Disability benefits - supporting information: qualitative research

5. How supporting information is used to make decisions

This chapter discusses how staff use supporting information to help make a decision and their views on the support available to them in the decision-making process.

The importance of supporting information

Firstly, staff understood that supporting information is necessary to be able to make a decision. However, they also acknowledged that Case Managers could make a decision in the absence of supporting information from a professional. Staff saw supporting information from individuals' wider support networks as playing a role here, but also knew that if all avenues to obtain any supporting information had been exhausted, it is still possible to make a decision. This is in line with the policy commitment that Case Managers have discretion to make an award in the absence of supporting information. However, none of the staff who participated gave examples of when they had done this. While they were clear it was possible, they tended to feel a decision without supporting information would not be ideal because it would not be as informed as it could be.

When no supporting information is available, there might be a case discussion between a Case Manager and a Practitioner before a decision is made. Case Managers also made the point that, if an application form is sufficiently detailed, then less supporting information is needed. However, their overall understanding of the decision-making guidance is that one piece of supporting information from a professional is needed. This aligns with the policy commitment. Staff were clear that this does not mean it is necessary for an individual to have a medical diagnosis to be eligible for the payment.

There was also some discussion about supporting information being important to mitigate against fraudulent applications and so staff can make a 'water-tight' decision in line with decision-making guidance. This highlights a tension that staff can experience when it comes to making a decision in practice. Though these staff did not talk about applicants in a less respectful or sympathetic way than any of their colleagues, they were less clear on how policy commitments such as the position of trust could be applied in decision-making (this is discussed further below). Although these staff were concerned about whether there may be fraudulent applications, they also demonstrated clear understanding of the policy commitments about approaching applications from a position of trust.

It was clear that supporting information was viewed by Case Managers as often very helpful for reaching a decision. The relative roles of the information in the application form and the supporting information differed from case to case, depending on how much detail was provided on the form, and what supporting information was available. In some cases, supporting information was described as crucial to the final outcome.

"…sometimes that supporting information is all the difference in either a nil award, an award, or a standard, and then enhanced."

(ADP Case Manager)

"I have even had a couple of cases where the application pretty much had nothing in it but the supporting information had everything in it that you needed to make a decision."

(ADP Case Manager)

Supporting information was felt to be particularly important in situations where an individual has not provided enough detail on their application form. This was more common where mental health conditions are concerned, where an individual is not explicit about additional support that they or their child require (particularly parents applying for CDP), or where they are reluctant to admit, or unable to understand their own situation and the extent to which they require support.

"…the medical evidence, or even just other supporting information that is from a family member, can give more clarification on the number of times they need help with something, or the amount they struggle with something that the client maybe didn't want to tell us."

(ADP Case Manager)

There was another view that, where an application has enough detail, some decisions could be based solely on the information provided in the application form. In these cases, supporting information from a professional was felt to be a formality to be able to write a justification for the applicant and for staff to demonstrate that they have followed decision-making guidance.

There were some comparisons made with the DWP process in relation to decision-making. Case Managers with experience of both DWP and Social Security Scotland application forms felt it was easier and quicker to make a decision with the DWP form.

"I know personally when I pull some of these like legacy applications in DWP, they have been a lot more detailed, I have been able to make that decision up much, much, quicker than I have with the Social Security Scotland applications."

(CDP Case Manager)

The DWP application forms were described as more "prescriptive", meaning applicants provide more detail about their condition and needs. This includes space within the application form itself to provide the equivalent of supporting information. There is therefore more information available upfront for Case Managers to help them make a decision. It was nevertheless recognised that there is a balance to be struck between the amount of information requested and the ease and accessibility of applying.

Value of different types of supporting information and 'equal consideration'

Supporting information from a professional, irrespective of length or level of detail, is accepted for the purpose of broadly confirming an individual's condition or level of need. However, where supporting information was used to provide additional detail on the individual's level of needs to allow Case Managers to make an informed decision on their entitlement, some groups of professionals were seen as providing better supporting information than others.

