. It is also intended to reflect the impact on carrying out a task that hallucinations or delusions may have on individuals with psychotic or dissociative states. It may be compounded by the effects of medication.

2 The descriptors reflect an increased time to complete a task, not a lack of motivation to commence a task. For example a person with severe OCD may take several hours to manage to get washed and dressed due to hand washing rituals preventing them from continuing a task.

3 It should also be noted that this Activity relates to mental disablement and not physical disablement. For example, a person with rheumatoid disease with no form of mental disablement, who has significant morning stiffness and takes several hours to get washed and dressed due to their joint problems, would not be included in this Activity.

Details of activities of daily living

4 The disability analyst considers routine activities and what would be reasonable for a person taking into account normal variation in a population without any form of mental disablement. For example, one person getting up in the morning may only take 20 - 30 minutes to be up, showered and dressed to leave for work, but others may take longer – perhaps an hour or slightly more. It may be useful to consider the overall typical day function. In this descriptor, further enquiry and clarification of detail will be necessary. For example, a customer may indicate that they rise at 8.30am but do not get dressed to get out to shopping until midday. This may initially seem an excessive time for this activity, however on further questioning it may be apparent that they choose to watch morning television after their shower and complete housework before dressing.

5 It must also be considered whether time taken to complete a task is due to personal preference or choice rather than mental disablement. For example a person with joint disease or back pain may choose to lie in a bath for an hour to help alleviate stiffness or simply because they enjoy relaxing in the bath.

6 The pattern of typical day activity should reflect a person who would struggle to get through the basics of a day due to their mental disablement as a result of tasks taking so long to complete, that they would be unable to cope with work. For example those who have severe and continuous disabling anxiety, where they struggle to even get out of their bedroom, may come into this category.

Mental State Examination

7 Assessment of cognition, evidence of abnormal perceptions and behaviour are required in the report. Those with anxiety or depression would be expected to have Mental State Examination findings consistent with severe

levels of anxiety where they may be extremely distracted, distressed or sweating. In those with significant depression, there may be evidence of slow speech or slow movements (psychomotor retardation).

DLA considerations

8 People with the most severe levels of anxiety, severe depression i.e. with psychomotor retardation, severe OCD, schizophrenia, learning disabilities & brain injury are likely to be restricted in their ability to execute tasks. Those whose level of restriction is described by ET (a) to ET (d) may need help with self-care or main meal preparation.

Initiating and sustaining personal action - Activity 16

Descriptors

IA (a) Cannot, due to cognitive impairment or due to a severe disorder of mood or behaviour, initiate or sustain any personal action (which means planning, organisation, problem solving, prioritising or switching tasks).

IA (b) Cannot, due to cognitive impairment or due to a severe disorder of mood or behaviour, initiate or sustain personal action without requiring daily verbal prompting given by another person in the person’s presence.

IA(c) Cannot, due to cognitive impairment or due to a severe disorder of mood or behaviour, initiate or sustain personal action without requiring verbal prompting given by another person in the person’s presence for the majority of the time.

IA(d) Cannot, due to cognitive impairment or due to a severe disorder of mood or behaviour, initiate or sustain personal action without requiring frequent verbal prompting given by another person in the person’ presence.

IA (e) None of the above apply

Scope

1 This Activity reflects the ability to initiate or sustain action without need for external prompting. It is intended to reflect difficulties that may be encountered by people with conditions such as depressive illness that result in apathy, or abnormal levels of fatigue, or abnormal levels of anxiety. It is also common in some people with schizophrenia. It may be compounded by the effects of medication.

2 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.

3 “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;

and • ability to cope with simple household tasks e.g. sorting laundry and

using a washing machine.

Details of activities of daily living

4 Areas considered by the disability analyst will include any behaviour that involves a decision to plan or organise a personal action to enable the customer 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; and • Caring for children, preparing clothing, lunches etc.

Mental State Examination

5 General memory, concentration, intelligence and severity of depression should be recorded. It should be noted that the descriptors refer to a severe disorder of mood.

DLA Considerations

6 Descriptors IA (a), IA (b) And IB (c) are relevant to customers with depression, severe anxiety, schizophrenia etc. who are at danger of self-neglect without prompting. Help with main meal preparation might be appropriate in someone covered by descriptor IA (d).

