DWP WCA Guidance On Severe Conditions

DWP Severe Conditions
Prognosis/Re-referral
Guidance at WCA Face
to Face Assessments
and Filework
(Distance Learning)
MED-DWPSCPRRWCAA~001(a)
Date: 14th September 2017

DWP Severe Conditions prognosis/Re-referral Guidance at WCA Face
To Face Assessments and Filework (Distance Learning)
Foreword
This training has been produced as part of a training programme for

Healthcare Professionals (HCPs) who conduct assessments for The Centre
for Health and Disability Assessments on behalf of the Department for Work
and Pensions.
All HCPs undertaking assessments must be registered practitioners who in

addition, have undergone training in disability assessment medicine and
specific training in the relevant benefit areas. The training includes theory
training in a classroom setting, supervised practical training, and a
demonstration of understanding as assessed by quality audit.
This training must be read with the understanding that, as experienced

practitioners, the HCPs will have detailed knowledge of the principles and
practice of relevant diagnostic techniques and therefore such information is
not contained in this training module.
In addition, the training module is not a stand-alone document, and forms

only a part of the training and written documentation that the HCP receives.
As disability assessment is a practical occupation, much of the guidance also
involves verbal information and coaching.
Thus, although the training module may be of interest to non-medical

readers, it must be remembered that some of the information may not be
readily understood without background medical knowledge and an
awareness of the other training given to HCPs.
MED-DWPSCPRRWCAA~001(a) Page 2 of 36
Document control
Superseded documents
Version history
Version Date Comments
st
1a draft 21 August 2017 Initial draft
nd
1b draft 22 August 2017 Updated with changes to DWP Guidance from
UC policy
rd
1c draft 23 August 2017 Formatting
th
1d draft 24 August 2017 Updated with DWP comments
th
1e draft 29 August 2017 Updated with further DWP comments
th
1f draft 30 August 2017 Updated following DWP guidance changes.
th
1g draft 30 August 2017 Formatting
st
1h draft 31 August 2017 Draft DWP Severe Conditions Guidance
inserted
st
1i draft 1 September 2017 Further update from DWP Strategy, Policy and
Analysis Group
1j draft
st
1 September 2017 Further update from DWP Strategy, Policy and
Analysis Group
th
1 Final 8 September 2017 Signed off by SH&S
th
2a Draft 13 September 2017 Further updates to DWP guidance added.
th
2 Final 14 September 2017 Signed off by SH&S
Updates to Standards incorporated
Issue control
Author: Clinical Training Team
Owner and approver: Department for Work and Pensions
Signature: Date:
Distribution:
Contents
Introduction 5
An introduction to your Learning Pack 5
A guide to using this pack 5
Section One Background to Severe Conditions Guidance 7

Objectives 7
Materials 7
Duration 7
Section Two DWP Severe Condition Criteria 10

Objectives 10
Materials 10
Duration 10
Section Three Key Assessment and Filework Considerations 17

Objectives 17
Materials 17
Duration 17
Section Four Brief Fictitious Case Scenarios 23

Objectives 23
Materials 23
Duration 23
Appendix A - DWP Severe Conditions Guidance 29
Appendix B - Answers to Questions 34
Appendix C - Severe Conditions Advice Flow Chart (Desk Aid) 35
Observation form 36
Introduction
An introduction to your Learning Pack
Welcome to the learning pack on the DWP Guidance and Policy Intent in
relation to providing prognosis/re-referral advice in cases where a severe
condition is identified. Within this learning pack, you will be provided with
some background information to this change, the criteria set out by the DWP
that defines a severe condition and case scenarios to consolidate your
understanding of when it is appropriate to offer advice that further
assessment of the claimant would not be required.
This learning pack will provide you with further detail and clarification on the
DWP severe conditions guidance and policy intent. Any extracts from the
actual guidance will be in italics. The full guidance can be found in Appendix
A.
The Learning Pack will take you approximately 1 hour to complete, which can
be done, in one go or at smaller separate sittings. It is important that you
complete learning activities in the order they are given; by doing so you will
reflect, consolidate and build on your learning throughout.
Following completion of this learning pack, there will also be an opportunity

for you to discuss further short scenarios with your CSL at team meetings.
A guide to using this pack

The following symbols are used to assist you in completing the learning
activities included in this folder.
Indicates a time for reading.
Indicates you should record / write your views and comments.
Advises you of the materials that are provided and/or needed.
Duration
Suggests the approximate time needed to complete any particular learning

activity
Learning Pack Objectives
Through completion of this learning pack you should:
Understand the background for this change to DWP guidance on

claimants with severe conditions
Understand the DWP policy intent in relation to those with severe

conditions and prognosis/re-referral periods
Understand the DWP criteria that define what a severe condition is

within the WCA
Be aware of considerations at assessment and Filework and the use

of the LIMA application
Have consolidated learning through considering brief case scenarios.
CPD Points
1 CPD point is allocated for the completion of this learning pack
Section One Background to Severe

Conditions Guidance
Welcome to the first section of your Learning Pack which concentrates on the
background to this DWP Guidance change.
Objectives
By the end of this section you will:
Understand the background for this change to DWP guidance in the

