Use of Employment and Support Allowance Information in Claims for Disability Living Allowance

7/31/2019 Use of Employment and Support Allowance Information in Claims for Disability Living Allowance

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USE OF EMPLOYMENT ANDSUPPORT ALLOWANCE

INFORMATION IN CLAIMS FORDISABILITY LIVING ALLOWANCE

A Handbook for Decision Makers

Forward

This handbook has been prepared by the Departments Health, Work and

Wellbeing Directorate. It considers how Disability Living Allowance (DLA)Decision Makers (DMs) can use the information obtained in assessingEmployment and Support Allowance in determining DLA benefit entitlement.

Employment and Support Allowance (ESA) has been introduced in October2008, for new claimants, and will replace Incapacity Benefit and IncomeSupport paid on grounds of incapacity. Analysis has shown that a largepercentage of DLA claimants have a current or recent claim to incapacitybenefit. Valuable information relating to the customers medical condition andfunctional limitations will be available in the documentation used to evaluatethe ESA claim. Using this information may save the customer from having to

undergo an examination in connection with their DLA claim, and reduce theneed to obtain further clinical information from the customers doctor oranother health care professional (HCP).

Section 1 Background

1 The Employment and Support Allowance has been designed to enablepeople to achieve their full potential through work and to help them to gainindependence from benefits. It will focus on what the person can do ratherthan what they cannot do. The overarching principle is that everyone should

have the opportunity to work, and that people with an illness or disabilityshould get the help and support needed for them to engage in appropriatework.

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

3 The assessment process for deciding entitlement to benefit and rate ofbenefit paid is the Work Capability Assessment (WCA). The Work CapabilityAssessment replaces the Personal Capability Assessment (PCA) used to

determine entitlement to Incapacity Benefit. Within the WCA, there are anumber of assessments:


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Limited Capability for Work Related Activity (LCWRA) Thisassessment aims to identify, through a series of descriptors, customerswith the most severe illnesses or disabilities. These customers willidentified as members of the Support Group of ESA and will not haveto 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 whowould benefit from assistance and support with work and health relatedactivity to maximise their full potential. This part resembles the PCA,but the descriptors have be reviewed and revised for both physical andmental functional capabilities. The report (ESA 85) generated from thispart of the assessment will available to the DLA Decision Maker.

Work Focused Health related Assessment (WFHRA) This partcomprises an interview with a healthcare professional to explore thecustomers 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 thefirst thirteen weeks of claiming Employment and Support Allowance. It willassess, for the purposes of determining entitlement, whether a customer canbe considered to have limited capability for work. It will also help determinethe rate at which ESA is awarded from week fourteen.

2 The Work Capability Assessment looks at the effects of any illness ordisability on the customers ability to carry out a range of everyday workrelated activities. The outcome of WCA determines if a person has limitedcapability for work. If a customer does not have limited capability for work theywill be provided with advice about registering for employment and claimingother 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;


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Vision including visual activity and visual fields, in normal daylight orbright electric light, with glasses or other aid to vision if such aid isnormally 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 intellectualfunction 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 ofstatements 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 customers illness or disability has ascore.

For example, Walking is defined as Walking with a stick or other aid if suchaid 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, andthere 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


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familiar, without being accompanied by another person on eachoccasion (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 thereforeincludes a means of taking into account the combined effects of differentdisabilities. For example, if a customer could walk 50 metres or more butcould not walk 200 metres without stopping or severe discomfort, this by itselfwould score 6. However, if they also had difficulties with Manual dexteritysuch as cannot physically use a pen or pencil, this would score an additional9. Any further score awarded in respect of functional limitation caused by amental health disorder is added to reach the total. If a customer is awarded ascore of 15 or more, they will be entitled to Employment and SupportAllowance 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 thirteenweek assessment phase. If it is apparent at this initial stage that the customeris terminally ill (Special Rules), benefit is paid without the need to undergofurther assessment. Some other customers, for example, people receivingchemotherapy or regular haemodialysis, will also be considered as havinglimited capability for work without taking part in the full Work CapabilityAssessment.

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

3 People eligible for inclusion in the Support Group are those who have themost severe illnesses and disabilities, including terminal illnesses. Customersfulfilling the criteria for the Support Group are treated as having limited

capability for work and for work related activity. They are assessed in respectof eleven Activities, and Medical Services will advise the ESA DM on report


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ESA 85A if at least one of the descriptors applies to the customer. The elevenActivities 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 andarms;

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 forassessment, when the medical examination is recorded on form ESA 85, anda WFHRA is carried out. The medical report ESA85 provides medicalevidence and information that is likely to be useful to the DLA DM. It may,however, become apparent at this assessment that the customer has asevere illness or disability such that they fulfill the criteria for the SupportGroup, and the ESA DM is advised accordingly.