Coping with change - Activity 17

Descriptors

CC (a) Cannot cope with very minor, expected changes in routine, to the extent that overall day to day life cannot be managed.

CC (b) Cannot cope with expected changes in routine (such as a pre-arranged permanent 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, unforeseen changes in routine (such as an unexpected change of 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

1 This Activity relates to the flexibility needed to cope with changes in normal routine. It is intended to reflect difficulties that may be encountered by people with severe learning disability, autistic spectrum disorder, brain injury or psychotic illness. It is not intended to reflect simple dislike of changes to routine, but rather the inability to cope with them.

2 It reflects a significant level of functional restriction 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.

Activities of daily living

3 In this functional activity the disability analyst will 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; and • Dealing with telephone calls.

4 It may be useful to consider some of these activities in terms of the level of disability intended, for example:

• A customer who becomes so upset by the phone ringing that they cannot function beyond that, rather than just feeling stressed or anxious.

• A customer 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 customer 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

5 Customers may have poor rapport and be extremely anxious at interview. It may be that they have been unable at all to attend the MEC for assessment. It would seem unlikely that a customer who manages to attend the MEC alone would meet the level of severity of functional restriction for anything other than CC (d) to apply.

DLA Considerations

6 The descriptors are intended to apply to people with functional restrictions due to severe learning disability, autistic spectrum disorder, brain injury or psychotic illness e.g. schizophrenia.

7 This Activity is more relevant to difficulties that people with these medical conditions might have in coping with work or in the work place or in travelling to work. It is probably of less help to the DM than some other Activities in determining need for prompting, supervision or getting around.

Getting about - Activity 18

Descriptors

GA (a) Cannot get to any specified place with which the person is, or would be, familiar.

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

GA(c) For the majority of the time is unable to get to a specified place with which the person is familiar without being accompanied by another person.

GA (d) Is frequently unable to get to a specified place with which the person is familiar without being accompanied by another person.

GA (e) None of the above apply

Scope

1 This Activity relates to an inability to travel without support from another person, as a result of disorientation; or of agoraphobia causing fear of travelling unaccompanied. It does not reflect lesser degrees of anxiety about going out, nor does it reflect planning and timekeeping.

Activities of daily living

2 The disability analyst considers how the person functions taking into account their level of anxiety and ability to leave the house. Activities include:

• Shopping; • Attending the pharmacy; • Attending hospital or GP appointments; • Walking the dog; • Supervising children outdoors; and • General safety awareness and abilities in kitchen may support

significant cognitive disruption resulting in safety issues if going out unaccompanied.

Mental State Examination

3 Intelligence and cognitive function are assessed. It would be expected that evidence of severe anxiety would be found on examination to support the level of functional restriction. Lesser degrees of anxiety would not fulfil the criteria. The descriptors reflect the effects of true panic disorder or severe agoraphobia.

DLA Considerations

4 The descriptors reflect the difficulties that people with learning disabilities, brain injury, and dementia experience in getting around due to cognitive impairment. They also apply to individuals with severe panic disorder and agoraphobia. Consideration of this Activity will be of use to the DM in determining whether people with these medical conditions require guidance and/or supervision out of doors.

Coping with social situations - Activity 19

Descriptors

CS (a) Normal activities, for example, visiting new places or engaging in social contact, are precluded because of overwhelming fear or anxiety.

CS (b) Normal activities, for example, visiting new places or engaging in social contact, are precluded for the majority of the time due to overwhelming fear or anxiety.

CS(c) Normal activities, for example, visiting new places or engaging in social contact, are frequently precluded, due to overwhelming fear or anxiety.

CS (d) None of the above apply.

Scope

1 This Activity is intended to reflect lack of self-confidence in social situations, which is greater in its nature and its functional effects than mere shyness or reticence. 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. 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.

Activities of daily living

2 The disability analyst considers any form of social contact including:

• Use of public transport; • Shopping;

• Talking to neighbours; • Use of phone; • Hobbies and interests; and • Social interaction with family.

Mental State Examination

3 The Mental State Examination findings would be expected to reflect severe anxiety. Rapport is likely to be poor with lack of eye contact. The customer might be sweating and find the consultation difficult. They may be somewhat timid in demeanour at interview. It would seem likely the person would require a companion to accompany them to the medical examination centre due to the high level of anxiety.

