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Saturday, 10 March 2012

Where I think we are now.

I am relatively new to all of this, but there must always have been a line between who is deemed fit for work and who is not, with the former subsidising the latter and it seems that going back a few years pre-ESA, there was at least some concensus that it was in about the right place.

Unfortunately, there is no complex quadratic equation that allows you to input a few variables about a person and a totally reliable answer pops out of the end.  We therefore have to live with something that occasionally gives a wrong answer (both ways) and one of the key questions is over what initial error rate is acceptable.  I have however never heard anyone talk about what it might be, before working out how the errors are subsequently identified and corrected.

I am not sure what currently is the root cause of all the fuss.  Is it that the Government is  attempting to move the line at all, or more about where it is moving it to and how it is going about it?  That is to say, is the arguement about the “what”, the “how” or both?

I guess my starting point is based on the assumption that for a variety of reasons, the financial balance between how much is going into the pot and how much is being taken out no longer works and one of the strategies is to move the line a bit to “transfer” marginal cases from the not FFW group to the FFW group.  The aim is simply to have a bit more going in and a but less coming out.  This need only be done to a point that a satisfactory balance is re-established.  There is no “do nothing” option.

(Worth estimating at the same point how much further (if at all) this line could be moved if needed, as this will dictate future policy.)

One of my early surprises was that I could not find any kind of official launch document for Prof Harrington’s project – normally called a PID (project initiation document) or PDD (project definition document).  The critical importance of such a document is that it spells out all of the key parameters of the project – its scope, inclusions, exclusions, assumptions, objectives, success criteria etc., etc., so absolutely indispensible to the point where it is impossible to run a project successfully without one.  The first thing you do with it is to get all of the so-called stake-holders to sign it off, so at least you have a fully agreed starting point.

The first Harrington report in 2010 is full of implicit assumptions and in the absence of a PDD, it is not possible to say why.  In my view, he is trying to improve a model that is fundamentally flawed and whilst he may be to a degree successful, he is actually barking up the wrong tree.  I do not believe the best possible outcome will be good enough and it will become even more expensive as the Government overlays yet more sticking plaster.  His 2011 second report is not much different from the first one and does not set a new direction.  If one believes there is a Government conspiracy, one also has to believe he is part of it and any suggestion of him being objective goes out of the window.

For all sorts of good reasons, WCAs need to be logged on a database and quite probably LIMA can do this very effectively – the issue is over the reliability of its diagnostic algorithm and the use to which it is put.  It does allow freeform text entry by an HCP, but they are discouraged from using is as it undermines the “effectiveness” of the algorithm.  All I am saying is let’s not throw out the baby with the bathwater.

Atos is deemed outside of the remit of the Care Quality Commission, with no explanation as to why.

It is worth remembering that Atos must be doing exactly what DWP wants them to do.  Not once has DWP criticised Atos – rather the reverse.  It proudly boasts about the regularity with which Atos meets its contractual KPIs and Chris Grayling has personally written to all HCPs thanking them for their efforts.

Personally, I think the whole occupational heath thing has been over-egged.  It is not a radically new branch of medicine, just a slightly different perspective and slightly different priorities.  It does not therefore need a whole infrastructure built around it, including the accreditation from Derby University – just another one of the hidden costs.

The whole issue of accountability and potentially liability is interesting. If DWP countermands my GP’s advice, it unavoidably assumes responsibility for my health together with the consequences if it suffers as a result of what they decide.  Although the direct causal link might be hazy, there is the balance of probabilities to consider – this could do with a test case.  DWP will not categorically deny it assumes this responsibility, but equally with not accept that it must.

Likewise, they do not have an equivalent of the Hippocratic Oath and will not (as you have highlighted) state that a patient’s health is their overriding priority.  They claim to ‘risk analyse’ their FFW decisions but cannot produce the template against which it would be undertaken (essential to ensure consistency of approach) or a sample of the end result.

It’s easy to make difficult decisions if you are not faced with the consequences.

So much more could be done to allow people to better prepare for a WCA, both in relation to the information they take with them and the devious nature of some of the questions they will be asked.

LIMA aside, not only does the content of the WCA not reflect the traumas of working, but misses totally the travelling to and fro each day at fixed times and doing this every day of the week.  Everyone accepts that many conditions can be highly variable and this needs to form part of a WCA.  This is really hard to do, particularly in a one-off interview with a ‘modestly’ trained/experienced HCP, who does not fully understand my condition, the surgery I may have undergone, my medication + side effects, me, my medical history, my work etc.  THIS IS WHY THE MODEL IS WRONG. 

In addition, DWP has been massaging descriptors to cut points and has tried to suggest the changes are evidence-based.  If you look closely at the evidence they offer, it does no such thing – just another element of the charade.

There is however someone readily available who has none of these disadvantages and certain distinct advantages – my records are close to hand, there are no complicated issues of confidentiality and there are well qualified people around to provide a second opinion if necessary.  Most of all I trust all of them and by and large will do what they tell me. 

OK, in the past GPs have been a bit soft, but if we can trust them with controlling £bn of the NHS budget, surely we can get them to adjust their thinking slightly on this issue too.  If on the other hand they are so untrustworthy and unreliable how on earth can the NHS strategy be tenable. 

11,000 WCAs a week, 40,000 GPs in 10,000 practices – do the math – the marginal cost is close to zero. Scrap Atos, condense the DWP Decision Making hierarchy down to the administrators needed to start or stop ESA payments based on a FFW decision made within the NHS.  Scrap appeals in favour of an immediate second opinion, which being on hand forms part of the first decision. 

If you do not trust my GP’s integrity when assessing my ability to work, how can you trust his ability to diagnose, prescribe medication and generally act in my best interests?  If going back to work is in my best interests this is exactly what he will say.  If he has done his job thoroughly and reasoned his case logically, why should it damage my relationship with him?  On what grounds could I argue against anything he says it in my best interests?  I don’t at the moment, so why would this change?

I firmly believe that it is perfectly possible to design a process that is based on establishing consensus early on, so that afterwards everything runs friction-free.  In contrast the present system revolves around suspicion, mistrust and conflict which requires even more bureaucracy to resolve.

DWP’s view of their NHS colleagues is actually pretty insulting and one would think the BMA would react to this accordingly, but not so.  Presumably there was no reduction in GP remuneration when Atos took on this work, so could this be the reason for BMA compliance if not quite collaboration?

“Spin” is the scourge of the 21st century and we are all guilty of using statistics selectively to emphasise a point.  This just becomes a distraction.  Tribunal reversals represent less than 10% of all WCAs (confirmed by Fullfact), so the question is over whether or not this is acceptable and if not what is - so let’s agree on the best measure(s) and all track the same thing.

Tactically, the principle of removing the cornerstones on which DWP’s strategy is based is obviously very worthwhile this piece of work with BMA/BMJ is perfect if it comes off.  I’ve had a pop at Derby University over the accreditation to no avail, but worth another try from someone with a louder voice than me.

DWP also portrays consultation with people & organisations as if the all wholly agreed with its final conclusions and recommendations, which again is often not the case.  All of these organisations should make this clear as publically and as frequently as they can.

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