5 On the basis of the information in report ESA85 the Decision Makerdetermines whether the customer has limited capability for work. Thecustomer 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 inany functional area attract 15 points and the lowest descriptors have a 6 pointvalue. A customer may reach the prescribed degree of disability to be

considered as having limited capability for work, if they are awarded thehighest descriptor in any one physical or mental function category or througha combination of lower scoring descriptors in a number of functional areas.

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

Section 4 Overview of how the WorkCapability Assessment can be used in DLA


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1 The medical report form ESA85 is completed as part of the assessment ofthe customer at the Medical Examination Centre. It contains valuableinformation including factual information about the medical condition and thecustomers 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 DLADM are described in detail in subsequent sections.

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

Section 5 What happens at the MedicalAssessment

Approved disability analyst

1 The medical assessment process as a whole differs in many respects fromtraditional history taking and examination that occurs in the general practice orhospital setting. It entails bringing together information gained fromobservation, questionnaire, medical evidence and examination in order to

reach an accurate assessment of the customers functional restrictions. Theassessment is carried out by an Approved Disability Analyst.

2All health care professionals who give advice relating to Employment andSupport Allowance must be approved by the Secretary of State for Work andPensions. The approved disability analyst may be a registered medicalpractitioner, registered nurse, registered occupational therapist or registeredphysiotherapist. Approval involves attendance at a prescribed training course,written assessment of medical knowledge, successful completion of thestages of the approval process, and ongoing demonstration that the workbeing carried out meets a satisfactory standard including attendance at future

professional educational events.


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3 Examining Medical Practitioners who carry out DLA/AA assessmentsundergo a similar process of training and monitoring, and are approved asdisability 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 orhospital specialist, which is to diagnose and treat the patient. The clinician isan expert in arriving at a diagnosis, using physical examination and specialinvestigations in combination with detailed knowledge of treatments.Clinicians are not experts in assessment of disability, since they have notreceived training in determining the disabling effects of medical conditions ona persons every day life and activities. See table at Appendix D.

5 The medical disability analyst provides the Decision Maker with justifiedadvice that takes into account the clinical history, examination, observedbehaviour and their knowledge of the disabling effects of the medical

condition(s). The advice is consistent, evidence based and in accordance withthe 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 inthe file. All the medical evidence is considered, including medical certificates,factual reports, any previous examination and other documents, includingTribunal documents. Particular attention is paid to the current customerquestionnaire (ESA 5O).

8 When the disability analyst has read the documents, he or she usually goesto meet the customer in the waiting room, and accompanies them from thewaiting 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 analystto observe the customers activities outside the examination room. Thedisability analyst will observe how the customer rises from the chair, walksetc.

Interviewing the Customer

9 The nature of the interview differs materially from the traditional consultationin clinical practice. The aim of the traditional interview is to arrive at adiagnosis and treat the patient. In the LCW/LCWRA interview, the disabilityanalyst gathers information to assess the claimants abilities in all of the

relevant functional areas. A concise and relevant medical history is included.


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10 One of the most important aspects of the interview is the Typical Dayenquiry. This is a record of the customers everyday life including a factualdescription of how the medical condition affects their day-to-day activities. Thedisability 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 thecustomers consent for physical examination of the relevant functional areas.The granting of this consent is noted in the report. Mental state examinationand completion of the Mental Function assessment is carried out where thereis evidence of mental disease or disablement (mental illness, learningdisabilities, cognitive impairment or sedative medication).

12 Informal observations of the customer are also made during the entireperiod of customer contact and incorporated into the report. The disabilityanalyst looks for consistency when evaluating the informal observations, theclinical examination findings, the clinical history, and the analysts knowledgeof the disabling effects of the customers medical condition(s).

Completing the medical report form ESA 85

13 The disability analyst completes the medical report ESA 85 choosing andjustifying the relevant descriptors. In the majority of claims a computerised

version of the report using Logic integrated Medical Assessment (LiMA) isprovided for the Decision Maker.

14 Where the disability analysts choice of descriptor differs from thecustomer's stated level of disability, the disability analyst provides justifiedadvice to the Decision Maker supported by the evidence to explain why theiropinion, rather than the customer's, should be accepted.