DLA Considerations

4 This Activity is most relevant to the problems that people with severe anxiety and panic disorder might experience in the work situation or in accessing work. Some information relating to this Activity may be helpful to the DM in determining whether help is needed to get around. However it should be borne in mind that the person will have significant problems in coping with social situations arising from a diagnosed mental health disorder. It is not intended to reflect normal feelings of anxiety or apprehension that anyone might experience in travelling to an unfamiliar place or when meeting new people.

Propriety of behaviour with other people - Activity 20

Descriptors

IB (a) Has unpredictable outbursts of, aggressive, disinhibited, or bizarre behaviour, being either:

(i) sufficient to cause disruption to others on a daily basis, or

(ii) of such severity that although occurring less frequently than on a daily basis, no reasonable person would be expected to tolerate them.

IB (b) Has a completely disproportionate reaction to minor events or to criticism to the extent that he has an extreme violent outburst leading to threatening behaviour or actual physical violence.

IB(c) Has unpredictable outbursts of, aggressive, disinhibited or bizarre behaviour, sufficient in severity and frequency to cause disruption for the majority of the time.

IB (d) Has a strongly disproportionate reaction to minor events or to criticism, to the extent that the person cannot manage overall day to day life when such events or criticism occur.

IB (e) Has unpredictable outbursts of aggressive, disinhibited or bizarre behaviour, sufficient to cause frequent disruption.

IB (f) Frequently demonstrates a moderately disproportionate reaction to minor events or to criticism but not to such an extent that the person cannot manage overall day to day life when such events or criticism occur.

IB (g) None of the above apply

Scope

1 This activity is intended to reflect difficulties in social behaviour that might be encountered by people with psychotic illness or other conditions such as brain injury that result in lack of insight, as well as 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. “Reaction to minor events” is intended to reflect difficulties that may be encountered by people with autistic spectrum disorder and other conditions, in which minor adverse events causes a moderately disproportionate, or significant reaction out with that which might normally be expected.

2 There should be clear evidence of a disorder of mental function. 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.

3 An example of a strongly disproportionate reaction would be a response to very minor criticism involving actions such as shouting, crying and storming out of the room. E.g. a comment such as “the soup could have been warmer” when eating the dinner prepared for them by the customer results in the customer crying and storming out of the room.

4 A moderately disproportionate reaction would be sitting shaking and crying in response to a minor criticism.

5 There must be evidence of mental disablement that causes a pattern of consistent behaviour triggered in different circumstance, not just directed towards one individual.

Activities of daily living

6 The disability analyst considers any activity involving interaction with others where criticism may occur such as:

• 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; and • Appointments with official persons such as the bank manager/ social

worker/ DWP staff.

Mental State Examination

7 There is likely to be evidence of reduced insight. Cognitive function may be impaired and evidence of addiction or thought disorder may be present. Rapport may be poor and communication difficult.

DLA Considerations

8 People with psychotic illnesses such as schizophrenia, bipolar disorder and those with brain injury, autistic spectrum disorder, learning disabilities and personality disorders may have the levels of functional restriction described under this Activity. Descriptors IB (a) to IB (e) are likely to be applicable to customers with these disorders who require supervision and help getting around.

Dealing with other people - Activity 21

Descriptors

DP (a) Is unaware of impact of own behaviour to the extent that:

(i) has difficulty relating to others even for brief periods, such as a few hours; or (ii) causes distress to others on a daily basis.

DP (b) The person misinterprets verbal or non-verbal communication to the extent of causing himself or herself significant distress on a daily basis.

DP(c) Is unaware of impact of own behaviour to the extent that:

(i) has difficulty relating to others for longer periods, such as a day or two, or

(ii) causes distress to others for the majority of the time.

DP (d) The person misinterprets verbal or non-verbal communication to the extent of causing the person significant distress to himself or herself for the majority of the time.

DP (e) Is unaware of impact of own behaviour to the extent that:

(i) has difficulty relating to others for prolonged periods, such as a week; or

(ii) frequently causes distress to others.

DP (f) The person misinterprets verbal or non-verbal communication to the extent of causing the person significant distress to himself or herself on a frequent basis.

