Confirmation from a professional that has gaps and inconsistencies

In their confirmation, professionals may provide information that is (partially) inconsistent with what the individual has told us on their application form. These inconsistencies can relate to:

• the broad confirmation of the conditions, disability, or needs
• the severity of the needs the individual has told us about.

Inconsistencies relating to the confirmation of conditions, disability, or needs

The confirmation from a professional might, for example:

• not mention one or multiple conditions the individual has told us about.
• Explicitly state that the individual does not have the condition they have told us about

The confirmation does not mention all conditions, disabilities, or needs

Confirmation from a professional, where needed:

• does not have to confirm all conditions, disabilities and needs the individual has told us about. However, sometimes this can be an inconsistency that is relevant and needs exploring.
• should confirm a condition that is related to the individual’s needs, and these must be relevant to the Pension Age Disability Payment eligibility criteria.

Relevant considerations when a confirmation does not mention all conditions, disabilities or needs might be as follows:

• Whether it is reasonable to assume that, on the balance of probabilities, it is more likely than not that the professional should have known about all the individual’s conditions
• You should consider whether the confirmation from a professional is a pre existing document, such as a referral letter. Here, it would be reasonable to expect that it will not mention all of the client’s conditions. In order to find out whether an additional confirmation from a professional might still be required, read the next section.

In some cases, however, it would be reasonable to expect that the confirmation from a professional mention all conditions the individual has detailed in their application form. For example, if one of the individual’s conditions is a known condition which is highly likely to coexist with the other condition the individual has told us about and the professional treating the individual only confirms one of the conditions, this would be a relevant inconsistency. This inconsistency would need to be explored, irrespective of whether the document confirms a significant portion of the needs mentioned in the application form. You should consider consulting medical guidance or utilising a case discussion to help you establish known conditions that are likely to coexist.

This list is not exhaustive.

If you decide that an inconsistency is relevant and needs to be explored, you should follow the existing guidance on gaps and inconsistencies, including potentially needing further supporting information.

When an additional confirmation from a professional may be required

The confirmation from a professional does not always have to cover the individual’s main condition. For example, where an individual has two conditions and provides a confirmation on one condition which causes a significant number, but not most, of their needs relevant to qualifying for PADP, you should accept this.

However, where both

• The needs the individual has as a result of the confirmed condition would not meet the PADP eligibility criteria
• the needs the individual has as a result of the unconfirmed condition/s would make them eligible for PADP

it would generally be reasonable for you to expect the individual to provide a confirmation of the condition that would qualify them for PADP.

If you conclude that the confirmed condition/s or need/s are

• not relevant to the PADP eligibility criteria

you should follow the guidance in the lack of a confirmation from a professional section of this chapter. Although you have concluded that another confirmation from a professional is needed to confirm the qualifying condition, the guidance regarding good cause still applies. You may determine that another confirmation from a professional is needed and still establish good cause. You should also use the decision tree to help you establish if another confirmation from a professional is needed.

Establishing when

• an existing confirmation from a professional is not relevant and
• another confirmation from a professional is needed

will differ from application to application. You should use your judgment to make this decision. If you struggle to understand whether an existing confirmation from a professional is acceptable, request a case discussion.

To establish whether you’ll need additional confirmation from a professional, you should:

• consider whether out with the confirmation they have already provided, they would have a reasonable explanation for not providing another confirmation and you can establish good cause.
• consider whether what condition/s or need/s have been confirmed can reasonably be expected to cause any needs relevant to the application
• use the balance of probabilities in your thinking to consider whether it is more likely than not that the confirmed condition would result in needs relevant to the PADP eligibility criteria
• consider involving a health and social care practitioner to understand the needs associated with a given disability or condition.

The confirmation explicitly denies what the individual has told us about their conditions, disability, or needs

In some instances, the professional you reached out to for confirmation of the individual’s conditions, disability or needs might directly deny that the individual has a certain condition, disability or need. This is different from instances where the confirmation from a professional simply does not mention one or multiple conditions or needs the individual told us about.

Taking a trust-based approach, you should establish whether this inconsistency needs to be explored or whether there is a reasonable explanation for it. For example, the professional might wrongly assume that the individual does not have a condition, because they have not seen the individual since that new condition developed.

Additionally, where individuals are applying with conditions that have not been diagnosed, the professional may give an accurate response stating the individual does not have the reported condition despite being aware of their needs. In this case, even though the professional has denied the existence of the condition, this does not necessarily constitute a denial of these needs or symptoms. You should remember that an individual does not always need a diagnosis in order to be eligible for our benefits, it is their level of needs that is being considered.

You should not automatically assume that the individual is dishonest and does not have that stated condition or need – it might be reasonable to assume that the professional was unaware of all of the individual’s conditions and/or needs.

If you establish that the inconsistency needs exploring, you should proceed to do so as you would with any other piece of supporting information, including applying equal consideration to the confirmation and the application form and requesting a case discussion, if needed.

If you can resolve the inconsistency (i.e. there is a reasonable explanation for why the confirmation does not broadly confirm what the individual told us in their application form), you should move on to establishing the individuals needs and entitlement.

You may be unable to resolve the inconsistency (i.e. there is not a reasonable explanation for why the confirmation does not broadly confirm what the individual told us in their application form).

You should discuss the case with your line manager. If they agree with your assessment that the inconsistency cannot be resolved, you should make a negative determination.

Inconsistencies relating to the severity of needs

The confirmation from a professional might:

• state that the individual’s needs are higher or lower than
• of a different nature from

needs described elsewhere in the individual’s application.

Consider whether this inconsistency is worth exploring. In order to determine this, you should, for example, consider whether the inconsistency would impact on the individual’s level of entitlement. For example, if

• the individual has reported a severe level of daytime needs but
• a professional describes the needs to be much lighter than that, but still significant enough for the individual to meet the criteria for the lower level of PADP,

this inconsistency would not impact on their level of entitlement and would not need to be explored further.

If you establish that the inconsistency needs exploring, you should proceed to do so as you would with any other piece of supporting information.