CDP staff mentioned individual education plans and ASD diagnostic reports as being particularly useful. A Third Sector staff member also suggested that reports from occupational therapy are particularly valuable because of their focus on day-to-day needs. This staff member hoped that supporting information from an individual's wider support network would be given more consideration than it would under DWP. When advising applicants, they encourage those who do not have supporting information from a professional, to provide supporting information from a friend or family member.

It was generally felt that supporting information from a GP is less useful than supporting information from other professionals or, indeed, an individual's wider support network. The main reasons given by staff for this are that GPs are less likely to know about an individual's day-to-day needs and are too busy to provide detailed information. Staff said that they recognised the pressures on GPs and there are now efforts, by both CDP and ADP staff, to contact GPs only when necessary.

That said, staff explained that it was still common for them to contact GPs. Reasons for doing so include:

• GPs being the only contact details provided by the individual and/or there being no involvement from other professionals relating to their condition.
• A perception that supporting information from a medical professional is required.
• A bias towards information from GPs (discussed further below).
• Staff being more familiar with the system used to contact GPs than that used for other professionals, such as local authority staff (as mentioned in Chapter 4).

The second and third bullet points above highlight existing misconceptions among staff about supporting information needing to be from a medical professional, and putting more weight onto this type of supporting information. This illustrates that these misunderstandings are held by both applicants and Case Managers, and reinforces a need for increased awareness and education about the different types of professional supporting information that are accepted. The following quote captures the misconceptions faced by Case Managers with regard to this:

"If the supporting information isn't medical based that you do have, you still need to get a medical based one, so it usually goes to the GP."

(ADP Case Manager)

While staff indicated that supporting information from different professional sources would generally be treated equally, there were mixed views on whether supporting information from professionals and an individual's wider support network would be given equal weight (see Understanding what to provide for an explanation of 'equal weight' and 'equal consideration'). Note that here staff were talking about the consideration of supporting information when it comes to making a decision as opposed to when they first review supporting information. While some staff felt all supporting information would be considered equally, others said they gave supporting information from a professional more weight in their decisions. It was also felt that some staff might have an 'unconscious bias' in favour of supporting information from a professional when it comes to making a decision. Furthermore, some ADP staff thought that 'equal weight' no longer applies when it comes to making a decision because of what was described as an increased emphasis on the importance of supporting information from a professional since their initial training. However, this is contrary to existing guidelines on equal consideration which have not changed. (See paragraph 23 in the ADP Decision Making Guide for staff and paragraph 30 in the CDP Decision Making Guide for staff.)

"Given that you can submit a case with one piece of professional supporting information and it will go through…you won't get a case through on one piece of supporting information from the client's mother. So, it can't be equal weight, in my eyes anyway."

(ADP Case Manager)

"I don't know whether it is like an unconscious bias, but people maybe think that the information provided by professionals is more likely to be accurate or that there is not going to have been any influence [from the applicant] on what has been written."

(CDP Decision Team Manager)

"…it was very much at the start of [training], it was the whole all supporting information is equally regarded, but it did change, it pretty much changed from when I was in training to going into live cases, pretty much there was a U-turn on that immediately to everything needs medical supporting evidence to make a decision…it seems to go up and down over time whether or not like how important getting that medical information is."

(ADP Case Manager)

When it comes to supporting information from an individual's wider support network, there were different views on how useful this tends to be. For example, one Decision Team Manager commented that information from a family member or neighbour can sometimes just repeat the information provided on the application form.

"Although obviously it does add value to what has been said on the claim form, they [statements from a person's wider network] are very unlikely to ever contradict or add any additional information."

(CDP Decision Team Manager)

However, in other cases it was described as adding to the overall picture needed to make an accurate decision, and as potentially being more informative than supporting information from a professional. This highlights that the usefulness of different types of supporting information can vary on a case-by-case basis. It was noted that wider network supporting information can be particularly helpful to build a picture of support needs where an applicant is less forthcoming with this information. This might be because they are struggling to come to terms with their condition.

"…medical information pretty much is only useful to a point to just confirm that those conditions are there so you can make your decision and all other supporting information like family letters of what the client has said, is what actually makes the decisions."

(ADP Case Manager)

"I have that quite a lot [in cases] where a client said they can do it, then there is maybe a letter from a carer or a sibling or someone that has specifically said 'they don't like to admit that they are losing their independence, but here is all the things that I do for them.'"