DP (g) None of the above apply

Scope

1 This activity is intended to reflect difficulties in social behaviour such as may be encountered by people with a variety of conditions, including autistic spectrum disorder, psychotic illness, and brain injury, which affect understanding and the application of social norms of communication. Descriptor DP (a) also includes any situation where lack of ability to self–care and to maintain personal hygiene causes the claimant to be totally unacceptable to other people.

Activities of daily living

2 The disability analyst considers the social interaction that occurs in:

• Social occasions; • Relationships with friends and family; • Previous occupations; • Conflict with authorities or exclusion from local amenities; • Shopping; • Public transport; and • Relationship with GP/ receptionists - ? frequently removed from

Practice lists etc.

Mental State Examination

3 It is likely that the customer will have very little insight into their behaviour. Intelligence and cognitive function may also be impaired. Addictions and thought disorder may be present. Rapport is likely to be poor when these descriptors apply, and it may have been difficult to establish good communication during the interview.

DLA considerations

4 In many respects the scope of this Activity relates most closely to the problems that abnormal social behaviour described might create in the work situation, such that effective functioning would be precluded. However the choice of the most highly scoring descriptors DP (a) to DP(c) would indicate the most severe disabling effects of the medical conditions mentioned above, and may indicate a requirement for supervision.

Section 15 - Summary of ESA Mental Function Information for DLA (table)

This table is reproduced at Appendix C.

Section 16 - The Support Group and ESA 85 1 If the customer is discovered at medical examination to have a severe illness or disability, they may fulfil the criteria for inclusion in the Support Group. The assessment and completion of report ESA 85 is usually curtailed in these cases. The report shows which descriptor (see below) applies to the customer and an additional report ESA 85A is generated by LiMA justifying the advice for the ESA DM.

2 The Support Group Activities are listed in the table at paragraph 4 below. The disability analyst is required to choose a descriptor in only one of the functional areas (Activities) to fulfil the Support Group (SG) criteria. Some of the Activities mirror those in the physical/mental function assessment described previously, when the SG descriptor represents a higher level of functional limitation in that category e.g. reaching, manual dexterity. Other Activities do not correlate closely and relate to different functional categories e.g. eating and drinking, communication.

3 Although the ESA 85 report may be shorter in length in these cases, it is likely to provide information about a customer with a severe level of functional restriction in at least one functional category. This information may be very helpful in determining care and/or mobility, especially if considered in relation to other details about clinical history, typical day, clinical examination etc. However it will be advisable to review other evidence, since the ESA 85 and 85A will not necessarily give a full account of all the disabling effects of the medical condition. For example, in the case of a customer who cannot walk at all because of severe lower limb pathology, there may be little information about upper arm function or mental health.

4 Support Groups are detailed in Appendix A.

Appendix A - Support Group

Column 1

Activity

Column 2

Descriptors

1. Walking or moving on level ground.

Cannot -

(a) walk (with a walking stick or other aid if such aid is normally used);

(b) move (with the aid of crutches if crutches are normally used); or

(c) manually propel his wheelchair;

more than 30 metres without repeatedly stopping, experiencing breathlessness or severe discomfort.

2. Rising from sitting and transferring from one seated position to another.

Cannot complete both of the following -

(a) rise to standing from sitting in an upright chair without receiving physical assistance from someone else; and

(b) move between one seated position and another seated position located next to one another without receiving physical assistance from someone else

3. Picking up and moving or transferring by the use of the upper body and arms (excluding standing, sitting, bending or kneeling and all other activities specified in this Schedule).

Cannot pick up and move 0.5 litre carton full of liquid with either hand.

4. Reaching. Cannot raise either arm as if to put something in the top pocket of a coat or jacket.

5. Manual dexterity. Cannot -

(a) turn a “star-headed” sink tap with either hand; or

(b) pick up a £1 coin or equivalent with either hand.

6. Continence -

(a) Continence other than enuresis (bed wetting) where claimant does not have an artificial stoma or urinary collecting device

(a) Has no voluntary control over the evacuation of the bowel;

(b) Has no voluntary control over the voiding of bladder;

(c)At least once a week, loses control of bowels so that the claimant cannot control the full evacuation of the bowel;

(d) At least once a week loses control of bladder so that the claimant cannot control the full voiding of the bladder;

(e) At least once a week fails to control full evacuation of the bowel, owing to a severe disorder of mood or behaviour; or

(f) At least once a week fails to control full voiding of the bladder, owing to a severe disorder of mood or behaviour.