15 If the customer has a severe illness or disability such that they fulfil thecriteria for inclusion in the Support Group both the examination and the reportcompletion 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 offunctional restriction in a number of areas i.e. the highest-ranking descriptorsare applicable for a number of Activities. Under these circumstances LiMAinvites the author to provide the most detailed justification in the most highlyscoring activities, and less information is provided about other Activities.

17 The time spent with the customer is recorded on the report, and includesthe time from greeting the customer in the waiting room until the end of theinterview and examination. The additional time that it takes to complete the

report is recorded. The time spent on the medical assessment will depend on


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

Section 6 - Choosing descriptors

1 The disability analyst selects their choice of descriptor in each of 11 physicalfunctional areas (Activities), and if relevant to the case, in each of 10 mentalfunction areas.

2 The choice of the most appropriate descriptor in the relevant functionalareas depends upon consideration of all the medical evidence, the customerinterview, the medical examination, and the disability analysts medicalknowledge 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 intoaccount such factors as pain, stiffness, response to treatment and variabilityof symptoms. This ensures that the opinion is not just a "snapshot" of thecustomer on the day of examination, but reflects their functional ability over aperiod of time. See below for more detail.

4 In certain functional areas, the descriptors do not conform to a simplehierarchical progression. In these areas the descriptor chosen is that whichmost accurately reflects the highest level of disability experienced by theclaimant. For example, in the functional area of Continence, when a customer

loses control of bladder so that the person cannot control the full voiding ofthe bladder at least once a month and loses control of bowels so that theperson cannot control the full evacuation of the bowel occasionally, the latteris selected, as it is the higher descriptor.

5 If the disability analysts opinion on the level of functional restriction in anyActivity differs from that of the customer, as indicated on the ESA 50questionnaire or as described at interview, the disability analyst provides a fulljustification for their opinion. The justification of descriptor choice is supportedby information from the clinical history, activities of daily living, observation ofthe customer, and clinical examination findings.

6A number of functional activity areas on the ESA 85 are linked e.g. walking,standing and sitting, and bending and kneeling, and justification for thesegroup 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 differentsections of the report. Any apparent contradictions are explained such that theDecision Maker is able to understand that two pieces of evidence, which atfirst sight appear contradictory, are in fact compatible with one another.

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


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7 The customer must be able to undertake the Activity safely. If a person withvertigo is physically able to bend to touch his knees but in so doing falls overdue 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 ofpain they are considered incapable of performing that Activity.

9 When considering the effects of pain, the predictability of onset and theeffectiveness of treatment are taken into account. Pain that starts withoutwarning and requires analgesia is very different from predictable angina ofeffort that can be forestalled, or rapidly relieved, with appropriate treatment(e.g. GTN spray).

10 Breathlessness is an important symptom, because it is not specificallyreflected in many of the descriptors, but it may contribute significantly to

disability, for example, in relation to walking. Therefore, a customer whoexperiences significant breathlessness when carrying out an activity shouldbe scored as if the activity cannot be undertaken.

11 The disability analyst will advise on the consistency of the variable factorswith the diagnosis and with the stage reached by the disease, and with thecustomers lifestyle.

For example, the medical certification says the customer has mechanical backpain, and on examination there is no lumbar spine abnormality. The customersays 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 notnormally vary to this extent.

Section 8 - Physical and Sensory Activities

Eleven specified physical Activities are assessed. These are grouped togetheras 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


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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 disorderhas been diagnosed, or where there is any condition, that could be mental,physical or sensory, that results in the cognitive or intellectual impairment. Inaddition 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 themental function assessment, they are required to justify this. This is likely tobe the case where there is no recent history of diagnosis or treatment ofmental illness, and where there is no evidence at the assessment of anycondition, diagnosed or apparent, that is likely to impair mental function.

3 There are ten Activities (functional categories) that are addressed in theESA LCW/LCWRA mental assessment. These categories cover a number ofareas relevant to those with a specific mental illness, or cognitive orintellectual impairment. These categories are grouped together in the ESA 85report 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;


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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 bythe disability analyst from which he or she draws evidence to support theirchoice 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 ESA85

1As described at the beginning of this guidance the WCA has been designedto focus on a persons capabilities with an emphasis on what they can dorather than what they cannot. Both the physical and mental Activities havemodified so that they reflect the type of work related activities relevant to themodern work place. The physical Activities recorded in the IB 85 have beenextensively revised for ESA. Changes include removal of some Activities,amalgamation of others, inclusion of new descriptors and revision anddeletion of existing descriptors. The descriptor scores have also been revisedto 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 bythe new ESA mental function assessment. There are no longer 25 descriptorspresented as a series of questions requiring a yes or no answer. In the ESA85 there are 10 new mental function Activities, each of which has a number ofranked descriptors. This mirrors the format of the physical assessment, andthe disability analyst chooses a descriptor for each Activity, and the descriptoris scored.