(ADP Case Manager)

If there are inconsistencies in different pieces of supporting information, some staff indicated that they would consider who has provided the supporting information and whether that person would have an in-depth understanding of the individual's situation. For example, in CDP applications, an inconsistency could arise where children with ASD have different behaviours in school and at home. Staff might also discuss the situation with their line manager and ask for supporting information from another contact of the applicant.

Overall, it was evident that quality of supporting information is preferable to quantity and each piece of supporting information is considered on its own merits.

Position of trust

The way in which Case Managers spoke about their approach to decision-making demonstrated they were starting from a position of trust. However, they highlighted difficulties they faced in trying to achieve a balance between starting from a position of trust, considering all the information provided (including the application from), and identifying any areas where they need clarification in order to make a decision.

"I think [staff] are aware of [position of trust] and always try and adopt that sort of attitude when they are dealing with the clients, but sometimes something just doesn't look right and it might need a bit of further investigation."

(Operations Manager)

Case Managers were clear that they are not looking for everything in an application to be supported by supporting information, just enough to be able to justify a decision to their Decision Team Manager or other staff who quality assured the decision. This was contrasted with the approach under DWP, where staff said that they used to require all the information in the application to have some sort of corroboration, whether from the supporting information or a physical assessment. Staff commented that, where supporting information supports one thing in the application form, then other information is usually supported too.

"Most of the time the application can help support itself, you just need that supporting information to confirm at least one thing or to support one thing and then you can go to everything else."

(ADP Case Manager)

Senior staff have played a role in reminding Case Managers of this trust-based approach. There was a suggestion that it is not always easy, in practice, for staff to take a position of trust. This is because there is a tension between requiring supporting information to support the decision-making process, and trusting the individual where information has not been 'confirmed' by another party.

"…whilst we do try and, you know, to trust everything that the client is saying, I think sometimes there is such an urge to make sure that we get that supporting information, I don't know if that is a bit of a disconnect between fully trusting the client if you are then saying we need all this information from a professional before we can even progress things."

(CDP Decision Team Manager)

When staff felt unsure about decisions in this regard, they would have a discussion with senior colleagues and refer to decision-making guidance. Decision Team Managers explained that, as Case Managers gained experience, they felt more confident in their decision-making.

In general, staff spoke positively about starting from a position of trust and felt it was in keeping with the overall approach of Social Security Scotland. That said, discussions around trust raised concerns among some staff over what amount of supporting information they do need in order to award, particularly when it comes to supporting information from an individual's wider support network.

"…sometimes I would feel uncomfortable about giving someone points for something that has not been confirmed, like giving out money that they could potentially just be lying about, I think you need to be careful about that as well."

(ADP Case Manager)

This concern was mentioned by staff at all levels, more so among those working on ADP applications. Again, staff were aware that words such as 'proof' and 'evidence' were not the preferred language, but these words were still used by some:

"…it is taxpayers' money that we are awarding people, there needs to be some…it's like folk are afraid to say words like 'proof'. You know, 'where is the proof?'"

(ADP Decision Team Manager)

The staff that made these points felt there is a contrast, or even a contradiction, between trusting applicants while also requiring supporting information from them, again highlighting the difficulties staff face when having to make a real decision in practice about someone's level of need and therefore entitlement to award. This tension is perhaps something which could be addressed directly in staff training on supporting information.

How staff are supported in decision-making

When asked about different aspects of their role and approach to their work, it was clear that staff generally work in line with the policy principles and that senior staff play a key role in supporting Case Managers in this.

"I think as an agency [the policy principles are] really encouraged internally and that feeds onto the work that we do. I think we are all really encouraged to believe the client, as much as we possibly can, to try and take responsibility away from them so they don't have to do things."

(CDP Case Manager)

Again, the high levels of applicant satisfaction (discussed in Chapter 2 Applicants' experience of the supporting information process) indicate that this approach is having a positive impact for applicants.

Senior staff generally felt that the majority of Case Managers understand how to use supporting information and are making the right decisions in line with the decision-making guidance. However, it was suggested by one Decision Team Manager that there could be better information sharing when it comes to re-determinations and appeals. This would help staff understand where and why there are queries about decisions:

"…my guys are getting pretty close to making quality decisions most of the time. I'm not pulling them up for major stuff, I'm not seeing things that are just completely wrong, if you will."