WCA
Materials
This learning pack
Duration
The learning activities during this section should take approximately 5
minutes to complete.
The following information has been extracted from the first section of the
DWP severe conditions guidance. The complete guidance can be found in
Appendix A of this document. You should read this information to help you
understand the reasons why the DWP have implemented this change.
Extract from DWP Severe Conditions Guidance
Under the LCW/LCWRA clinical procedures Healthcare Professionals (HCP)

are required to provide advice on the re-referral period or prognosis as part of
an assessment.
When considering prognosis or re-referral period, the HCP has to consider

whether the condition or its functional effects are likely to improve. This may
be due to the natural resolution of the condition, or improvement with
treatment, with adaptation or with the use of appropriate aids and appliances.
The approved HCP should provide this advice based upon their assessment
of the claimant, their knowledge of the natural progression of the identified
medical conditions, and the time they feel a claimant may need to adapt to
their condition.
HCPs currently are able to provide reassessment advice for 3, 6, 12, 18, 24
months or in the longer term. In practice DWP policy meant that where a re-
referral period of in the longer term had been agreed by a DWP Decision
Maker, the claimant be re-referred for a further WCA in 3 years if in the
Support Group, or 2 years in the Work-Related Activity Group, and the
equivalent Universal Credit (UC) groups.
However, there is an acceptance that this approach does not work for all
claimants. There will be a small number of those for whom their health
condition or disability is such that there can be no realistic expectation that
they would move towards work or take part in work-related activity at any point
in the future. To that end, in October 2016, the Secretary of State announced
that the Department would stop reassessments for claimants in the ESA
Support Group/UC LCWRA Group (those with Limited Capability for Work-
Related Activity) with the most severe and lifelong health conditions or
disabilities for whom reassessments are likely to provide no further new
information.
The new re-referral period will apply to those with LCWRA ONLY. If a claimant
has LCW but not LCWRA, the process remains as now.
The principles behind this change are to:
Reduce any unnecessary disruption caused to claimants by a repeat

assessment when we do not expect re-assessments to tell us anything
new for the purposes of administering their benefit.
Reduce the burden placed on claimants to continue to produce evidence
confirming the impact of a health condition or disability
Reduce the need for the Department or CHDA to conduct unnecessary
assessments when resource could be better focused.
The Department has set out the criteria for when to apply the new severe
conditions re-referral period. This can be applied at filework and following a
face-to-face assessment.
The criteria will be considered in the next section of this document.
Questions from Section 1 (Answers in Appendix B)

1. This change applies only to claimants who meet LCWRA criteria? True or
False
2. The prognosis/re-referral advice on severe conditions can be given at

either the Filework or Face to Face assessment stages? True or False
3. When advice is provided that a person meets the severe conditions

criteria, there will be no further requirement for the claimant to be re-
assessed? True or False
Section Two DWP Severe Condition Criteria

The second section of your Learning Pack focuses on the DWP Severe
Conditions Criteria.
Objectives
Gain an understanding of the DWP criteria that must be met in order

to advise that the severe conditions prognosis/re-referral option
applies
Materials
This learning pack
Duration
Overview
The DWP guidance has 5 severe conditions criteria that must all be met in
order to advise that significant improvement is unlikely and there is no
requirement for further assessment. These are listed below.
The 5 criteria are:
Key primary Criterion: Meets Functional LCWRA Threshold
Then in addition all 4 of the below must be met:
1. The level of function would always meet LCWRA
2. Lifelong condition
3. No realistic prospect of recovery of function
4. Unambiguous condition
This learning pack will take you through each criterion in turn and provide you
with some key clarifications.
Key Primary Criterion

ONE of the following Functional Support Group (LCWRA) criteria must be
met:
Mobilising 50m Learning tasks
Transfer independently Awareness of hazards
Reaching Personal actions
Picking up and/or moving Coping with change
Manual dexterity Engaging socially
Making yourself understood Appropriateness of behaviour
Understanding Unable to eat / drink / chew /

communication swallow / convey food or
drink
Weekly incontinence
Guidance Notes
Where you identify that any one of the functional LCWRA descriptor applies, you
must then consider whether the other 4 severe conditions criteria apply.
There is no change to how you consider the LCWRA criteria. The same principles
of considering variability, reliably and repeatedly remain. There is no change to
the scope or policy intent of any of the LCWRA criteria.
Note the severe conditions criteria only apply where a functional LCWRA
category is identified.
The severe conditions guidance does not apply to the Treat as LCWRA
criteria. (LCWRA Special Circumstances Criteria). This means you cannot
advise that the severe conditions prognosis/re-referral period applies where
LCWRA Substantial Risk, Terminal Illness, Cancer Treatment, or Pregnancy Risk
is deemed to apply.
Criteria 1 4 to be considered when functional LCWRA applies