Section 11 The ESA 85 report and its relevanceto the DLA Decision Maker


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

1A list of medical conditions, previously diagnosed, found at the medicalassessment 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 disabilityanalysts 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 3months.

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 analystschoice of descriptors for the eleven physical functional areas (Activities). TheActivities are grouped together under a number of headings i.e. Lower limb,Upper limb, Special senses, Continence and Remaining Conscious. Withineach 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 functionassessment has been applied. If not, an explanation why it has not beenapplied is recorded.

11 Medical opinion Mental function. This section records the disabilityanalysts choice of descriptors for the ten mental functional areas (Activities).The Activities are grouped together under three headings i.e. Understandingand focus, Adapting to change and Social Interaction. Within each of thesegroupings the medical evidence used to justify the choice of descriptor foreach 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.

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


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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 usuallyhave significant functional restrictions, it is unlikely that the informationpertaining to this category will be of direct relevance to the DLA DM.

13 Limited Capability for Work Related Activities. In this section the disabilityanalyst gives an opinion as to why the customer does not meet any of thedescriptors for the Limited Capability for Work- Related Activity. i.e. fulfill theSupport Group criteria. This is the most likely outcome in the majority ofcases, 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 onreport 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 insection 16.

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

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

Section 12 The Physical Assessment and itsuse 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 eachActivity is combined with notes about the type of specific evidence that thedisability analyst takes into account in making their descriptor choice. Foreach Activity additional guidance on how the ESA 85 report may be used toevaluate 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


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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 repeatedlystopping 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 orsevere discomfort.

W (f) None of the above apply.

Scope

1 This Activity is intended to reflect the level of mobility that a person wouldneed in order to be able to move reasonably within and around an indoorenvironment. It is intended mainly to apply to lower limbs impairments;however walking ability may also be restricted by limited exercise tolerancedue to respiratory or cardiovascular disease. Conditions affecting upper limbfunction i.e. ability to use a stick, are not taken into consideration.

2 Walking is bipedal locomotion, that is, movement achieved by bearingweight first on one leg and then the other. Those who are wheelchairdependant 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, thedisability analyst takes account of brief pauses made out of choice rather than


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

4 Descriptor W(c) also reflects a severe limitation of stair climbing. This maybe caused by severe lower limb impairments or breathlessness. It should be

noted that the descriptor indicates inability to perform this task even if holdingon to a handrail(s). Therefore the individuals abilities are considered withinthe context of a handrail being present. This activity reflects a test of walkingup or down 2 steps, not of whether one hand or two hands is needed forsupport while doing so. Therefore a person who can manage the two stepswith support of two

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

6 Walking may occasionally also be affected by disturbances of balance dueto for example, dizziness or vertigo. The effects of any such condition will benoted 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 thecustomer 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 than40m/min.

9 The method of travel to the examination centre is relevant. The disabilityanalyst is likely, from local knowledge, to be aware of the distance from thebus 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 areato the examination room, and notes their gait, pace and any problem withbalance. They will look for evidence of breathlessness caused by walking.

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


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Clinical examination

12 Restricted ability to walk will commonly be due to musculoskeletal andneurological disorders affecting the lower limbs, and sometimes the lumbarspine. Restrictions may also be due to diseases of the respiratory or

cardiovascular systems, with limitation of exercise tolerance as a result ofbreathlessness, angina or claudication.

13 Where relevant, an appropriate assessment of the heart and lungs iscarried out, with a record of any cyanosis, dyspnoea at rest or on minimalexertion, the presence of audible wheeze, signs of heart failure such as ankleoedema, and the state of peripheral blood vessels. Any respiratory orcardiovascular factors affecting exercise tolerance are taken into accountwhen choosing the descriptor.

14 Peak flow may be measured, if appropriate, and the recordedmeasurement interpreted for the DM within the context of the other availableinformation. 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 thatthe person has difficulty in using stairs.

