Advice on claiming PIP/ESA for mental health issues

[hamustro]

Hi everyone,

As the title suggests, I'm looking for some advice on claiming ESA/PIP. This isn't for me but my husband.

We're planning to book an appointment with Citizens Advice to ask for their help, but I'm wondering if anyone has any knowledge of the system from their own experience.

My husband has had mental health problems for a couple of years now. The short-ish version is that there has been no actual diagnosis but he has seen a GP, seen a psychiatrist (though only to make sure he wasn't psychotic, not for any positive diagnosis), and had therapy where they discussed that he maybe has CPTSD. He is currently on antidepressants and on the waiting list for another type of therapy. He has previously been under the community mental health team and had a care coordinator, though he has now been discharged as is just under his GP.

Without going into too much detail, his problems affect both of us daily and are exacerbated by working. He has had a couple of jobs over recent years and both ended in mental health crises and trips to A&E.

I suppose the crux of my question is do we need some sort of involvement from a medical specialist before we stand any chance of a successful PIP/ESA claim? I feel like we've been passed around a lot of services over the past couple of years but no diagnosis has been given and ultimately he's now just been passed back to his GP. I've seen online that letters from medical professionals help with claims but we've nobody to write one as his GP doesn't really know a huge deal about it.

No. He won't need a diagnosis either. It is all down to the restrictions he experiences in terms of PIP activities. These are:
Daily Living
1 meal prep
2 taking nutrition
3 managing medication/ therapy
4 washing and bathing
5 toilet needs
6 dressing/ undressing
7 communication
8 reading
9 engaging with others
10 prompting

Mobility
11 planning/ following journeys
12 mobility

With mental health issues he'd probably be looking at needing prompting, reminding and encouraging with:
Daily Living:
Meal prep
Medication
Taking nutrition - possibly (we're talking weight loss from not eating - snacking doesn't count)
Washing/ bathing
Dressing/ undressing
Engaging
Budgeting - possibly?

Mobility:
Planning and following journeys

He needs to talk about how he is 'most days' (50% or more of the time).

He'll need to satisfy the qualifying period too - so difficulties 3 months before the claim and be reasonably expected to have the difficulties 9 months into the future.

Then focus on weather he can complete a PIP activity: safely, within a reasonable time, to an acceptable standard.

I'd focus on what would happen if he was left home alone for a few weeks without contact from you or anyone else. Would he prepare a meal for himself? Would he wash/ shower? Would he dress/ undress?

In terms of engaging with others face to face - does he avoid friends, social situations, keep his head down if he's out?

In terms of planning/ following a journey. Can he go to places unaccompanied? Can he only go to familiar places alone? What would happen if he got lost or there was an unexpected diversion? The bar is quite high - he'd need to evidence 'overwhelming psychological distress' (basically panic attacks).

What I would suggest is getting is medical records from about the past year to the present date. So a full print out. And sending them with the claim form. It sounds like he's been back and forth a lot. So it'll all be evidenced. He can access them free - just needs to make a subject access to records request.

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In terms of ESA. That is more challenging. He may qualify for the support group under some of the mental/ cognitive descriptors. But I would think it'd be more because work would present a substantial risk to him, because it leads to a deterioration in his mental health. It's something called a Regulation 35 argument. CAB may or may not be able to help with that unfortunately. You may be better off seeing out your local council Welfare Rights Service for more specialist knowledge. Medical records evidencing the deterioration would be priceless to help this argument.

Have a look at pip.info and WCA.info. They contain stacks of useful info and will show the scoring systems for both PIP and the Work Capability Assessment.

