RELACIONES ENTRE INFRA Y SUPERESTRUCTURA

Mental health problems canbe both

a

cause and a consequence of severe disability, greatly complicating any association between psychiatric disturbance and DLA outcomes. It may be that, on their own, mental health problems rarely determine the result of an application for DLA. With appropriate medication and support, including day care, most mental health sufferers cope with daily living and would not be sufficiently disabled to qualify for DLA. However, almost everyone in this

14 _{Nor is there any positive association, statistically speaking, between walking difficulties and guidance}

needs. The correlation between locomotion disability and 'guidance disabilities' are: seeing (r = -01), behaviour (-0.20), intellectual functioning (-0.19) andconsciousness disability (-0.10).

study has other disabilities and how these combine with psychiatric disorders would be taken into consideration when assessing their claim for DLA. Psychiatric problems can themselves imply care needs especially in the form of supervision or watching over; mobility needs may also occur.

Although the OPCS disability scales provide a comprehensive account of the experience of disablement, they do not cover many of the consequences arising from psychological impairments. To remedy this we asked respondents to complete the 12-item version of the General Health Questionnaire, a widely used screening instrument for detecting psychiatric disorder (Goldberg and Williams, 1991). Findings on the prevalence of psychiatric or chronic cases and measures of severity of psychiatric disturbance are summarised in Annex 5.1.

Our findings suggest that the distribution of DLA awards largely reflect variations in supervision needs arising from mental health problems. Psychiatric symptoms are most prevalent among recipients of middle or higher rate care, and lower rate mobility. Despite this, some of the most severely disturbed respondents had their claim for DLA disallowed.ls As suggested above, such people may not qualify for DLA because eligibility is not based on the nature or degree of mental health problems. However, it may be that applicants with mental health problems, or their carers, fail to give a full account of their needs or that these are not fully addressed in the claiming and adjudication process. To investigate this further we compared the pattern of disabilities among people with and without mental health problems across DLA outcomes.

Our examination found no evidence to suggest that people with mental health problems are more likely to be rejected for a DLA award than other applicants. Where they have disabilities implying care or mobility needs, they are as likely to get the same award as similarly disabled people who do not have psychiatric symptoms. In other words, the findings suggest that people with mental health problems are not treated differently from other DLA applicants solely on account of those problems. If people with severe mental health problems do have care or mobility needs, they may not be sufficient to attract an award or are not identified in the claiming and adjudication process.

5.5 Summary and conclusions

Eligibility for DLA is based on the effects of disability rather than the severity or nature of disability. Measures of different types of disabilities, therefore, can never be more than proxies for the conditions of entitlement to DLA. They are conceptually one step removed from the handicaps that DLA aims to address. Our examination of DLA outcomes according to patterns of disability does not pretend, therefore, to evaluate the extent to which the conditions of entitlement are consistently applied. That is the subject of the next chapter. Rather, in this chapter we aimed to take a broader look at the targeting of lower rate awards, to assess

their scope, describe the disabilities of people brought into benefit by the conditions of entitlement, and locate the boundaries of entitlement. If DLA is functioning as intended, the new lower rate criteria should identify a group of beneficiaries with distinct patterns of disability. Additionally, disabilities reflecting the middle or higher rate conditions of entitlement should be less severe among lower rate recipients. This was largely confirmed.

The findings show that:

a. Lower rate recipients of each component of DLA are mostly defined by distinct subsets of disabilities which reflect the criteria for lower rate care and lower rate mobility awards respectively. As might be expected, there is considerable variation in the types of disability considered here, both within and between DLA outcomes. There are no watertight categories

15 _{This was the case even after excluding respondents who may not be eligible for a care award because}

54

because different types of disability, especially when considered one at a time, represent imperfectly the frequency or severity of care and mobility needs in a disabled population. Certain well-defined combinations of disabilities are consistent with the conditions of entitlement, however. Where a link with entitlement can be inferred, variations in the prevalence and severity of disabilities correlate with outcomes. Disabilities reflecting the lower rate criteria are more prevalent and most severe among lower rate recipients. Moreover, lower rate recipients are less severely disabled in respect of disabilities reflecting the middle or higher rate criteria than recipients of these awards.