16 If descriptor W (d) is chosen Cannot walk more than 100 metres onlevel ground without stopping or severe discomfort, it is unlikely that theperson is restricted in their walking to a lesser distance. If the disability analystjudged 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 accountfactors such as pain, fatigue, balance, gait, ability to walk at a reasonablespeed and breathlessness. If the person has severe breathlessness due tocardiac 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 analysts ownobservation of the person walking at the examination centre, and the accountof their daily activities. It is worth noting that a person who can easily managearound the house and garden is unlikely to be limited to walking less than 200


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metres; a person who can walk around a shopping centre/supermarket isunlikely 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 10minutes before needing to move from the chair because the degree ofdiscomfort experienced makes it impossible to continue sitting.

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

S (d) Cannot move between one seated position and another seated positionlocated next to one another without receiving physical assistance fromanother 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 30minutes 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 reflectthe need to be able to remain in one place, either sitting or standing. Whenstanding, a person would not be expected to have a need to stand absolutelystill, but would have freedom to move around or shift position whilst standing.

S (d) Moving between adjacent seated positions is intended to reflect awheelchair 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 withoutsupport 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


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discomfort makes it impossible to continue sitting, and therefore anyactivity being undertaken in a seated position would have to cease.

Inability to remain seated in comfort is only very rarely due todisabilities other than those involving the lumbar spine, hip joints andtheir related musculature.

Details of daily living

3 The disability analyst considers the customers 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 withno arms).

Time spent travelling in cars or buses.

Observed behaviour

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

Standing

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

6 S (e) reflects the ability to stand even with the use of aids. The ESAregulations specify the person is to be assessed as if wearing any prosthesiswith which [he] is fitted, or wearing or using any aid or appliance which isnormally worn or used. So a person who can stand with the aid of two sticksis, for the purpose of descriptor choice, able to stand.

7 The requirement to sit down suggests a greater degree of disability thansimple discomfort resulting in a need to move around. It would normally beexpected that significant lower limb problems and muscle weakness would bepresent

Details of activities of daily living


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.


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Standing to watch sporting activities.

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

Observed behaviour

9 It is usually only possible to observe the customer standing for short periodsof time during the assessment and the report should reflect this, e.g.

"I observed him standing for 3 minutes only during my examination of hisspine but he exhibited no distress and this, in conjunction with the clinicalexamination recorded, would not be consistent with his stated inability tostand for less than 30 minutes. He may need to move around to ease spinaldiscomfort but would not need to sit down."

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

Rising and Transferring

11 When considering the ability to rise from sitting to standing, the descriptoronly applies when the customer is unable to rise from sitting without theassistance of another person. If they could rise using the arms of the chair orother appropriate aid this descriptor would not apply. The descriptor would beconsistent with severe lower limb problems and muscle wasting. The

functions of the major leg joints have more relevance than lower spinalfunction to this activity, since rising can be achieved without spinal flexion.

12 Similarly, the inability to transfer between one seated position and anotherindicates significant disability. It reflects those who are wheelchair dependantand unable to transfer independently. Upper limb function may be relevant inthis activity. For example, a rehabilitated paraplegic who is able to transfer byuse of his upper limbs would not satisfy the transferring descriptor (howeverthey may well satisfy the higher standing descriptor depending on degree oflower limb weakness).


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

Getting on and off the toilet unaided, without the assistance of anotherperson.

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.


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Observed behaviour

14 The disability analyst observes the customers ability to rise from sittingand notes the type of chair, when the person is collected from the waitingarea. There is a further opportunity to observe this function during and at the

end of the interview.


15 Restricted ability to sit and stand will commonly be due to disordersaffecting the lumbar spine or lower limbs. The level of restriction required forsitting or standing descriptors to apply would indicate that there should beevidence of positive clinical findings in the majority of cases. Normalfunctional ranges of movement for rising are considered. Evidence of musclewasting and reduced power in the lower limbs are important clinical findings.

16 Upper limb function is reviewed when considering ability to transfer. Aparaplegic who has suffered a complete spinal cord transaction but who hasgood upper limb power may be able to transfer, however a quadriplegic withan incomplete spinal cord injury who has limited power in both upper andlower limbs may be unable to transfer.

DLA Considerations

17 The Activity provides information about the ability to stand, to rise from achair, to transfer and to sit comfortably. Consideration of the descriptor

chosen will be useful to the DM when determining the help needed withgetting in and out of bed, use of bath/shower, rising from a chair, using thetoilet 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 maylimit the ability to stand. Someone who cannot stand unassisted for more than10 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 formore than 30 minutes are likely to more independent in respect of these careneeds. Corroboration of a persons ability to stand will be found in the recordof daily activities e.g. waiting for the bus, queuing at the supermarket checkout, waiting for children outside school.