(b) Continence where claimant uses a urinary collecting device, worn for the majority of the time including an indwelling urethral or suprapubic catheter

(a) Has no voluntary control over the evacuation of the bowel;

(b) Has no voluntary control over the voiding of bladder;

(c)At least once a week, loses control of bowels so that the claimant cannot control the full evacuation of the bowel;

(d) At least once a week loses control of bladder so that the claimant cannot control the full voiding of the bladder;

(e) At least once a week fails to control full evacuation of the bowel, owing to a severe disorder of mood or behaviour; or

(f) At least once a week fails to control full voiding of the bladder, owing to a severe disorder of mood or behaviour.

(c) Continence other than enuresis (bed wetting) where claimant has an artificial stoma appliance

(a) Is unable to affix, remove or empty stoma appliance without receiving physical assistance from another person;

(b) Is unable to affix, remove or empty stoma appliance without causing leakage of contents;

(c) Where the claimant’s artificial stoma relates solely to the evacuation of the bowel, has no voluntary control over voiding of bladder;

(d) Where the claimant’s artificial stoma relates solely to the evacuation of the bowel, at least once a week loses control of the bladder so that the claimant cannot control the full voiding of the bladder; or

(e) Where the claimant’s artificial stoma relates solely to the evacuation of the bowel, at least once a week, fails to control the full voiding of the bladder, owing to a severe disorder of mood or behaviour.

7. Maintaining personal hygiene (a) Cannot clean own torso (excluding own back) without receiving physical assistance from someone else;

(b) Cannot clean own torso (excluding back) without repeatedly stopping, experiencing breathlessness or severe discomfort;

(c) Cannot clean own torso (excluding back) without receiving regular prompting given by someone else in the claimant’s presence; or

(d) Owing to a severe disorder of mood or behaviour, fails to clean own torso (excluding own back) without receiving—

(i) physical assistance from someone else, or

(ii) regular prompting given by someone else in the claimant’s presence.

8. Eating and drinking

(a) Conveying food or drink to the mouth.

(a) Cannot convey food or drink to the claimant’s own mouth without receiving physical assistance from someone else;

(b) Cannot convey food or drink to the claimant’s own mouth without repeatedly stopping, experiencing breathlessness or severe discomfort;

(c) Cannot convey food or drink to the claimant’s own his mouth without receiving regular prompting given by someone else in the claimant’s physical presence; or

(d) Owing to a severe disorder of mood or behaviour, fails to convey food or drink to the claimants own mouth without receiving—

(i) physical assistance from someone else, or

(ii) regular prompting given by someone else in the claimant’s presence

(b) Chewing or swallowing food or drink

(a) Cannot chew or swallow food or drink;

(b) Cannot chew or swallow food or drink without repeatedly stopping, experiencing breathlessness or severe discomfort;

(c) Cannot chew or swallow food or drink without repeatedly receiving regular prompting given by someone else in the claimant’s presence; or

(d) Owing to a severe disorder of mood or behaviour, fails to—

(i) chew or swallow food or drink; or

(ii) chew or swallow food or drink without regular prompting given by someone else in the claimant’s presence.

9. Learning or comprehension in the completion of tasks

(a) Cannot learn or understand how to successfully complete a simple task, such as the preparation of a hot drink, at all;

(b) Needs to witness a demonstration, given more than once on the same occasion of how to carry out a simple task before the claimant is able to learn or understand how to complete the task successfully, but would be unable to successfully complete the task the following day without receiving a further demonstration of how to complete it;

or

(c) Fails to do any of the matters referred to in (a) or (b) owing to a severe disorder of mood or behaviour.

10. Personal action (a) Cannot initiate or sustain any personal action (which involves planning, organisation, problem solving, prioritising or switching tasks);

(b) Cannot initiate or sustain personal action without requiring daily verbal prompting given by someone else in the claimant’s presence; or

(c) Fails to initiate or sustain basic personal action without requiring daily verbal prompting given by someone else in the

claimant’s presence, owing to a severe disorder of mood or behaviour.