Criterion Description Examples of Examples of conditions
conditions that might that might not meet the
meet the criteria criteria
The level of The level of Motor Neurone Disease Conditions which might
function would function would (MND), severe and be severe at times but
always meet always meet progressive forms of recovery of function might
LCWRA LCWRA criteria MS, Parkinsons, All be present for substantial
dementias, All periods, such as recently
chromosomal diagnosed relapsing non-
conditions, Huntingtons, progressive forms of MS
severe irreversible or some people with less
cardiorespiratory failure, severe mental health
severe acquired brain conditions with periods of
injury this list is not reasonable function
exhaustive
Lifelong The condition will Conditions which might
condition, once always be present. be cured by transplant /
diagnosed Some lifelong surgery / treatments or
conditions are conditions which might
present from birth, resolve. This should be
but others will based on currently
develop or be available treatment on the
acquired later in NHS and not on the
life prospect of scientists
discovering a cure in the
future
No realistic Advice on this As per criterion 1 A person within the first
prospect of should be based 12 months following a
recovery of on currently significant stroke who
function available treatment may recover function
and not on the during rehabilitation , so
prospect of whilst the condition is
scientists lifelong, function might
discovering a cure improve
in the future
Unambiguous They have been Non-specific symptoms
condition through relevant not formally diagnosed or
clinical still undergoing
investigation and a investigation
recognised medical
diagnosis has been
made
Criteria 1-4 must be considered where you have identified that the claimant meets
one of the Functional LCWRA criteria.
Criterion 1:
Criterion Description Examples of Examples of

conditions that might conditions that might
meet the criteria not meet the criteria
The level of The level of Motor Neurone Disease Conditions which might
function function would (MND), severe and be severe at times but
would always always meet progressive forms of MS, recovery of function
meet LCWRA LCWRA criteria Parkinsons, All might be present for
dementias, All substantial periods,
chromosomal conditions, such as recently
Huntingtons, severe diagnosed relapsing
irreversible non-progressive forms
cardiorespiratory failure, of MS or some people
severe acquired brain with less severe mental
injury this list is not health conditions with
exhaustive periods of reasonable
function
Key Guidance Points

Although this criterion refers to a level of function that would always meet
LCWRA, this does not in any way exclude people diagnosed with a
condition subject to fluctuation or variability.
The key issue is that the persons condition is not subject to such variability
that their function would ever be significantly improved from the LCWRA
descriptor identified such that a lower descriptor would apply.
For example, a person with severe multiple sclerosis may still have some
fluctuation in their functional ability - but their fluctuation is between severe
and very severe restriction. For example most of the time they are
restricted to mobilising in the house, but during a period of further flare up
the person may be bed bound.
This criterion would not apply for example to a person who has moderate
to severe COPD who has had recent exacerbations where they will meet
LCWRA criteria but at other times can manage reasonable walking
distances.
Remember there is no change to the advice you would give in terms

of when functional LCWRA applies. The criteria and aspects of
repeatedly, reliably and safely continue to apply.
The key question to think about is If I assessed this person at any point
would my advice always be that functional LCWRA is likely to apply
Criterion 2:

conditions that that might not meet the
might meet the criteria
criteria
Lifelong condition, The condition Conditions which might
once diagnosed will always be be cured by transplant /
present. Some surgery / treatments or
lifelong conditions which might
conditions are resolve. This should be
present from based on currently
birth, but others available treatment on
will develop or the NHS and not on the
be acquired later prospect of scientists
in life. discovering a cure in
the future
Key Guidance Points

This criterion seems reasonably clear. The diagnosed condition must be
permanent with no realistic possibility of resolution through recognised
medical treatment.
The condition may have been present from birth but could present later in
life. This may include acute events from trauma/cerebrovascular accident
(CVA) etc or may be from chronic disease processes where the condition
progresses to a severe level and there is no cure or therapy likely to
significantly improve function.
In terms of considering transplantation, the DWP guidance is that where

the clinician responsible for the care of the person has advised the
claimant that they are not suitable for transplant, this information can be
accepted by the HCP as long as it seems medically reasonable. For
example a person with end stage chronic kidney disease who also has
significant left ventricular dysfunction is unlikely to be considered as a
suitable candidate for transplant as they may well not be able to withstand
the effects of the surgery. In this case as long as all the other criteria are
met, severe conditions advice could be offered.
The DWP have confirmed that where a claimant has refused an

intervention advised by their clinician that may improve function, the DWP
advice is that the severe conditions prognosis should not apply as the
persons circumstances may change at a later date, altering their views on
this.
Criterion 3:

conditions that conditions that might
might meet the not meet the criteria
criteria
No realistic Advice on this As per criterion 1 A person within the
prospect of should be based on first 12 months
recovery of currently available following a
function treatment and not on significant stroke
the prospect of who may recover
scientists function during
discovering a cure in rehabilitation , so
the future whilst the condition
is lifelong, function
might improve
Key Guidance Points

Whilst this criterion may seem very similar to criterion 2 at first glance, there
are conditions that may be lifelong but may not necessarily meet this
criterion.
For example, an acquired brain injury (ABI) may have lifelong sequelae,
however; recovery of some function is possible over time and this must be
carefully considered when considering severe conditions advice. A person
with an ABI may initially have profound effects but with rehabilitation etc, may
improve substantially to a point where LCW only applies or indeed, the effects
on their day to day life may be minimal.
The HCP must use their clinical knowledge to consider and advise whether
further recovery of function at the point of assessment point is possible.
The advice must be based on recognised and current interventions - not

based on some research initiatives or proposed research. For example stem
cell research in Parkinsons Disease.
Criterion 4:

conditions that that might not meet the
might meet the criteria
criteria
Unambiguous They have been Non-specific symptoms
condition through relevant not formally diagnosed
clinical or still undergoing
investigation and a investigation
recognised
medical diagnosis
has been made
Key Guidance Points