(ADP Decision Team Manager)

Nevertheless there were some comments – particularly from CDP staff – that there is a lack of consistency in the interpretation of supporting information because of gaps in decision-making guidance. These gaps suggest that the decision-making guidance can be interpreted in a number of ways, thus leading to inconsistencies.

"… the interpretation of supporting information is very varied across Case Managers… Calibration would be good, just the opportunity for people to calibrate on how they are interpreting the supporting information that's coming in and how they apply that to guidance then and how that brings the outcome of decision. They don't really get a chance to do that."

(CDP Decision Team Manager)

"…a lot of the ways in which my new team interpret some of the legislation and the guidance is very different to how my previous team interpreted a lot of the guidance and legislation."

(CDP Case Manager)

These differences in interpretation could indeed reflect the need for supporting information to be considered on a case-by-case basis, where similar supporting information may have different implications across different cases. However, this also does highlight the difficulty Case Managers face in applying the same decision-making guidance to a variety of cases.

In relation to the second quote above, it should be noted that the decision-making guidance explains and interprets relevant legislation. Case Managers are trained to refer to the decision-making guidance rather than to the legislation during the decision-making process.

These staff felt that the following would help to improve consistency across teams:

• Further development of decision-making guidance (see section on Guidance).
• The introduction of a quality assurance framework for decision-making.
• The introduction of a separate quality assurance team.
• More opportunities for staff to learn from each other.

A further issue, raised by staff in one focus group, was that most Case Managers had been trained remotely and then started working in the office while Covid-19 restrictions were still in place. This meant that teams did not mix and talk to each other about cases in the way that they might normally have done. It was agreed by this group that this has resulted in a somewhat siloed culture, where it is not common for Case Managers to ask questions of colleagues in different teams. It was suggested that more networking across teams would be beneficial for staff development. This did not seem to be an issue for senior staff members who mentioned reaching out to colleagues in different teams for support (discussed further below under Support).

There are some types of cases that are more difficult for Case Managers to deal with, from a decision-making point of view. Both CDP and ADP staff mentioned less common conditions or complex conditions with which they are less familiar. They also mentioned applications covering anxiety and other mental health conditions. This is because of the difficulty gathering supporting information and because the impact on an individual can vary considerably day by day. One Decision Team Manager explained how fluctuating conditions, whether that be mental health conditions or physical conditions, can make decisions more complex:

"I think with fluctuating conditions it is how often it happens, and I think in some cases we are saying, well, is this person actually on a recovery trail? How are they going to be in maybe three months' time? They might not have any disability at all. So, you have to try and weigh, factor, those things into it as well."

(ADP Decision Team Manager)

CDP staff were fairly confident with neurodevelopmental and cognitive conditions because they come across them relatively often. However, deciding between the higher and lower rate of the mobility component for these conditions was mentioned as a particular challenge. CDP staff also described challenges with applications for young children where it can be tricky to know what is over and above the expected care needs for a child that age. This is in line with applicant interviews: some parents, who did not have older children they could compare experiences with, said that it can be difficult to know what is a typical level of support need.

Support

For more difficult cases, Case Managers felt that there was support available to help them make a decision – whether that be from peers, Decision Team Managers or Practitioners.

As mentioned above, senior staff members said that questions from Case Managers had decreased as staff gained experience. However, common questions or issues where staff still needed advice included:

• Whether certain pieces of supporting information were acceptable – such as documents that are not on headed paper or photographs of medication.
• Whether they have enough supporting information to make a decision.
• What they should do if a GP does not respond to a supporting information request.
• If there is no supporting information, at what point have they tried everything reasonable to get it.
• Where a Practitioner is involved, who is responsible for making a decision.

Where senior staff were unable to answer questions, it was clear that they knew they could contact colleagues in different teams for advice. This seemed to contrast slightly with the experience of Case Managers described above. However, Social Security Scotland was described by all staff participants as having a supportive environment.

"I think as Decision Team Managers we are all really good at supporting each other and if I got a case I have never come across before, or a scenario, it is likely someone else has, so I speak to them, and then if I don't get an answer from that can use the decision support team or the Case Practitioners."