If he has paid NI contributions in the past 2-3 years and is currently unfit to work and any SSP has ended, then he can claim Contributions based ESA (called new style ESA). He will just need to provide a sick note to claim and after a while of handing in sick notes then he will be sent a form to complete and then will likely have a phone assessment. If awarded support group, then money will go up.
PIP does not need a sick note. PIP is not about ability to work but about the effect that a disability has on daily life and mobility. So it looks at things like whether you can cook a meal, communicate, wash and dress yourself, manage medications etc. I have just helped someone apply for both with mainly MH issues. It's important to get medical evidence to back up what you say on the forms. I think PIP is probably harder to get overall. I am very experienced in helping people to navigate the process but virtually everyone I've helped recently has been turned down bar one which went to mandatory reconsideration and was awarded then. I can't emphasize enough how important the medical evidence is. One lady I helped recently with a purely MH one, I sent in letters from her CPN, details of her recent lengthy stay in a mental health unit, explained in detail what support she was receiving etc and in this case it was awarded with no problem. I would also detail medications, therapies etc on the form. Ask CAB for help with the form. Also be aware that once ESA support group is awarded then that may qualify you for Universal credit even if you are working, or you may qualify for UC already. CAB will be able to do a full benefit check to advise what is best to apply for.

Regarding PIP, Its based on a point system, I would check the descriptors first to ensure you would get enough points for a successful claim it's minimum 8 points for each componant. If not it would be a waste of time applying because you would be refused. PIP is not based on a diagnoses, so having a condition is no guarantee of a successful claim, many people assume that because they have a diagnoses/disability that they are automatically eligible, that is not the case. People with the same disability could get completely different decisions. Remember it's about how your disability effects your ability to do certain activities related to the descriptors, if it affects something not related to the descriptors then it won't be relevant.

Thanks very much everyone - all very helpful advice.

We've taken a look at the PIP forms and think he would score enough points to get some level of PIP, but presumably they'll also need evidence as we could be making it up. We will take @morningstar15 's advice and do a subject access request to help with that, and also speak to CAB for general advice.

Yes, you will need evidence, and they tend to reject anything "unofficial" like private counsellors' letters for example. GP's letters are often only so useful too, since it's a "he has told me that he has difficulty with..." type situation, which they don't put much stock in. It is worth gathering as much as you can though. PIP is notoriously difficult to get for mental health conditions and hidden disabilities because there's very little concrete evidence that can be provided in the form of medical scans etc, and they discount as much as they can get away with.

If you're confident your husband will have a claim, I can advise signing up to benefitsandwork.co.uk when you come to actually write the application. It's £20 for the year, but they have really thorough guides and a forum to get any questions answered. More info than you get through CAB etc.

GP records will be absolutely fine in your husbands case. I've got a generic letter I send out to clients (my job is representing at benefit tribunals - we mainly do PIP) they use to access records. I've adapted it a bit. You'll just need to adjust the date. I'd suggest going back a year or so. They always include a summary of active conditions and significant past conditions though.

GPs and other professionals will often charge for specific letters. Sadly they are rarely of any use!

Make sure you take a copy of the records before you send them. Also the PIP form. Send them recorded delivery too.

It's here:

Dear Doctor

Name:
Address:
Date of birth:

I am in the process applying for Personal Independence Payment (PIP).

I have been advised by my representative to request under the Freedom of Information as per the General Data Protection Regulations, copies of my GP notes including letters from my consultants, hospitals and other healthcare professionals who are treating and supporting me.

My representative has specified that the information being sought is to cover the period January 2019 to the present date. I have been asked to provide this information as soon as possible.

I require and need any information that you can provide and I am prepared to collect this evidence from the surgery in order that I can forward it to DWP.

Please let me know when it is convenient for me to collect.

Thank you for your assistance with this matter.

Yours sincerely

I'm just starting an appeal myself @morningstar15 - I might have to nab that letter! (Thank you!)

@morningstar15 That is very helpful - thank you so much!

@notyourmam Best of luck with your appeal! Benefitsandwork looks so helpful that I think for £20 you can't go wrong - as I understand it you get a weeks free trial anyway, so we'll definitely be giving it a go. Thanks.

I have really poor mental health and also can’t work at all because of it.
I am sorry to hear about your husband feeling unwell.
I get PIP and also I am in the support group for ESA.

Sorry to hear that you struggle too, but glad that you are getting some support in the form of ESA and PIP. I hope things aren't too tough for you at the moment.

Did you find the PIP/ESA process difficult?