b. As a result, lower rate recipients of each component are readily distinguished from other beneficiaries. Lower rate mobility awards in particular identify a new constituency of recipients because guidance needs, represented here mainly by intellectual and behaviour disabilities, are quite distinct from, and often unrelated to, walking difficulties. The three rates of care award represent a more graded sequence, at least in terms of attendance needs, and it is not clear that the so-called `meals test' breaks new ground. Many of those with dexterity disabilities - who need help to prepare a cooked main meal - have personal care disabilities, and vice versa. It seems that in practice the lower rate care criteria reduce the threshold of care needs rather than establish a different or additional dimension of entitlement. They nevertheless bring into benefit people with distinct patterns of disabilities which are quite different from that of those who qualify for a middle or higher rate award.

c. The similar patterns of disability among people applying or not applying for one or other component is potentially worrying. Those claiming both a care and a mobility award have had their claims considered, at least in part, on the basis of the evidence submitted by claimants. However, many respondents who did not apply for a component have patterns of disability similar to that of their counterparts whose claim was successful and, on the face of it, they also have similar care or mobility needs. Adjudication officers may not have had these needs brought to their attention in any additional evidence they considered to determine such claims. Whether the needs of these claimants are sufficiently frequent or severe to satisfy the criteria for an award is a separate matter but the findings raise a question about their potential entitlement. It seems that they would have been best advised to apply for both components.

d. Some respondents with severe psychiatric disorders, as measured here, often do not qualify for any award. Comparing their disabilities with those of other applicants provided no firm evidence to suggest that unsuccessful claimants with mental health problems would satisfy the criteria for an award. We recognise, however, that the presentation of such conditions, particularly their fluctuating nature, can make it difficult to determine the level of care or mobility needs and their likely duration. It may also be that the care or mobility needs of such applicants are insufficient to attract an award or that their needs are not identified in the claiming and adjudication process. Further investigation of these issues is required.

It is now clear why so many lower rate recipients fall above the target severity categories 5 and 6 on the OPCS scale, discussed in Chapter 4. Not only are most people multiply, and therefore severely, disabled (Table 3.12). Many of the disabilities they have, and which can contribute to their overall severity scores, are unrelated to the entitlement criteria for DLA. Disabilities related to lower rate awards are most prevalent at the higher overall severity levels. It is not surprising, therefore, that there is little association between severity of overall disability and the distribution of lower rate awards. Considering different types of disability, however, shows that lower rate recipients are less severely disabled in respect of those disabilities that give rise to the care or mobility needs covered by the middle or higher rate criteria. In this sense, the new lower rate awards are meeting one of

the chief objectives of DLA: to extend help with care and mobility needs to people with moderate disabilities who did not qualify for the former attendance or mobility allowances.

The analysis presented here can provide no more than a broad assessment of the targeting of DLA for reasons discussed above. In the next chapter, we move on to examine DLA outcomes according to explicit measures of the care and mobility needs that correspond more closely to the conditions of entitlement.

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ANNEX 5.1

Mental health problems

To measure the psychological health or ill-health of individuals and estimate the prevalence of psychiatric disturbance, we included in our survey of adults the 12- item version of the General Health Questionnaire, or GHQ-12. This is a widely used screening questionnaire for detecting psychiatric illness and has been shown to be valid and reliable in community surveys (Goldberg and Williams, 1991). It is designed to identify difficulties in carrying out one's normal `healthy' functions, and elements of distress such as depression and anxiety.

We developed three measures of prevalence. Two are derived from questions which Goldberg and Williams recommend as a simple way of detecting psychiatric or chronic cases:

a. Are you taking any medicines or tablets for your nerves? b. Do you think that you have a nervous illness?