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


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

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

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

22 The ability to sit comfortably (descriptors S (b) and S (e)) are of lessrelevance to the need for care, and are more applicable to the persons 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 pieceof 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 andstraighten 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 reflectability 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 forsupport to straighten up again.

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

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


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



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 leisureand recreational activities involving bending e.g. gardening, tending to pets.

Observed behaviour

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

6 The disability analyst will observe the customers ability to climb on and off

the couch.

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


8 Restriction of spinal movement to the degree indicated by B (a) suggests asevere 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 kneesand hips. In some neurological conditions an assessment of balance includingtests of cerebellar or proprioceptive function may be recorded. Assessment ofpower in the lower limbs is essential.

DLA Considerations

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


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10A person with lumbar back pain who has good hip and knee function wouldbe expected to be able to bend to an oven safely, since they would not relysolely 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 coator 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

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

2This functional category considers the customers ability to reach upwards. It

is an evaluation of power, co-ordination, and joint mobility in the upper limbs.

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

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

Details of activity of daily living


Dressing and undressing (including reaching for clothes on shelves/inwardrobes).

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 ona washing line.

Leisure activities such as aerobics, golf, painting and decorating.


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Observed behaviour

6 The disability analyst records any spontaneous movements of the upperlimbs, particularly if these are in excess of those elicited by formalexamination.

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

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

Examination

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

DLA considerations

10Cases in which any of the descriptors R (a) to R (d) have been chosen arelikely to have severe bilateral joint conditions or neurological disordersaffecting function e.g. rheumatoid arthritis, tetraplegia, muscular dystrophy.This information will be useful to the DM when considering the need for helpwith dressing, washing, feeding etc., and will be supported by observations of

upper limb use in the examination centre, and an account of relevant dailyliving 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 thataffects 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 analysts opinion in respect of the function in each will besupported in the usual manner by the observations and the persons ability toperform 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 upperbody 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.


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P(c) Cannot pick up and move a light but bulky object, such as an emptycardboard 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 andco-ordination of movement are also considered. It is intended to reflect theability to pick up and transfer articles at waist level, i.e. at a level that requiresneither bending down and lifting, nor reaching upwards (these capabilities arecovered in other areas). It does not include the ability to carry out any activityother than picking up and transferring, i.e. it does not include ability to pourfrom a carton or jug. Note that the descriptors apply to people who havefunctional restriction affecting both upper limbs.

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

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

Details of activities of Daily Living


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 theease (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 upperlimb function.

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


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

Examination

9 The report contains information about joint movement and power in thelimbs. Reduced co-ordination or other neurological problems such as tremore.g. Parkinsons disease, is assessed when considering these activities.

DLA Considerations

10 The information in the report will applicable to care needs in respect ofdressing, 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 jointconditions such as rheumatoid arthritis or neurological disorders such asmultiple sclerosis, Parkinsons disease.

11 The Activity does not apply to someone who can pick up or transfer withone arm only, whether the dominant arm or not. However if a person has acondition that affects one upper limb only e.g. stroke, this will be documentedin the report. Clinical findings will be recorded for both the impaired and thenormal limb, and the disability analysts opinion in respect of the function ineach will be supported in the usual manner by the observations and thepersons 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 withpersonal 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 theother.


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

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 thelevel of ability to manipulate objects that a person would need in order to carryout work-related tasks. Ability to use a pen or pencil is intended to reflect theability to use a pen or pencil in order to make a purposeful mark. It does notreflect a persons level of literacy. The same concept applies to use of acomputer 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 canonly be accomplished with the support of the other limb. For example, thecustomer whose right-arm is in a plaster cast where they can only completetasks by supporting it with the left arm.

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

4An individual in a forearm plaster may still have good movements of their

hands but the level of pain experienced should be taken into account whenchoosing a descriptor, e.g. an individual with a fractured wrist may have goodfine movements of their hand but turning a star headed sink tap would causesevere pain in their wrist.

Details of Activities of daily living


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 thecustomer handles tablet bottles, their expenses sheet or a repeat prescriptionsheet. 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,


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expressive dysphasia (inability to express ones thoughts) resulting from braininjury.

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

3 Speech is an extremely complex activity, involving intellectual, neurologicaland musculoskeletal components. It may, therefore, be affected by anycondition involving these areas. In rare cases, it may be that bothpsychological and physical factors play a part in the causation of speechdifficulties.