11. Communication (a) none of the following forms of communication can be achieved by the claimant—

(i) speaking (to a standard that may be understood by strangers);

(ii) writing (to a standard that may be understood by strangers);

(iii) typing (to a standard that may be understood by strangers)

(iv) sign language to a standard equivalent to Level 3 British Sign Language;

(b) none of the forms of communication referred to in (a) are achieved by the claimant, owing to a severe disorder of mood or behaviour;

(c) Misinterprets verbal or non-verbal communication to the extent of causing distress to himself or herself on a daily basis; or

(d) Effectively cannot make himself or herself understood to others because of his disassociation from reality owing to a severe disorder of mood or behaviour.

Appendix B- Comparison ESA 85 (WCA) with IB 85 (PCA) for the Physical Activities

Activity Differences compared to IB 85

ESA 85 Significance of change & notes

Walking Descriptors W(e) & W(f) removed - cannot walk more than 400 metres (& 800 metres respectively) without stopping or severe

Descriptors added –

W (c) – cannot walk up or down 2 steps even with the support of handrail.

W(d) - cannot walk

Both refer to walking with stick or other aid if normally used. 50 and 100 metre delineations provide more

discomfort more than 100 metres without stopping or severe discomfort

clarity in respect of ‘virtually unable to walk’ Ability to manage stairs incorporated into this Activity

Walking up and down stairs

No separate Stairs Activity in ESA 85

Stairs - covered by descriptor W(c) see above and other high descriptors in the Walking category

If customer virtually unable to walk, always need to consider whether they have difficulty on stairs

Sitting Not a separate Activity in ESA 85.

In IB 85 separate Activity with 5 descriptors describing ability to sit comfortably without having to move because of discomfort

Incorporated into the new Activity Standing and Sitting as 2 descriptors S(b) & S(f) – cannot sit in a high back chair for more than 10 minutes ( 30 minutes respectively) before needing to move from the chair because the degree of discomfort experienced makes it impossible to continue sitting.

These sitting descriptors not of direct relevance to DLA; more applicable to the work situation

Rising from sitting

Not a separate Activity in ESA 85.

In IB 85 separate Activity with 4 descriptors

Incorporated into the new Activity Standing and Sitting as 2 descriptors S (c) – cannot rise to standing from sitting in an upright chair without physical assistance from another person and S (d) - cannot move between one seated position and another seated position located next to one another without receiving physical assistance

Indicate cases where help need to rise from a chair and in wheelchair transfers.

Note refers to an upright chair

from another person

Standing Not a separate Activity in ESA 85.

In IB 85 separate Activity with 7 descriptors

Incorporated into the new Activity Standing and Sitting as descriptors S (a) – cannot stand for more than 10 minutes, unassisted by another person, even if free to move around, before needing to sit down and S(e) cannot stand for more than 30 minutes, even if free to move around, before needing to sit down.

Under ESA regulations someone who can stand with 2 sticks is considered to be able to stand

Standing and Sitting

ESA 85 Activity – combines 3 activities that are evaluated separately in IB 85

Clinical findings, observations and daily activities more logically considered and presented together in report.

Bending and Kneeling

Descriptor B(c) removed – sometimes cannot either, bend or kneel, or bend and kneel as if to pick up a piece of paper from the floor and straighten up again

Descriptors added –

B(b) - cannot bend, kneel or squat, as if to pick up a light object, such as a piece of paper, situated 15 cm from the floor on a low shelf, and to move it and straighten up again without the help of another person

B(c) - cannot bend, kneel or squat, as if to pick up a light object off the floor and straighten up again without the help of another person

Removes the difficult to define time scale of ‘sometimes’. ESA Activity describes the function being evaluated more clearly.

Reaching Descriptors RS (e) & RS(f) removed-

RS(e) - cannot rise one arm to head as if to put on a hat but can with other

RS (f) - cannot rise one arm to head as if to reach for something but can with other.

Descriptors R(a), R(b), R(c) & R (d) all refer to inability to raise either arm.