This criterion means that a medically recognised diagnosis has been
confirmed following investigation.
The reference to unambiguous should not be confused with medically

unexplained conditions. For example there are many conditions that
are not fully understood in terms of the exact pathophysiological
mechanisms of disease but are fully recognised in the medical
community as a diagnosis. For example Chronic Fatigue Syndrome,
Fibromyalgia, Complex Regional Pain syndrome etc.
The key issue is that there has been thorough clinical investigation and
a recognised medical diagnosis has been made.
Severe conditions advice cannot be provided where unexplained

symptoms are still undergoing investigation. For example a person
may be undergoing investigation for symptoms of sweats, joint/muscle
pain and fatigue. The investigations could potentially uncover a
treatable condition such as brucellosis and therefore while there is
ongoing active investigation, severe conditions advice should not be
provided.
A flowchart illustrating the severe conditions criteria has been provided in

Appendix C. You may find this a useful prompt as a desk aid.
Section Three Key Assessment and Filework

Considerations
The third section of your Learning Pack focuses on key considerations at
Filework and face to face Work Capability Assessments.
Objectives
Understand key aspects of evidence gathering at WCA Filework in

relation to severe conditions advice
Understand key aspects of evidence gathering at face to face Work

Capability Assessments in relation to severe conditions advice
Materials
This learning pack
Duration
Filework Considerations
During WCA Filework, as detailed earlier, advice that a claimant meets the
severe conditions criteria can be provided.
The following are some points extracted from the DWP Severe Conditions
Guidance. Where relevant, further explanatory points are provided.
As per filework guidelines request further evidence if it is possible that

one or more of the LCWRA criteria might be met but the information
has not been provided.
As normal, where the HCP identifies that one of the LCWRA criteria may
apply, FME should be requested.
Remember Severe Conditions advice can only be given where a

Functional LCWRA criterion is applicable.
Any request for further evidence should be based on indicators in the

clinical information available to you.
Where further evidence is considered necessary to enable advice

regarding review or no review for a longer term prognosis further
medical evidence review should always be chosen. As per current
process only one request for written medical evidence should normally
be made and at review only one telephone attempt to chase the
evidence is required. If the claimant or their representative needs to be
contacted for further evidence then a maximum of two telephone calls
should be made. These should be documented on an FRR4. If the
evidence is not available, you cannot advise that the claimant has a
Severe Condition and normal filework case control action applies.
You must carefully consider the most appropriate form of FME to help with
your advice. You must keep in mind what information you have in relation to
all 5 severe conditions criteria and what information you may need.
It may therefore be necessary to consider use of an FRR2 to ask a specific

question around whether any further treatment options are being considered
such as whether a transplant may be an option in future.
There is no change to the number or follow up of requests for FME as a

result of this case. FME to review criteria will continue as per current process.
Filework HCPs should not default to calling a claimant to an

assessment if the evidence required to meet the criteria is not
available. If at filework a HCP feels that enough evidence is available
on which a LCWRA in the longer term recommendation can be made,
but is unable to make a recommendation based on the Severe
Conditions criteria, the advice is that they do not seek to call for exam
but instead make a paper-based recommendation that change is not
expected in the longer-term. The reason being that DWP believes
that to increase the burden on this group of claimants would be
unnecessary and go against the spirit of the policy announcement.
The above point carries a high degree of importance. It would be

inappropriate to call a person to face to face assessment solely to
ascertain whether all the severe conditions criteria are met. (E.g. you are
unable to determine whether any further management options such as
transplant are being considered). Remember the severe conditions option
does not impact on benefit entitlement. You can still advise the longer term
prognosis/re-referral period.
The difference in providing the normal long term prognosis/re-referral advice

vs. the severe conditions prognosis/re-referral period is that a person with the
longer term prognosis will have a further questionnaire sent to them in 3
years.
NB - in the guidance above, there is a reference to paper based

recommendation this simply means rather than face to face. All advice will
still be completed on LiMA (other than sensitive cases).
If none of the criteria are met, continue with normal case action.
Where one or more of the severe conditions criteria are not met - you should
continue with case action as per normal process.
An HCPs default position should be that a future review is required. If

you are certain that the evidence indicates that a claimant meets the
Severe Conditions criteria, and a future review is therefore not
required, this should be fully justified.
The DWP have clarified that you must be certain that all of the severe
conditions criteria are met before advising severe conditions applies. If you
have any uncertainty that all the severe conditions criteria apply then you
should not advise severe conditions applies.
Aspects of justification will be covered later in this section.
Face to Face Assessment Considerations