As a third measure of prevalence, any four positive answers on the GHQ-12 was chosen as the threshold for the identification of probable psychiatric cases: a `GHQ case'.

To measure severity and place individuals on an overall dimension of psychiatric disturbance, the GHQ-12 can be scored in various ways. Three scoring methods, described by Goldberg and Williams are used here: the GHQ score, the simple Likert score and the chronicity score or CGHQ scoring method. For each method, the higher the score the greater the degree of disturbance measured by the questionnaire. The findings are summarised in Tables 5.7 to 5.10.

Table 5.7 Prevalence of psychiatric disorder by DLA care awards

Higher rate care Middle rate care Lower rate care Rejected claims Not claimed Psychiatric case _(%) (%) (%) (%) (0/0)

Takes medication for nerves 33 28 17 21 11

Thinks has a nervous illness 38 31 15 22 14

GHQ case 80 59 59 69 56

Base (= 100%) 60 181 699 374 312

Table 5.8 Severity of psychiatric disorder by DLA care awards GHQ scale Higher rate care mean (SD) Middle rate care mean (SD) Lower rate care mean (SD) Rejected claims mean( SD) Not claimed mean (SD) GHQ score 6.7 5.3 5.3 6.3 4.9 (4.0) (4.0) (4.0) (4.1) (4.0) GHQ Likert score 20.5 18.0 17.6 19.5 17.3 (8.0) (7.5) (7.2) (7.7) (7.1) GHQ Chronicity score 8.2 7.5 7.5 8.1 7.5 (3.1) (3.0) (3.2) (3.2) (2.9)

Table 5.9 Prevalence of psychiatric disorder by DLA mobility awards

Higher rate Lower rate Rejected Not mobility mobility claims claimed

Psychiatric case (%) (%) (%) (%)

Takes medication for nerves 13 29 18 23

Thinks has a nervous illness 10 33 20 22

GHQ case 61 51 66 60

Base (= 100%) 572 306 645 103

Percentages sum to more than 100 because of multiple response.

Table 5.10 Severity of psychiatric disorder by DLA mobility awards

Higher rate Lower rate' Rejected Not mobility mobility claims claimed GHQ scale mean (SD) mean (SD) mean (SD) mean (SD)

GHQ score 5.4 4.6 5.9 5.8 (3.8) (4.2) (4.1) (4.3) GHQ Likert score 17.8 16.5 18.9 18.7 (6.8) (8.1) (7.5) (7.8) GHQ chronicity score 7.7 6.7 8.0 7.7 (2.9) (3.5) (3.1) (3.2)

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Chapter 6

Care and Mobility Needs

6.1 Introduction

The DLA application form consists of two sections. The first section asks for personal details about the applicant and for basic factual information to register a claim. Section 2 goes on to ask how illness or disability affects the claimant's life and covers a range of mobility and care needs described in the conditions of entitlement. There is also space for two `

supporting' statements about the applicant's illness or disabling condition: one from someone who looks after the applicant or knows them well like a relative or friend, and one from a GP or other health professional who knows most about the applicant's illness or disability.16

In addition, adjudication officers may request a full medical report from the applicant's GP, a hospital or an EMP appointed by the DSS. The EMP usually visits the claimant in their own home. Adjudication officers may also seek further information from the claimant by telephone, letter or a visit from a Benefits Agency visiting officer. It was beyond the scope of this study to investigate how such information is used to determine claims and awards. Clearly a full account of the volume, pattern and timing of the help needed by each applicant is required to make an informed decision on his or her claim. Such an account provides, therefore, an important yardstick against which to evaluate the targeting of awards.

We did not repeat the questions from the claim form, nor was it practical to talk to applicants' families or professional carers. As noted in Chapter 2, the research design for this study required us to use the disability questionnaire developed for the OPCS survey. With some adaptation, however, this questionnaire covers much the same ground as the assessment of needs in Section 2 of the application form. The information generated by our survey is used here to investigate:

a. the extent to which respondents, classified according to the outcome of their application for DLA, can be distinguished according to patterns of need, and

b. whether variations in patterns of need according to DLA outcomes reflect the conditions of entitlement.