Descriptors refer to customers with bilateral impairment(s). This is a greater degree of functional restriction than in the PCA

Picking up or moving or transferring objects

Replaces Activity known as Lifting & Carrying in IB 85 5 descriptors removed :-

MH(a) - Cannot pick up a paperback book with either hand

MH© - Cannot pick up and pour from a full saucepan or kettle of 1.7 litre capacity

MH(d) - Cannot pick up and carry a 2.5kg bag of potatoes with either hand

MH(e) - Cannot pick up and carry a 0.5 litre carton of milk with one hand but can with the other

MH(f) - Cannot pick up and carry a 2.5kg bag of

Descriptors added

P(a) - Cannot pick up and move a one litre carton full of liquid with either hand.

P(c) - Cannot pick up and move a light but bulky object such as an empty cardboard box, requiring the use of both hands together

Descriptors refer to customers with bilateral impairment(s). This is a greater degree of functional restriction compared to the PCA. The weights used in ESA are lighter and are more applicable to DLA personal care and meal preparation.

potatoes with one hand but can with the other

Manual dexterity

Descriptor D (e) removed: – cannot tie a bow in laces or string

Descriptors added

M(e) - Cannot physically use a conventional keyboard or mouse

M (f) - Cannot do up/undo small buttons, such as shirt or blouse

M (i) - Cannot pour from an open 0.5 litre carton full of liquid.

More emphasis on use of both hands to carry out the functions, and therefore more applicable to DLA personal care and meal preparation. Ability to use a keyboard or mouse shows importance to work related activities in ESA.

Vision Descriptors V (a) & V (b) removed:-

V (a) - cannot tell light from dark

V(b) - cannot see the shape of furniture in the room.

Descriptors added

V(A) - cannot see at all

V(c) - has 50% or greater reduction of visual fields.

V(e) - has 25% or more but less than 50% reduction of visual fields.

ESA evaluates both visual acuity and visual fields, and therefore provides a more detailed assessment of visual impairment. More useful information in respect of work capability and how a customer manages tasks of daily living including ability to get around.

Hearing Descriptors H(b) & H (e) removed:-

H(b) - cannot hear well enough to follow a television programme with the sound turned up

H(e) - cannot hear

Descriptor added

H (d) - cannot hear someone talking in a loud voice in a busy street, sufficiently clearly to distinguish the words being spoken.

Evaluated with hearing aids, if normally worn. Report likely to contain information about people with profound hearing impairments, and therefore of more use in DLA claims.

well enough to understand someone talking in a normal voice on a busy street

Speech Descriptor SP (b) removed: – speech cannot be understood by family or friend

Remaining descriptors unchanged

No significant change.

Continence Activity subdivided under 3 headings10(a), 10(b) and 10(c):-

10 (a) Continence other than enuresis (bed wetting) where the claimant does not have an artificial stoma or urinary collecting device.

10 (b) Continence where the claimant uses a urinary collecting device, worn for the majority of the time including an indwelling urethral or suprapubic catheter.

10 (c) Continence other than enuresis (bed wetting) where the claimant has an artificial stoma.

See main text for full details of individual descriptors.

10 (a) Evaluates if customer has urinary and/or bowel continence and how frequently. 10(b) Relates to use of urinary collecting devices and whether help is needed to manage these. 10(c) Relates to individuals with an artificial stoma and whether they need help to manage it.

Although presentation of information in this Activity appears complex, the nature and effects of incontinence are identified. People who need help with incontinence devices are clearly identified.

Remaining IB 85 Activity is ‘ ESA 85 Activity is Less detailed

conscious Remaining conscious without having epileptic or similar seizures during waking moments’ 3 descriptors removed:-

F(a) - has had an involuntary episode of lost or altered consciousness at least once a day

F ( e) - has had an involuntary episode of lost or altered consciousness at least once in the last 6 months

F(f) - has had an involuntary episode of lost or altered consciousness once in the last 3 years

‘Remaining conscious during waking moments’ and the descriptors refer to ‘lost or altered consciousness, resulting in significantly disrupted awareness or concentration’ and the 3 descriptors attracting a score are:-

F (a) - ........at least once a week

F (b) - ..........at least once a month

F (c) - .........at least twice in the last 6 months ....

information about the frequency of episodes, but time intervals are more applicable to work related activities. Applies to generalized & partial epileptic seizures including absence seizures (petit mal), and also cardiac arrhythmias and hypoglycemia. Scope of medical conditions that may be included appears to be wider than PCA

Appendix C - Summary of how to use ESA 85 Mental Function Information

DLA Considerations

Mental Health Functional Activity

Relevant Descriptors Metal health disorders

Learning or comprehension in completion of tasks (Activity 12)

LT (c),LT (d) & LT (e) Learning disabilities, dementia, brain injury.

