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Tuesday, 21 August 2012

A letter to the Atos CEO

Dear Ms Morgenstern
Re:  Medical Services Contract with the DWP

From your response to the National Audit Office’s recent report, (http://blog.atoshealthcare.com/2012/08/atos-healthcare-response-to-the-nao-review/), you clearly do not believe that their investigation was well conducted or objective and are highly disgruntled with the findings and this is your attempt to set the record straight.  It does however raise a number of important issues, so I feel compelled to do likewise.
I am not sure at which audience your blog is aimed – it is your actions to date that have determined who loves you and who hates you, so I don’t think this plea of mitigating circumstances will influence current opinion one way or the other.
You have been doing the job now for 4 years, so one has to ask how long it will be before you can genuinely sit back and say that you have achieved the required standard.  The WCA process has as you know been highly controversial since its inception and a significant reason for this has been the lack of clarity in a number of key areas.  Whilst this may serve a political expediency, “muddy water” only ever inhibits efficiency and real progress.  My aim therefore is to put a series of propositions to you which, in the main, you can answer with a clear ‘yes/no’ or ‘agree/disagree’ supplemented perhaps with whatever qualification/elaboration you feel necessary, but the latter is of little use without the former.  It is much better (in the interests of clarity) that you provide the ‘yes/no’ rather than leaving me to surmise.
 If you feel unable to address any point directly, I would much prefer you to say so rather than insult my intelligence with unsubstantiated claims and meaningless clichés, all of which I can guarantee I have heard before.  I am reasonably well-read over the whole WCA debacle, so there is no need for you to cut & paste the standard responses that appear elsewhere.  What I am seeking here for everyone’s benefit is something fresh, objective and honest.
Rarely are assumptions clearly stated, but my only one here is that there is no place for morality in private enterprise and I have not therefore commented on whether Atos has it or not – it most certainly is not one of my expectations.  If you feel this assumption is unfair on Atos, please say so.
I will try to deal with the issues in the sequence they arise in your blog.
1)        In your opening paragraph there is an implied criticism of the NAO for not “sharing” its findings with you.
Yes it has, at the same time as it did with everyone else.  It seems you think you were entitled to a sneak preview and presumably the facility to suggest alterations prior to final publication.  This is not how the concept of independent audit operates.  I suggest you read the information on the NAO website at http://www.nao.org.uk/about_us.aspx  where you will find that they have worked exactly within their remit.

The “confusion “appears to be over your understanding of independence.  The NAO uses the conventional definition that most people would understand.  Your interpretation is however different as demonstrated by the arrangements around the so-called “Independent Tier”, which do not comply with any definition of the word I can find.
You will no doubt wish to defend the independence of the IT despite the fact that it is appointed by and paid by Atos, its members are secret (as is the precise nature of their qualifications to fulfil this important role), it sits in-camera and the only access to it is through Atos.  The direct analogy would be a court case where the only access to the (secret) judge is through your adversary’s lawyer – I doubt you would regard this as a satisfactory arrangement let alone one modelled on objectivity and indeed independence. 
Any suggestion that objectivity and impartiality can only be achieved through secrecy not only denigrates the entire British legal system but also rather flies in the face of the basic democratic principles of public accountability & scrutiny and the Prime Minister’s own views about the “disinfecting power of sunlight” – something he talks about frequently. 
2)        You cannot have your cake and eat it too, by on the one hand claiming autonomy and discretion to improve the process and then dive behind the contract when things get a bit sticky.  This disingenuousness will not earn you respect or credibility.  If the contract requires you to do anything other than a comprehensive, sensitive and accurate job, you must say so unambiguously (setting aside the question of why you signed it in the first place).  The “I was only following orders” defence was exposed for what it is over 60 years ago. 
3)        Of course the task is “challenging” – whoever said it would be easy?  You are making recommendations that result in potentially life or death decisions.  It is all very well having an appeals process, but even if it took days rather than months to deliberate, the damage has already been done - the worry and trauma cannot be erased.
Nobody expects a foolproof process that never makes a minor error of judgement – there is too much inherent variability involved and inevitably an element of subjectivity.  What we do expect is a process that recognises these characteristics and adapts appropriately to them.  Nobody has the right to irresponsibly gamble with my health and well-being except me – and the medical lawyers would contest even that.  You therefore have to show compassion and err on the safe side rather than take a risk – the stakes are too high.  We expect any errors to be only at the margins and quickly corrected.  We do not expect errors at the extremes.  Can you guarantee categorically that a claimant’s overall long-term health and well-being is your primary consideration – yes or no?
 A number of the extreme assessment errors are well documented, together with the irreparable consequences – yes, people have literally died and one is one too many.  However, you have never once commented on any of your errors or indeed apologised, so you cannot now expect sympathy, respect or even a “fair hearing” as that is not what you have provided to many of the people you have assessed.  The end does not always justify the means and the amount of collateral damage you have created is simply unacceptable.
The stakes could not be higher – my health and possibly my life, so I expect you to be conservative, cautious and err on the safe side.  I do NOT expect you to be cavalier on the basis that it will all get sorted out sooner or later by someone else.  You do not give the impression that you accept this – in fact rather the opposite. 
4)        You refer to the high standards you set yourselves – easily said, but what exactly are they? 
5)        You mention in a number of places WCA improvements for which you should receive credit and it is worth being clear as to quite what this means – there have undoubtedly been changes over the past 3 – 4 years but their effects are debatable in the absence of clear evidence one way or the other.
I am sure you are familiar with the old management cliché that says in essence, “If you don’t measure it, you can’t manage it”.  What quantifiable measures do you have to support this claim of ongoing, continual improvement? 
Everyone talks about the critical importance of right-first-time classification (fit for work or otherwise).  Why then don’t you make any attempt to track it over time?  Improvements would then be self-evident and instantly quell criticism.  It may be a bit difficult to measure accurately, but NOT impossible and its value is beyond dispute, so well worth the effort. 
6)        You may be able to technically claim that you have implemented all of the Harrington recommendations, but have you really addressed the underlying issues?  Take for example the matter of audio recording WCAs.
Yes, you arranged a trial (albeit it was an extremely poorly conceived and managed project which meant accurate interpretation of results was impossible) and you made clear recommendations to offer the facility widely, recognising as long ago as Spring 2011 that there was rapidly increasing demand.  By contrast, you now only offer the service on a ‘best endeavours’ basis, which could in the extreme mean not at all, or at best on some sort of unpredictable, random basis.  I cannot see how this is tenable and indeed fair to claimants.
It is rarely discussed, so you may wish to comment on the justifiable lack of trust in the process that brought this suggestion about in the first place– even Professor Harrington could see it and you clearly agreed, hence your recommendation.  There are only two possibilities given the current situation:
·         Either you believe the underlying problem has been resolved, in which case what specific evidence do you have to show this is the case?  Or
·         The underlying problem still exists (and increasing demand for audio indicates it is getting worse), so what is your alternative plan to get rid of it? 
7)        Returning to the difference between change & improvement, descriptor amendments were implemented around March 2011. One of these was to remove all references to bending and kneeling within the WCA on the basis that neither is relevant to the workplace any longer.  I am sure I do not need to point out to you that:
·      Every single warehouse in the country (if not world), stores stock down to floor level.
·      Every single self-service retail outlet in the country (if not world) stores merchandise down to floor level.
·      4-drawer filing cabinets are still widely in use and I believe the vast majority of offices still use the bottom drawer.
There have been suggestions that this change was ‘evidence-based’ but in fact relies upon unproven assumptions about compliance with certain equality legislation – in fact one quoted report says precisely the opposite.  The truth is that it was a thinly veiled ruse to cut points and bias assessment in the desired direction.  Nobody has been fooled.
 