The main area you may need to slightly adapt within the face to face WCA is
in terms of evidence gathering to ensure you can consider whether all severe
conditions criteria are met.
Evidence Gathering in the Condition History.
As always, you must ensure you have adequate information from the
clinical history, typical day and examination findings to fully justify your
advice that a LCWRA functional category is met.
The same advice contained in the WCA Handbook at present continues

to apply around the level of information required at assessment.
The HCP must use their clinical judgement to tailor any assessment
where LCWRA is identified and decide on the amount of history and level
of clinical examination required in each case in order that they can fully
justify their opinion to the DM
However; adequate information must be obtained before you can offer

severe conditions advice.
Within the clinical history - you must ensure you have adequate
information to ensure all the severe conditions criteria are met. This may
mean you need to ask a couple of further questions in relation to
proposed treatment. You must ensure your questioning is sensitive.
Issues such as the prospects of transplant must be carefully but

sensitively explored. DWP guidance is that where the claimant indicates
they have been told they would not be considered for transplant, the HCP
should accept this information as long as it appears medically reasonable.
Within the clinical history, you must also explore if the claimant has
refused any interventions recommended by the consultant in charge of
their care.
Justification
An HCPs default position should be that a future review is required. If you

are certain that the evidence indicates that a claimant meets the Severe
Conditions criteria, and a future review is therefore not required, this
should be fully justified.
The DWP have clarified that where all severe conditions criteria apply,
and severe conditions advice is offered, you must fully justify your
opinion.
In many ways, this is a good opportunity to go through a final mental

checklist for yourself that you do indeed have adequate information to be
able to advise all criteria apply.
Within LiMA, additional phrase options will be available to support your

justification.
The LiMA changes do not have any inbuilt logic. This means the changes
will not identify if LCW/ Functional LCWRA or treat as LCWRA (LCWRA
Special Circumstances) advice is being given and the severe conditions
option will be available in all cases where prognosis/re-referrals advice is
an option. You need to take extreme care that you only use this phrase in
FUNCTIONAL LCWRA cases where all criteria are met.
Be very careful as LiMA would technically allow you to apply this phrase
in LCW/ treat as LCWRA(LCWRA Special Circumstances) cases (Cancer
Treatment/ Pregnancy Risk/Substantial Risk).
Remember Severe Conditions advice only applies where

FUNCTIONAL LCWRA status is identified and all the other 4 criteria
for severe conditions are met.
LiMA Justification
Within LiMA the longer term prognosis button will be used.
You will then have 2 options when this prognosis/re-referral option is chosen.
Option 1 No further assessment will be used where severe conditions advice

applies.
Option 2 Re-assess in the longer term will be used where not all severe
conditions criteria are deemed to be met.
No further assessment
The [LCWRA Evidence] suggests that due to the [diagnosis] the clients condition is unlikely
to improve and is consistent with a severe condition as defined [Free Text]. As per
departmental policy the category of no further assessment cannot apply where the outcome
is Cancer treatment, Risk (LCWRA), Risk (pregnancy) or LCW
Below the above phrase will include a list of LCWRA evidence reviewed in making the
decision. The [diagnosis] will be free text. [Free Text] Will provide a mandatory free text box
for the HCP to fully justify their reasoning.
Re-assess in the longer term.

The [LCWRA Evidence] indicates the client has [diagnosis] however there could be
improvement in the longer term [Free Text].
The phrases above would provide the HCP with a list of LCWRA evidence they have
reviewed in making the decision. The diagnosis box will be free text.
There will also be a mandatory free text box for the HCP to fully justify their reasoning.
The DWP have confirmed that there is no requirement to justify why the
severe conditions prognosis/re-referral advice has not been given. Your
justification will remain as normal for any other LCWRA Prognosis/re-referral
period.
Section Four Brief Fictitious Case Scenarios

The fourth section of your Learning Pack focuses on some brief fictitious
cases scenarios to consolidate your understanding of the DWP Severe
Conditions Guidance.
Objectives
Have consolidated your understanding of DWP Guidance on Severe

Conditions through considering brief case scenarios.
Materials
This learning pack
Duration
The following Case Scenarios are fictitious and have been developed solely
to support learning activities. The amount of information supplied is kept as
minimal to allow time for more scenarios to be considered. You should
assume adequate information from the clinical history and typical day has
been obtained to advise LCWRA. You can also assume any clinical
examination findings are in keeping with the LCWRA criterion.
Case Scenario 1
Key Case details
58 year old Male.
Diagnosis Schizophrenia. No FME returned.
Medication Depo Injections of Clozapine administered by CPN.
Diagnosed age 20. Most information provided by carers. Multiple hospital

admissions over the years. Multiple different medication regimes have been
tried over the years and Stable for the last 4 years on clozapine
administered by CPN.
No active psychotic symptoms for 4 years but negative features of

Schizophrenia increasingly predominant and unchanging over many years.
Lives in supported accommodation with full time carers providing full
assistance with all aspects of living (Meets Personal Action LCWRA criteria).
(Accompanied by 2 carers to assessment). Minimal variation - needs the
same level of support daily for personal care, nutrition etc every day.
Psychiatrist does not wish to further make changes to medication as no other
medication regimes controlled severe psychotic symptoms. Behaviour
therapy options have all also been exhausted.
Letter from CPN supplied at assessment indicates: Mr X has a long standing

diagnosis of Schizophrenia confirmed. He has had negative features of the
condition for many years. Historically his condition was extremely difficult to
control and he had multiple admissions with acute episodes of psychosis. He
has been on multiple treatment regimes over the years. He has had no
recent episodes of psychosis on clozapine but unfortunately his general
function is very poor and he demonstrates severe negative symptoms of
schizophrenia. Outlook is very poor.
Guidance for Case Scenario 1:
Severe conditions advice would apply.
Functional LCWRA criteria applies (Personal Action)
The level of function would always meet LCWRA
Schizophrenia is a lifelong condition
Given duration of condition, multiple treatment regimes over the years

and long terms negative features of disease, and significant functional
improvement seems unlikely.
Condition is formally diagnosed by specialist
Case Scenario 2
Key Case details
57 year old female
Diagnosis COPD. No FME returned
Medication - Almost maximal medication with the exception of O2 therapy.