Preparing a main meal

Memory and concentration (Activity 14)

MC (a), MC(b) & MC (c)

Learning disabilities, dementia,

brain injury, depression, anxiety, schizophrenia

Execution of tasks (Activity 15)

ET(a), ET(b), ET(c) & ET(d)

Learning disabilities, dementia, brain injury, depression, anxiety, schizophrenia, obsessive-compulsive disorder.

Initiating and sustaining personal action ( Activity16)

IA(a), IA(b),IA(c) & ID(d)

Depression, schizophrenia

Awareness of hazard (Activity 13)

AH(a) & AH(b) Learning disabilities, dementia, brain injury.

Learning or comprehension in completion of tasks (Activity 12)

LT(a),LT(b),LT(c),LT(d) & LT (e)

Learning disabilities, dementia, brain injury

Memory and concentration (Activity 14)

MC (a), MC(b) & MC (c)

Learning disabilities, dementia, brain injury, depression, anxiety, schizophrenia

Execution of tasks (Activity 15)

ET(a), ET(b), ET(c) & ET(d)

Learning disabilities, dementia, brain injury, depression, anxiety, schizophrenia, obsessive-compulsive disorder.

Attention/prompting – self-care, avoidance of self-neglect, maintenance of nutrition, hydration.

Initiating and sustaining

IA(a), IA(b),IA(c) & ID(d)

Learning disabilities,

personal action ( Activity16)

dementia, brain injury, depression, schizophrenia

Learning or comprehension in completion of tasks (Activity 12)

LT(a),LT(b),LT(c),LT(d) & LT (e)

Learning disabilities, dementia, brain injury

Memory and concentration (Activity 14)

MC(a), MC(b) & MC (c) Learning disabilities, dementia, brain injury, depression, anxiety, schizophrenia

Awareness of hazard (Activity 13)

AH(a) & AH(b) Learning disabilities, dementia, brain injury

Proprietary of behaviour with other people (Activity 20)

IB(a), IB(b) & IB(c) Learning disabilities, brain injury, autistic spectrum disorder

Supervision

Dealing with other people (Activity 21)

DP(a),DP(b) & DP(c) Learning disabilities, brain injury, autistic spectrum disorder, psychotic episodes

Getting around (Activity 18)

GA(a), GA(b), GA (c) & GA (d)

Learning disabilities, dementia, brain injury agoraphobia, severe anxiety

Awareness of hazard (Activity 13)

AH(a) & AH(b) Learning disabilities, dementia, brain injury.

Getting around

Proprietary of IB(a), IB(b), IB(c), IB(d) Learning

behaviour with other people (Activity 20)

& IB(e). disabilities, brain injury, autistic spectrum disorder

Dealing with other people (Activity 21)

DP(a), DP(b), DP(c),DP(d), DP(e) & DP(f).

Learning disabilities, brain injury, autistic spectrum disorder, psychotic episodes

Appendix D Comparison of roles undertaken by clinicians and disability analysts

Clinician Disability analyst

Role Makes diagnosis and treats • Assesses • Impairment • Functional

limitations/restrictions • Disability

How History

• Tends to take what patient says at ‘face value’

• Concentrates on symptoms Examination

• Tends to take findings at ‘face value’

• Usually ignores informal observations

History

• Accepts diagnoses from clinician

• Brief history of medical condition

• Symptoms • Asks how medical condition

affects function • Daily living activities • Looks for consistency in

overall picture Examination

• Informal observations (often very important)

• Objective clinical examination • Looks for consistency and

inappropriate signs (i.e. findings not indicative of disease)

Specific skills

Diagnostic techniques (special tests)

Detailed knowledge of treatments

Objective assessment of disability

Opinion fully justified

Knowledge of legal framework when giving advice

Other Usually the patient’s advocate

• Acts in patient’s beat interest

• Maintains doctor/patient relationship

Not acting as patient advocate

• Gives objective advice in accordance with law

• Advice based on detailed functional assessment