8)        You suggest an error rate of “only” 9%.  9% may not sound too bad, but just consider it against:
·           GPs making a wrong diagnoses
·           Surgeons undertaking unnecessary operations
·           The transfusion service wrongly classifying blood types
·           And even cars that are unsafe but are passed through an MOT.
In all of these areas, such an error rate would cause outrage.  
You carefully refer to this as decision errors rather than assessment errors – ok, so what is the assessment error rate bearing in mind those FFW recommendations from Atos that are corrected by DWP before an appeal is raised?  Somewhat higher I presume.
You are assuming (without evidence) that the absence of an appeal means the FFW recommendation was correct, which is of course not necessarily so.    This percentage is no more meaningful than me suggesting to you that the true overall assessment error rate is more likely to be 40%, based on Tribunal data.  I would not do this as I understand the limitations of the data and you should do likewise.  “Spin” will prove to be the scourge of the 21st Century.  All this does is again highlight the overriding need for universally agreed, objective performance measures.
 The frequent suggestion that DMs and Tribunals have more information than HCPs is a myth and confirmed by analyses from the TS itself.  Even if it was true, you have only yourselves to blame – you go to great lengths to tell claimants how to prove who they are, but do nothing to ensure they bring all the medical information they could to help the assessment.  It is as if you don’t want to know. 
·          Do you regard this figure of 9% as acceptable, at least for the time being? The answer can only be yes or no.
·         Do you make any attempt to track assessment error by seriousness – clearly there is a fundamental difference between extreme and marginal mistakes.
·         What is your target error rate (accepting it will never be 0%) and when will you reach this figure?  If you don’t have one, how will you know when you have reached the end-point?  There is no value in looking for improvements that are in reality unachievable – an expensive waste of time.
·         How can you be sure that the current model and process is capable of reaching this target?   
9)        Whilst in theory the WCA is only part of the decision process, it without doubt carries the greatest weight by a long way – and quite right too - it is disingenuous of you to suggest otherwise.  If its significance is understated, it will reduce the urgency to get it right on the false assumption that there are adequate checks and balances further down the line.  DWP DMs have no medical training.
10)     You mention the training given to your staff, but you do not have a foolproof mechanism that guarantees their qualifications are always up to date.  This has been confirmed by DWP through FoI Act requests.
11)      Where are these independent reviews that confirm high standards of service?  You claim they are accurate, impartial and statistically sound, but given previous misrepresentations (spin), this is hard to believe. 
Your “Mystery Shopping” programme is in fact no more than a site/admin audit and does not touch (as one would expect) on the WCA itself.  These audits no doubt have a place, but call them something else that accurately describes their content.  Similarly, the audio recording trial in Newcastle was approached in such an ill-thought out, haphazard manner, none of the conclusions it drew could be treated with any credence, which in part explains the chaos around the principle now.   
12)     You are clearly complicit in the deception and dishonesty within the process and support the ‘benefit scrounging’ philosophy - if you did not, you would approach the task in a far more open and honest manner. The hypothetical wheelchair mobility evaluation sums this up perfectly, not to mention all of the unsupported assumptions made elsewhere (a visit to a supermarket means you can walk unaided and without pain for at least 800m – where on earth did that come from?).  You cannot expect respect by attempting to defend the indefensible. 

Yours sincerely

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