4 Speech problems may occasionally be claimed such that speech is affectedin cases of Chronic Fatigue Syndrome, where the customer asserts thatspeech becomes unclear when they are tired. A similar claim may be made bycustomers suffering from panic attacks, who describe difficulty in making

themselves understood during an episode of acute anxiety. It may be the casethat such customers should be assessed under the mental function Activities.The disability analyst considers their ability to make themselves understoodmost of the time.

5 Some customers who suffer from breathlessness due to physical causes willdescribe difficulty with speech. However, in many of these cases, the problemis transitory and only occurs during extra physical effort, like walking quickly orclimbing stairs. Therefore, for the majority of the time, they will have normalspeech.



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 anydifficulty they have in understanding the customer. The report will detail anyabnormalities 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


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H (b) Cannot hear well enough to be able to hear someone talking in a loudvoice 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, sufficientlyclearly 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 beable to follow a conversation. It is intended to take into account hearing aids ifnormally worn, but not non-verbal means of communication such as lipreading or use of sign language.

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

3A "busy street" does not mean one rendered intolerably noisy byexceptional 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 busytraffic passes by. The assessment will consider whether the customer couldhold such a conversation under these circumstances, or whether hearing is sodiminished that background traffic noise would render conversationimpossible.

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

5 The report will describe the persons ability to wear a hearing aid. If theperson 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 hearingaid and has abandoned its use should be assessed without aids.

6 It should be remembered that hearing aids can cause distortion of soundand do not restore normal hearing to people with hearing impairments. Olderpeople may have difficulties adapting to hearing aid use.

7 The report will provide examples of how a person with hearing impairmentcommunicate in day to day life with family, out shopping, travelling by publictransport etc. People with severe hearing impairment who use British SignLanguage may attend for assessment. In these circumstances the disability

analyst is asked to enquire, via their interpreter, about their ability to


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

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


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

10 The report will describe the use of any accessory aids such asheadphones or loop system amplification for TV, radio, or video; amplificationfor telephone handset; loud front door bells or door lights.

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

Observed behaviour

12 The customers response to an ordinary or quiet voice during interview is agood 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 functionpoorly at the interview requiring the examiner to raise their voice and repeatquestions.

Examination

14 The most relevant examination technique is the conversational voice test.One ear is masked with the customers hand and the customer looks awayfrom the examiner. The customer is asked to repeat numbers or words oranswer simple questions, which are posed in a normal conversational voice.The furthest distance away from the ear that the words can be heard isrecorded.

15 The normal ear can detect a conversational voice at 9 metres, which isimpractical in most examination centres. A distance of 3 metres is acceptableproof of hearing for the purposes of reasonable functional hearing ability.

16 In unilateral hearing loss the normal ear generally compensates for thedeaf one, so the overall hearing loss in such a case is unlikely to be


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significant. However, checking the hearing in each ear separately and thenboth ears together provide opportunity to detect unreliable responsessuggestive of non-organic hearing loss.

Tinnitus

17 Tinnitus the perception of sound where there is no external stimulus. It isoften 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 tomask tinnitus. Customers may also have developed their own maskingtechniques, 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 insleep disturbance, anxiety and depression. The following factors will giveindication 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 itcan significantly impact on concentration. The Mental Function test is carriedout in cases of tinnitus where there is anxiety/depression or other mental

disablement.

Menieres disease

21 Menieres disease is characterised by recurring bouts of profound,prostrating vertigo, nausea and vomiting with deafness and tinnitus. Suchattacks can last for anything up to 24 hours, but unsteadiness and loss ofconfidence can persist for several further days. Sensorineural low/mid-frequency hearing loss and tinnitus may persist between bouts and if thecondition is chronic the deafness may be progressive. The occurrence ofattacks 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 thefrequency and duration of the attacks, and also the therapeutic measuresbeing taken to control the condition, and the effectiveness of the measures.

23 The effects of the Menieres disease should be fully taken into accountwhen choosing physical descriptors (i.e. the activity must be performed safely,reliably and repeatedly).


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DLA Considerations

24 People with significant degrees of hearing loss represented by descriptorsH(a) to H(c) will be assessed at the WCA with a view to facilitating a return towork, or entry into work for those who have not worked previously e.g. people

with congenital deafness. The report will provide information on how theycommunicate on a day to day to basis including use of BSL, and whether theyhave any additional learning disabilities or mental health problems that mightincrease their level of disability. The information will be of use to the DM bothin 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 brightelectric 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 greaterthan 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 15metres

V (g) None of the above apply

Scope

1 The Activity is vision in normal daylight or bright electric light, with glassesor 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 intendedto 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 toallow a person to read a reasonable amount of text at a time, not justindividual letters. However it does not include ability to sustain concentrationwhile reading or literacy.

