Sources of evidence

Self-assessment is the prime source of evidence, but the claim pack should be checked to see who has completed it. If the form has been filled in by the customer, due to the nature of their condition, it might not necessarily be an accurate or reliable description of their problems.

If the claim pack has been completed on behalf of the customer, by someone who has a good understanding of his or her needs, then it could provide good evidence.

The DM should bear in mind that the completion of the corroborative statement by a mental health professional does not necessarily mean that they endorse what has been said in the claim pack.

In the vast majority of cases of moderate and severe personality disorders a consultant psychiatrist will have been involved in the management and treatment of the individual. Indeed the absence of any documented history of a psychiatric consultation should raise doubts about the nature and/or severity of the given diagnosis. However in some areas, people with moderate or severe personality disorders may not be referred to psychiatric services. Hospital factual reports should therefore be obtained if they are required and they are available.

An HCP examination report may be helpful if the person has physical problems

Other sources of information include the following:

Care co-ordinator

When the customer is being supported by a community mental health team the care co-ordinator on that team will be the preferred source of further evidence.

They have lead responsibility for the delivery of the care plan and so they can give details of the support that the customer has been assessed as needing. They will also know whether the customer is being helped by an Assertive Outreach or Crisis Resolution team.

Community Mental Health Team

The community mental health team provides a multidisciplinary team approach. The team will include psychiatrists, community psychiatric nurses, occupational therapists and social workers working in close collaboration with social service departments. One member of the team may co-ordinate the care and is known as the Care Co-ordinator.

Community Psychiatric Nurse (CPN)

A customer may be in regular contact with a CPN who will have assessed their care requirements. Advice is given about the amount of psychiatric nursing required and the administration of drugs.

The CPN will be in contact with other mental health professionals. They are well placed to provide detailed evidence about the customer’s needs.

NHS Care Programme Approach (CPA) care plan

When the customer is in contact with mental health services there will be a care plan under the NHS Care Programme Approach. The care plan will include information on health and social care as well as domestic support and is reviewed regularly.

The customer is given their own copy, which could be requested, as it will contain useful evidence of needs.

Social Services care plan

Social Services departments may be approached for help by someone with mental health problems. A community care assessment by a social worker/care manager will be arranged and a care plan produced.

The care plan will include details of the customer’s day-to-day living and the support provided. A copy can be obtained from the customer.

Mental Health Social Worker

Where a mental health social worker has been appointed to support a customer they will have information about the customer’s ability to cope with everyday living.

Subject to consent to approach them being given, the mental health social worker will be able to provide some useful evidence about the customer’s needs.

Day Centre and Psychiatric Day Hospital

Attendance at a day centre (not on hospital site) or psychiatric day hospital (on hospital site) is likely to indicate severe disability.

These are therapeutic environments for evaluation, diagnosis and treatment of patients with mental health problems. They are staffed by psychiatric nurses, and there is input from all other members of the community mental health team. Attendance presents an alternative for patients whose condition requires intensive treatment, but do not need to be hospitalised.

Accommodation manager

When the customer is living in supported accommodation then the type and level of support provided could be helpful in determining their need for help.

A phone call to the accommodation manager could provide useful evidence.

Crisis Resolution Team

The customer may have been supported during a crisis by the Crisis Resolution Team. The teams are mainly comprised of CPNs, who would make urgent visits, day or night to anyone who is thought to be in need of hospitalisation.

The idea is to provide intensive treatment at home instead. The Crisis Resolution Team would be well placed to provide details of the customer’s condition.

General practitioner factual report

If there is no specialist mental health professional involvement or evidence cannot be obtained from them, then it may be necessary to request a GP factual report from the customer’s own doctor.

The GP may have only limited knowledge of customer’s mental health problems, even when there is no one else involved.

Amended June 2008