Daily nebulisers, low dose oral steroids, tiotropium, long acting B2 inhalers
and steroid inhalers.
Diagnosed age 32 with COPD. Heavy smoker since age 13. Breathless on
minimal exertion. Minimal variability. Average days manages to slowly
mobilise around ground floor of house (unable to get upstairs for the last 2
years). Bad days- she is bed bound and needs assistance for toileting using
commode. Never leaves house other in wheelchair that her daughter pushes
for her to go to hospital appointments. She was told she was Grade 5 on the
breathlessness scale. In addition has atrial fibrillation and severe
osteoarthritis affecting multiple joints (Meets LCWRA criteria for mobility)
Consultant has indicated that no further treatment options are available. She
continues to smoke so he has said she cannot have home oxygen. He says
this would improve things perhaps just a little but not to any great extent
so she feels she would rather enjoy a few cigarettes as the oxygen would
not help much at all. She has also been told that due to all her other
conditions and the advanced nature of her disease, she would not be
considered as a candidate for transplant.
Guidance for Case Scenario 2
Severe conditions advice would apply.
Functional LCWRA criteria applies (Mobilising)
COPD is a lifelong condition and in this case at advanced level
The advanced nature of the condition, co-existing disease and ongoing

smoking seems consistent with her statement that the consultant
advised she would not be a suitable candidate for transplant. Although if
she stopped smoking, O2 therapy may become an option, this is
unlikely to improve her function to such an extent she would be able to
mobilise beyond 50m.
Condition is formally diagnosed by specialist.
Case Scenario 3
Key Case details
56 year old Male.
Diagnosis- Osteoarthritis. FME returned-confirmed diagnosis of osteoarthritis.
Medication MST 30mg twice daily. Diclofenac 75mg twice daily. Morphine
10mg as required for breakthrough pain. (Usually 3-4 times daily)
Diagnosed age 45 when he saw his GP with bilateral hip pain. Pain affects
mainly hips but increasingly his wrists as well. Minimal variation in pain.
Had a right hip replacement 4 years ago which was successful and gives him
few problems. His left hip was replaced 5 years ago but unfortunately he
had recurrent dislocations in this joint. This was revised 2 years ago but he
has had ongoing pain in this hip since. His consultant is concerned about
infection in the replaced joint and has referred him to a tertiary referral centre
for advice on whether a further hip revision would be possible. He manages
to walk minimal distances due to the pain in his left hip. (Manages only in the
house or out to the car). His physiotherapist has tried various aids and he
uses an adapted walking stick in the house. He requires splints for his wrists
and with these he manages basic things in the house. He tried to use a self
propelled wheelchair but the pain in his wrists was too severe. If he needs to
get further distances e.g. in the hospital, his son takes him and propels him
in the wheelchair. He meets criteria for LCWRA - mobilising
Guidance for Case Scenario 3:
Severe conditions advice would not apply.
Functional LCWRA criteria applies (Mobilising)
Osteoarthritis is a lifelong condition however, although he has had

complications of hip replacement, further treatment options are still
being actively considered, therefore this criterion would not be met at
this time.
If a further hip revision is considered reasonable, with further

rehabilitation, it would be hoped that improvement in mobility could
occur. Therefore at this point, you could not advise that this criterion
would be met at this time.
Condition has been formally diagnosed.
Case Scenario 4
Key Case details
26 year old female
Diagnosis Antisocial Personality Disorder. No FME returned returned

as no longer registered at this practice. Removed from our practice list
for threatening behaviour towards staff.
Medication No current medication. Awaits a further referral to the

psychiatrists.
MSRS information PV marker flag.
Attended AC with mother. Consent was obtained to include details of

forensic history. Initially diagnosed with ADHD as a child. Had problems
from an early age truanting from school, shoplifting and began to self
harm by cutting wrists age 13. By age 15, problems with violence began
and she was expelled from various schools. She had been in trouble with
authorities and by the age of 16, she received a custodial sentence in a
Young Offenders Institution (YOI) as a juvenile offender.
The GP changed the diagnosis to depression while she was in the YOI
and commenced her on citalopram. This did not help and following her
release she had several more sentences served in the YOI.
Following further release, she again had problems with authorities and
after several assault convictions, she received an adult custodial
sentence age 22. After some time in prison, she was assessed by the
psychiatric team and a diagnosis of Antisocial Personality Disorder was
made. She was taken off medication and she engaged in some CBT and
anger management therapies which helped her gain control of her
behaviour to some degree.
She was released on parole 3 weeks ago and awaits referral to the
community psychiatric services. (Appointment next week). Her physical
violence to others has decreased, but she still has extreme verbal
episodes of aggression and harms herself through hitting her head off
walls or cutting her wrists when it all gets too bad. This occurs on a daily
basis. (LCWRA for unacceptable behaviour applies).
Guidance for Case Scenario 4
Severe conditions advice would not apply.
Functional LCWRA criteria applies (Unacceptable Behaviour)
Personality disorder is a lifelong condition but the therapies she