3 "Recognising a friend" implies the ability to recognise a friend's features, notto recognise them, for example, from the clothes they are wearing.


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4 Normal vision is taken as visual acuity of 6/6 at a distance of 6 metres fromthe Snellen chart. To hold a class 1 driving licence (permits driving of a privatecar) 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 visualacuity, an individual cannot read whole sentences or scan a page, causessignificant disability. An appropriate descriptor in this situation would be V(b)

6 Visual field loss is considered in the LCW/LCWRA. Visual field loss mayresult in significant functional limitations and can be caused by a number ofconditions such as glaucoma, retinopathy or homonymous hemianopia. It mayreduce safety awareness in situations such as traffic or cause a tendency tofalls.

Details of Activities of daily living


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 examinationcentre, and how they found their way around the centre, and whether theyneeded 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, andwhether the claimant is able to read their medication labels or repeatprescription sheet.

Examination

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


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12 If the customer forgets their spectacles but there is evidence from thetypical day activities and behaviour observed that there is no significantdisability with vision, then this will be reflected in the descriptor choice. Inthese cases or in cases where the VA is poor but the examiner thinks that itcould 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 equivalentof normal newsprint.

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

15 For the purposes of the LCW/LCWRA, the examiner will provide an opinionof 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 theirvisual acuities. In addition it will also contain information about any reductionin visual fields. The latter is expressed as a percentage reduction.

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

distance of greater than 20cm.

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

19 The disability analyst will have observed the ease with which the customermoves around the examination centre, their ability to read documentation, tomanage personal possessions such as a handbag and to make eye contactduring interaction. Their ability to watch TV, go shopping, to drive and partakein 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 theperson does not have an artificial stoma or urinary collecting device.

Descriptors

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


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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 cannotcontrol the full evacuation of the bowel.

C (d) At least once a week loses control of bladder so that the person cannotcontrol the full voiding of the bladder.

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

C (f) At least once a month loses control of bladder so that the person cannotcontrol the full voiding of the bladder.

C (g) Risks losing control of bowels or bladder so that the person cannotcontrol 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 stressincontinence.

2 The descriptors cover an assessment of continence while the customer isawake. Incontinence which occurs only while asleep (enuresis) is notregarded as incontinence in terms of the legislation as, with the appropriatepersonal 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 periodwhen there is a period of altered consciousness, so incontinence will not ofitself affect functioning. Seizures should be considered under the appropriatefunctional area.

4 Urgency, as typically associated with prostatism, will not usually meet thecriteria for `incontinence' or `loss of control', as it can be controlled by regularvoiding. Customers with gastro-intestinal problems or frequency of micturitionshould be considered as possibly meeting the criteria for C (g), when theirproblem is unpredictable to the extent that they would become incontinent, ifthey did not leave their work place immediately or within a very short space oftime.

5 In situations where a customer has problems of control with both thebladder and the bowels the highest descriptor should be applied, e.g. in acustomer 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 ofthe two descriptors (C (e)) should be chosen.


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

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

8 Mild stress related incontinence, where the person has voluntary controlover 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'.



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 clinicaldiagnosis, medication and previous investigations or specialist input are takeninto account.

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

Descriptors

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

CU (b) Is unable to affix, remove or empty the catheter bag or other collectingdevice 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 personcannot control the full evacuation of the bowel.

CU (e) Occasionally loses control of the bowel so that the person cannotcontrol the full evacuation of the bowel.

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

CU (g) None of the above apply


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Scope

10 This functional category reflects the ability of an individual to manage theirurinary continence by use of a urinary collecting device. It should be notedthat 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 cansuccessfully manage to maintain their urinary collecting device withoutspillage, would not score in this category.

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

13 Upper limb function and mental abilities must be considered in this activityin relation to the persons ability to cope with the collecting device.

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

Descriptors

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

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

CB(c) Where the persons artificial stoma relates solely to the evacuation ofthe bowel, at least once a week, loses control of bladder so that the personcannot control the full voiding of the bladder.

CB (d) Where the persons artificial stoma relates solely to the evacuation ofthe bowel, at least once a month, loses control of bladder so that the personcannot control the full voiding of the bladder.

CB(e) Where the persons artificial stoma relates solely to the evacuation ofthe bowel, risks losing control of the bladder so t