My husband gets PIP and is in the Support Group for ESA due to mental health issues. It honestly took me about a week to fill in the form as I kept having to take a break from it and I included a copy of his prescription and his Care Plan. I also wrote a statement myself at the end of the form, explaining how he is on a day to day basis and what help and support he needs. He was awarded it for 3 years. Don't be put off by the form, I'm no expert and I managed it OK, I just read and answered the questions carefully, no one word answers if you can help it, give as much information as possible. You mention he was with the Community mental health team previously. Why did they discharge him so quickly if he still needs help? I only ask because my husband had just recently been taken on by them and I assumed he would be with them for a few years.

@Eightiesgirl That's a very helpful insight - thanks!

It was all a bit of a blur to be honest so I can't remember the exact reasoning, but I think he was under the CMHT while he was in 'crisis mode' so to speak. Over the next couple of months he then had therapy and things improved somewhat, and he was discharged back to his GP. I believe this was because things were no longer at crisis level, though obviously weren't 'fixed' as such.

There's every chance it'll be different for your husband, particularly if he isn't just there as a crisis admission and if you're in a different part of the country to me! You say he's got PIP, ESA and is already on medication so I'm assuming at the point of referral to CMHT he's already tried a few things and maybe they're expecting to work with him long-term. For my husband it was near the start of his mental health 'journey' and just to make sure he was safe in the short-term, I gathered. These are just my musings, by the way - I'm far from an expert on all this stuff!

I found the PIP process okay just very long winded and they took around five months to get back to me once a decision was made. I was awarded it straight away. At the time I was working part time but then my mental health took a big decline and I was unable to work for about six months and was on sick leave. I then left the job due to being unwell and was initially receiving contributions based ESA.
Unfortunately, I dipped even further and has another assessment and got moved into the support group.
I am awaiting a PIP review again but this is delayed apparently. I am now under the CMHT and unfortunately have been feeling quite unwell.

Good luck!

Even with a diagnosis and lots of medical team intervention it's hard to qualify because physically they can do stuff even though in DD's case she won't. I'm waiting for appeal currently. Dd had been in hospital twice this year and still pip was rejected

It is hard to get pip based purely on MH conditions because the MH conditions don't necessarily stop you being able to physically cook a simple meal for 1 or dressing for example. Also they require you not to be able to function for more than 50 percent of the time whereas MH issues often come and go. The problem is with design of form.

Have a look at the descriptors which are on this link:

www.citizensadvice.org.uk/Global/Migrated_Documents/adviceguide/pip-9-table-of-activities-descriptors-and-points.pdf

Basically you need to satisfy two regulations for PIP (both defined in the legislation). Neither the regs or the descriptors are in the form so as PP says, it sets you up to fail.

If you understand you need to be talking to a particular descriptor. Eg Meal Prep would be descriptor D at a guess. Your husband needs prompting and motivating to prep and cook a meal.

Then satisfy reg 7 - this is that he has the difficulty (in his case low mood means he needs prompting) 'most' days. Most days being defined as 50% or more of the time. So PP is incorrect as PIP absolutely does cater for fluctuating conditions.

The other regulation to satisfy is 7. We call it reliably. It is defined as:

• safely
• reasonable time period
• acceptable standard
• repeatedly

So using the meal prep example for prompting.
Safely
He can not prep a meal safely, his mood is low so he doesn't focus and leaves pans on as he forgets.
Reasonable time period
He can not prep and cook a meal in a reasonable period of time because his low mood means he pontificates, over thinks and has little motivation.
Acceptable standard
He resorts to snacks and ready meals most of the time, this is easier due to his lack of motivation as a consequence of his low mood.
Repeatedly
He is sufficiently motivated to prep a meal for breakfast. But can not do this repeatedly for lunch and tea because he has become exhausted from his thoughts and low mood.

Don't forget for PIP. A meal is classed as a meal for one prepared from fresh ingredients which are then cooked. So peeling, chopping, cooking veggies. Maybe doing some meat or fish. Perhaps some pasta.

Another thing to note is the difference between prompting and supervision.

Prompting is someone there intermittently during the task. It can be text and telephone prompting.

Supervision is the continuance presence of another person throughout the activity. Most general low level mental and physical health issues are 'resolved' by prompting or an aid.

To successfully argue supervision I would be expecting active attempts to self harm most of the time. Or someone who is completely physically incapable even with an aid - eg crippling hand arthritis, shoulder restrictions etc.