Our principal focus is the distribution of lower rate awards. The first aim addresses the question of who is being reached by these awards, while the second examines the question of whether lower rate recipients reflect the intended scope of the lower rate criteria. Both aims embrace the principle of consistency, that is, the extent to which those with similar patterns of care or mobility needs are treated the same in accordance with the eligibility criteria. Consistency is measured here by the accuracy of statistical predictions.

In this chapter we identify various measures of care and mobility needs from our survey assessment. The choice and definition of these indicators were informed by the conditions of entitlement. They are then used to evaluate the targeting of lower rate care awards and lower rate mobility awards in turn. Observed and predicted

16

Section 2 of the application form is optional so adjudication officers may rely on other sources of information instead of, or in addition to, that supplied by the applicant to decide a claim. The applicant can also choose to fill in the first part of Section 2 which covers mobility needs, or the second part covering care needs, or both. The primary function of the two 'supporting' statements is to verify the applicant's identity, as required by the Secretary of State, but they often contain valuable information about applicant's illness or disability and how it affects them.

outcomes are compared and incorrect predictions are examined further to shed light on the degree of consistency in the initial distribution of awards.

Although we did not fully assess levels of need, the findings show that the vast majority of lower rate awards (96 per cent of care and 70 per cent of mobility awards) can be predicted from our survey assessment. The relative lack of success in predicting lower rate mobility awards can be attributed chiefly to the difficulties of ascertaining guidance needs and to the structure of the mobility component which, as noted in Chapter 5, comprises essentially two distinct benefits. Sizeable minorities of unsuccessful applicants are predicted to receive lower rate awards, but there is no firm evidence to suggest that they might have expected a more favourable outcome on their initial claim. Some applicants are also predicted to receive a lower rate award for that component of DLA for which they did not apply, raising a question about their potential entitlement. Overall, however, the evidence supports the view that the lower rate criteria of each component identify new and distinct constituencies of beneficiaries. It further shows that adjudication officers are successful in consistently identifying those who are eligible for an award.

Table 6.1 Care needs: lower rate awards and rejected claims

Care needs Lower rate care (%) Rejected claims (%) OR OR*

Needs help preparing a hot meal 72 40 3.9 3.2

Needs 20 hours or more help a week 66 52 1.8 ns

Needs to be accompanied outdoors 54 42 1.6 ns

Needs help washing up and drying dishes 52 29 2.7 ns

Needs help dressing and undressing 42 29 1.8 ns

Needs help washing all over 39 24 2.0 ns

Needs help preparing a snack 35 16 2.9 ns

Needs help making a hot drink 30 14 2.6 ns

Needs help getting in and out of bed 30 22 1.6 ns

Needs help feeding including cutting up food 23 6 5.0 3.1

Needs help every few hours during day/most nights 22 11 2.3 ns

Cannot pick up and pour from a full kettle 17 6 2.9 ns

Cannot unscrew the lid of a coffee jar 15 4 4.2 3.1

Cannot serve food from a pan using a spoon or ladle 11 4 2.8 ns

Cannot pick up and hold a mug of tea or coffee 9 4 2.3 ns

Needs a lot of help/attention throughout day or night 9 5 1.7 ns

Needs help washing hands and face 6 3 2.0 ns

Needs help drinking from a cup or mug 3 1 5.5 ns

Needs less than 20 hours help a week 33 47 0.6 ns

Gets so upset that runs away 13 20 0.6 0.5

Cannot turn a tap on and off 9 6 ns _0.5

Base (= 100%) 699 374

* OR adjusted for the effects of one indicator upon another. ns = not significant.

Percentages sum to more than 100 because some people have more than one need for help.

In document LOS CONCEPTOS ELEMENTALES DEL MATERIALISMO HISTÓRICO (página 60-66)