commenced while in prison have helped to some degree and some
medications can assist with symptoms of aggression etc. Therefore as
not all treatment options have been exhausted, this criterion could
not be deemed to be fully applicable.
Although Antisocial Personality Disorder is difficult to treat, current

evidence does suggest that improvement in function can occur often by
the age of 40 with appropriate therapies, so again this criterion could
not be advised as being met.
Although there have been various proposed diagnoses for this person,
there is no doubt that she has a significant mental health disorder that
would be recognised by the medical community.
Appendix A - DWP Severe Conditions Guidance

Severe Conditions Guidance
1. Under the LCW/LCWRA clinical procedures Healthcare Professionals (HCP) are

required to provide advice on the re-referral period or prognosis as part of an
assessment.
2. When considering prognosis or re-referral period, the HCP has to consider

whether the condition or its functional effects are likely to improve. This may be
due to the natural resolution of the condition, or improvement with treatment, with
adaptation or with the use of appropriate aids and appliances.
3. The approved HCP should provide this advice based upon their assessment of
the claimant, their knowledge of the natural progression of the identified medical
conditions, and the time they feel a claimant may need to adapt to their condition.
4. HCPs currently are able to provide reassessment advice for 3, 6, 12, 18, 24
months or in the longer term. In practice DWP policy meant that where a re-
referral period of in the longer term had been agreed by a DWP Decision Maker,
the claimant be re-referred for a further WCA in 3 years if in the Support Group, or
2 years in the Work-Related Activity Group, and the equivalent Universal Credit
(UC) groups.
5. However, there is an acceptance that this approach does not work for all
claimants. There will be a small number of those for whom their health condition
or disability is such that there can be no realistic expectation that they would
move towards work or take part in work-related activity at any point in the future.
To that end, in October 2016, the Secretary of State announced that the
Department would stop reassessments for claimants in the ESA Support
Group/UC LCWRA Group (those with Limited Capability for Work-Related Activity)
with the most severe and lifelong health conditions or disabilities for whom
reassessments are likely to provide no further new information.
6. The new re-referral period will apply to those with LCWRA ONLY. If a claimant
has LCW but not LCWRA, the process remains as now.
7. The principles behind this change are to:
Reduce any unnecessary disruption caused to claimants by a repeat

assessment when we do not expect re-assessments to tell us anything new for
the purposes of administering their benefit.
Reduce the burden placed on claimants to continue to produce evidence
confirming the impact of a health condition or disability
Reduce the need for the Department or CHDA to conduct unnecessary
assessments when resource could be better focused.
8. The Department has set out the criteria for when to apply the new severe conditions
re-referral period. This can be applied at filework and following a face-to-face
assessment.
CRITERIA
9. ONE of the following Functional Support Group (LCWRA) criteria must be met:
Mobilising 50m
Transfer independently
Reaching
Picking up and/or moving
Manual dexterity
Making yourself understood
Understanding communication
Weekly incontinence
Learning tasks
Awareness of hazards
Personal actions
Coping with change
Engaging socially
Appropriateness of behaviour
Unable to eat / drink / chew / swallow / convey food or drink
10. If ONE of the above criteria is met, ALL FOUR of the following criteria must also
be met:

conditions that conditions that
might meet the might not meet the
criteria criteria
The level of The level of Motor Neurone Conditions which
function would function would Disease (MND), might be severe at
always meet always meet severe and times but recovery
LCWRA LCWRA criteria progressive forms of function might be
of MS, present for
Parkinsons, All substantial periods,
dementias, All such as recently
chromosomal diagnosed relapsing
conditions, non-progressive
Huntingtons, forms of MS or
severe irreversible some people with
cardiorespiratory less severe mental
failure, severe health conditions
acquired brain with periods of
injury this list is reasonable function
not exhaustive
Lifelong The condition will Conditions which

condition, once always be might be cured by
diagnosed present. Some transplant / surgery
lifelong conditions / treatments or
are present from conditions which
birth, but others might resolve. This
will develop or be should be based on
acquired later in currently available
life. treatment on the
NHS and not on the
prospect of
scientists
discovering a cure
in the future
No realistic Advice on this As per criterion 1 A person within the
prospect of should be based first 12 months
recovery of on currently following a
function available significant stroke
treatment and not who may recover
on the prospect of function during
scientists rehabilitation , so
discovering a whilst the condition
cure in the future is lifelong, function
might improve
Unambiguous They have been Non-specific
condition through relevant symptoms not
clinical formally diagnosed
investigation and or still undergoing
a recognised investigation
medical diagnosis
has been made
11. If all of the above and any of the LCWRA criteria are met, advise the decision
maker that the claimant has a Severe Condition and has LCWRA.
12. As per filework guidelines request further evidence if it is possible that one or
more of the LCWRA criteria might be met but the information has not been
provided.
13. Any request for further evidence should be based on indicators in the clinical
information available to you.
14. Where further evidence is considered necessary to enable advice regarding