(CDP Decision Team Manager)

Guidance

It can be difficult for staff to find relevant sections of the decision-making guidance through keyword searches and to keep track of updates to the guidance. It was suggested that changes could be communicated more clearly on the front page of the intranet. One Decision Team Manager described how they take time to share updates and go through changes with Case Managers:

"…we have morning meetings anyway so I kind of speak through any updates or if there is anything that I think is important, that we go through or do a demo, I will just make the meeting longer and we will just talk through it in a team and then if they come round to doing something for the first time I just say, well give me a call and we will work through it together."

(CDP Decision Team Manager)

In terms of improvements to decision-making guidance, staff explained that they would find it helpful if there was more detail on what is acceptable as supporting information, including on what is needed as a minimum. For example, there was some discussion of the pros and cons of accepting prescription lists and photos of medication. It was also felt that decision-making guidance could be clearer on what staff should do if there is no supporting information. This may be related to the initial training where the example cases all had provided supporting information – discussed in the next section on Training.

"I think the bit where we are probably not that comfortable yet, or me, personally, is if we don't get anything, what do we do?... I just don't think anybody is that clear on exactly what we should and shouldn't do. I've got no doubt there will be some awards out there that are highly questionable."

(ADP Decision Team Manager)

Client Support Advisors working in local delivery made similar suggestions for additional or expanded guidance that would help them support applicants. This included a separate document for applicants explaining what is acceptable as supporting information and what is most useful to Case Managers. Client Support Advisors said that some individuals they support in local delivery find the application form and guidance daunting and therefore may not have read existing materials on supporting information. Some Client Support Advisors felt unsure of what applicants should upload because they are not medically qualified. They also thought it would be helpful to have clarity on how old a piece of supporting information can be before it is considered irrelevant. Expanded decision-making guidance on this point is forthcoming but was not live at the time of the interviews.

Training

It was clear that there is continuous improvement of the Learning and Development (L&D) provision based on staff feedback, and that improvements were made between the pilot and the full launch of both benefits. Training in relation to eligibility criteria was generally felt to be good.

"I think training is good for understanding like marking the framework that we work within, so the different awards and the eligibility criteria and those kinds of things."

(CDP Case Manager)

However, Case Managers commented that the initial training had focused on "ideal situations" where training cases had accompanying supporting information. They were surprised once the benefits launched because very few cases they received looked like the example given in the training. This led to some confusion about what supporting information is needed, and required Case Managers to learn much of what they know about obtaining supporting information on the job.

"All the cases that we were given in training were like cookie cutter, had everything you needed, like we didn't have a case where maybe you would need supporting information, so we weren't kind of trained to identify when supporting information was required."

(ADP Case Manager)

Case Managers commented that there are so many different types of cases that it feels appropriate learn on the job and from peers and managers, however, they indicated that more ongoing training would be welcome. (Chapter 6 suggests potential areas for future staff training).

Decision Team Managers felt they would benefit from additional specific training on decision-making, quality assurance and implementing policy changes. Decision Team Managers explained that they have the same training as Case Managers but with a further focus on management. Some Decision Team Managers felt they did not have enough additional knowledge to advise CMs on decision-making or time to keep up with policy changes.

"The L&D for my job role was exactly the same as the L&D for the Case Managers really, so that probably wasn't ideal that we weren't getting oversight of the part we were going to play in kind of quality assuring the process."

(ADP Decision Team Manager)

"I think when changes do occur, we don't really get the chance to sit and think about the impact of that and to go into training and actually get taught what the impact of that is…I think all of us as Decision Team Managers need upskilled."

(CDP Decision Team Manager)

Client Support Advisors in local delivery said the training they had received on 'a day in the life of a Case Manager' was very useful in helping them to understand the importance of supporting information. This session involved Client Support Advisors being told about supporting information from a Case Manager's point of view, among other aspects of their job. One Client Support Advisor commented that, before taking part in that course, they had submitted applications without supporting information because they did not realise how important it is. It was suggested that this course should be a requirement for new joiners and also that Client Support Advisors should have the chance to practice uploading documents before meeting applicants for the first time.