I would also add. It absolutely isn't hard to get PIP for mental health difficulties alone. I would say there's approximately a 50/50 divide in the PIP appeals I rep on. 50% we are just going for physical heath relevant descriptors. The other 50% solely mental health related. I've only ever lost 2 out of years of doing the job. Both of these are were challenged and won at upper tier.

The take home information is - don't let others put you off. Also, if he's turned down (most are) wang in the Mandatory Reconsideration (he'll have 28 days from decision date). It's not difficult. 90% of MRs are refused. So there's no point putting your heart and soul in to that. Literally just write "I don't believe you have fully understood the nature of my health conditions and how these restrict my ability to manage." Or words to the effect of. Then once the MR is inevitably turned down, you have 28 days to request the appeal. Again keep it simple for the request.

The appeal point is where you need the representation. Don't pay for it. Some CABs offer it. Best bet is local Law Centre, Unemployed Workers Centre or council Welfare Rights Service.

On the flip side you absolutely can do a successful first time claim. I got a client enhanced rate, both components purely on mental health. She didn't even have the medical. Evidence was limited to a fairly useless letter from her councillor. It was the way I filled the form in as I understand the rules, so knew exactly what to point. Admittedly if she'd have not got that result we'd have smashed it at appeal and she'd have walked away with that decision.

You've just gotta be prepared to be in it for the long haul and don't let the rejection put you off. It's meaningless.

I think you should always try and win at MR if possible. Not surprising 90% fail if people don't make the effort to supply additional evidence. What's the point of waiting up to a year for a tribunal if you can put effort into a successful MR. I won an MR a few weeks ago, admittedly the first one I'd done and admittedly they were only a few points short of an award so fairly easy to argue for the extra points.

Because it's extremely unlikely to win is why and it can cause issues at tribunal. As a service we used to chuck everything at the MR - request a delay to enable us to obtain medical evidence and write a fully submission (to the standard we submit for an appeal). Unfortunately we weren't getting the results to justify the time. I high percentage (over 80%) were still losing at MR. 90% would then go onto win at an appeal.

That's why there is little point getting stressed, despondent and not feeling believed by putting everything into an MR. If a service full of experienced advisors can not overturn a decent volume of MRs, how on earth can Joe Public who's left to scratch around on internet forums for advice?

MRs are looked at by DWP. Appeals are dealt with by independent panels, one member of whom is legally trained and actually understands the legislation and caselaw... unlike the majority of Decision Makers and Appeal Writers at DWP. It's not their job to make a 'fair' decision I'm afraid. Of course they aren't all awful - hence your decent MR result. But experience dictates many are.

I think MR should be taken as the very best chance to avoid appeal, so giving them every chance to get it right. With DD2's DLA I went through every part of their decision rationale, saying "you say x, I told you you y in question 6." "You said this but I told you this, which conflicts with your assertion." At the end, I had really got annoyed, so added that the only conclusion I could come to was that they hadn't read her form or accompanying evidence. She was upgraded from nil award to MRC/LRM.

DLA is a completely different kettle of fish to PIP. It's far more claimant friendly - simply because it's been around for much longer. Therefore as a consequence it's evolved to be claimant friendly through challenges which have set caselaw. Obviously we'll get to that point with PIP too. But then of course a new disability benefit will come on the scene.

I applied with lots of evidence (bipolar II, GAD and OCD) - scored zero points.

Ok well I worked previously at CAB with a very experienced team of people who challenged PIp decisions and they would always still put a lot of effort into MR's because the wait for appeals could take so long and causes a lot of stress for the claimant during which time they have no money. It was usually a case of the client had done the form themselves, then our team would do the MR. I'm not sure what percentage of MR's were successful . Prior to me leaving that job appeals were taking up to a year. Sorry I just don't think it's helpful to tell people not to bother spending too much time on an MR when the alternative takes so long. The work spent on an MR can still be used towards the appeal submission if the MR fails surely.

I did a PIP form for a lady with Bi-polar recently and got lots of medical evidence from CPN and from recent hospital stay in a pyschiatric unit. She got enhanced on both components with no problem although did have some physical health issues too. It is a bit of a lottery but definitely worth challenging their decision. Good luck.