review or no review for a longer term prognosis further medical evidence review
should always be chosen. As per current process only one request for written
medical evidence should normally be made and at review only one telephone
attempt to chase the evidence is required. If the claimant or their representative

needs to be contacted for further evidence then a maximum of two telephone
calls should be made. These should be documented on an FRR4. If the evidence
is not available, you cannot advise that the claimant has a Severe Condition and
normal filework case control action applies.
15. Filework HCPs should not default to calling a claimant to an assessment if the
evidence required to meet the criteria is not available. If at filework a HCP feels
that enough evidence is available on which a LCWRA in the longer term
recommendation can be made, but is unable to make a recommendation based
on the Severe Conditions criteria, the advice is that they do not seek to call for
exam but instead make a paper-based recommendation that change is not
expected in the longer-term. The reason being that DWP believes that to
increase the burden on this group of claimants would be unnecessary and go
against the spirit of the policy announcement.
16. If none of the criteria are met, continue with normal case action.
17. An HCPs default position should be that a future review is required. If you are
certain that the evidence indicates that a claimant meets the Severe Conditions
criteria, and a future review is therefore not required, this should be fully justified.
Appendix B - Answers to Questions

Section 1
Question 1 - True
Question 2 - True
Question 3 - True
Appendix C - Severe Conditions Advice Flow Chart

(Desk Aid)
Functional LCRWA Severe conditions
Applies advice does not apply
No
Yes
Severe conditions
Would their level of advice does not apply
function always meet
LCWRA criteria? No
Yes
Is this a lifelong Severe conditions

condition? advice does not apply
No
Yes
Is there no realistic Severe conditions

prospect of recovery? advice does not apply
No
Yes
Is the condition Severe conditions

unambiguous (fully advice does not apply
investigated and
diagnosed? No
Yes
SEVERE
CONDITIONS
ADVICE APPLIES
Observation form
Please photocopy this page and use it for any comments and observations
on this document, its contents, or layout, or your experience of using it. If you
are aware of other standards to which this document should refer, or a better
standard, you are requested to indicate this on the form. Your comments will
be taken into account at the next scheduled review.
Name of sender: ________________________ Date: _____________
Location and telephone number:____________________________________
Please return this form to : Centre for Health and Disability Assessments
Learning & Development
Room 236 2nd Floor
Five Ways House
Islington Row Middleway
Birmingham
B15 1SL

DWP WCA Guidance On Severe Conditions

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What is the purpose of this document?

What is the purpose of this document?

What criteria must be met for a condition to be considered 'severe' according to the guidance?

What criteria must be met for a condition to be considered 'severe' according to the guidance?

DWP Severe Conditions

Date: 14th September 2017

This training has been produced as part of a training programme for

All HCPs undertaking assessments must be registered practitioners who in

This training must be read with the understanding that, as experienced

In addition, the training module is not a stand-alone document, and forms

Thus, although the training module may be of interest to non-medical

Updates to Standards incorporated

Owner and approver: Department for Work and Pensions

Section One Background to Severe Conditions Guidance 7

Section Two DWP Severe Condition Criteria 10

Section Three Key Assessment and Filework Considerations 17

Section Four Brief Fictitious Case Scenarios 23

Appendix A - DWP Severe Conditions Guidance 29

Appendix B - Answers to Questions 34

Appendix C - Severe Conditions Advice Flow Chart (Desk Aid) 35

An introduction to your Learning Pack

Following completion of this learning pack, there will also be an opportunity

A guide to using this pack

Indicates a time for reading.

Indicates you should record / write your views and comments.

Advises you of the materials that are provided and/or needed.

Suggests the approximate time needed to complete any particular learning

Learning Pack Objectives

Through completion of this learning pack you should:

Understand the background for this change to DWP guidance on

Understand the DWP policy intent in relation to those with severe

Understand the DWP criteria that define what a severe condition is

Be aware of considerations at assessment and Filework and the use

Have consolidated learning through considering brief case scenarios.

1 CPD point is allocated for the completion of this learning pack

Section One Background to Severe

Understand the background for this change to DWP guidance in the

Extract from DWP Severe Conditions Guidance

Under the LCW/LCWRA clinical procedures Healthcare Professionals (HCP)

When considering prognosis or re-referral period, the HCP has to consider

The principles behind this change are to:

Reduce any unnecessary disruption caused to claimants by a repeat

The criteria will be considered in the next section of this document.

Questions from Section 1 (Answers in Appendix B)

2. The prognosis/re-referral advice on severe conditions can be given at

3. When advice is provided that a person meets the severe conditions

Section Two DWP Severe Condition Criteria

Gain an understanding of the DWP criteria that must be met in order

The 5 criteria are:

Key primary Criterion: Meets Functional LCWRA Threshold

Then in addition all 4 of the below must be met:

1. The level of function would always meet LCWRA

3. No realistic prospect of recovery of function

Key Primary Criterion

Mobilising 50m Learning tasks

Transfer independently Awareness of hazards

Reaching Personal actions

Picking up and/or moving Coping with change