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Monday, 30 April 2012

The WCA - Condition variability, task repeatability & pain.

The venerable Professor Harrington has recognised there is a problem in accurately assessing all of these aspects of any condition in a single session – it doesn’t matter how long the session is or the sophistication of the equipment available – it is simply an impossible proposition.
What therefore is the best that anyone can do?  Well, it starts with a good, in depth understanding of the diagnosis.  All but the most recently discovered illnesses & disabilities are well documented together with the range of symptoms and impairments associated with each.  Likewise with surgical remedies, the range of outcomes is generally very precisely recorded from the most to the least common.    At the end of the day, all the HCP can do is ensure that the description offered fits within these expected ranges and consistent with any other evidence.
However, (with all due respect) this requires a far greater degree of medical knowledge than a nurse or physiotherapist would possess.  The mantra of the WCA – that it does not require clinical expertise or diagnostic experience – in this area is an obvious nonsense.
It will be interesting to see how Prof H attempts to solve this problem using his current philosophy – the Atos model is sound.

Thursday, 19 April 2012

WCA - Fit for Purpose? - Parliamentary Question (2)


A fairly innocuous parliamentary question to Chris Grayling, brings an important issue to the surface again:

There is another complicated area contained within the simple point at 4.1.2.5:  “ ....in plain English and free of medical jargon".  This is included because DWP Decision Makers are not medically trained.  However:

1)    This is all very well but is likely to understate or dilute the seriousness of a condition, particularly if concentrating only on its symptoms.  An acute spinal problem becomes  “back ache” and a brain tumour becomes “occasional headaches”
2)    DMs are encouraged to reach decisions proactively and imaginatively.  They are for example allowed to undertake their own “research” into a condition using whatever resources they have available, notably the World Wide Web.  This is scary enough for a person with no medical training, not to mention issues like:
o    Not all websites can be regarded as independent and/or reliable – even Wikipedia needs to be read with considerable caution and there is no guidance provided.
o     In some areas there are genuine differences of opinion between experts – how can a DM reach a conclusion?
o    Sometimes highly technical terminology is unavoidable or indeed essential for accuracy.
o    From 1) above, if the HCP has simplified the condition, the DM may not even be researching quite the right thing.

This is all a direct result of the current “model” and the use of an outsourced private sector supplier.

WCA - Fit for Purpose? - Parliamentary Question


A fairly innocuous parliamentary question to Chris Grayling, brings an important issue to the surface again:

The requirement under 4.1.2.8:  “ . . .fully clarifying any contradictions in medical evidence” is extremely significant and in fairness to DWP & Atos, this is stated in the WCA Handbook.

What is means in practice is that if the Atos HCP feels there is inconsistency or between what they are observing during the WCA and other evidence (notably the ESA50 questionnaire completed by the claimant in advance), they must

a)      acknowledge it and
b)      adapt the assessment so that they can resolve the dilemma based on some degree of evidence, even though in the end they may have to base their conclusion on the balance of probabilities.

They categorically cannot just base their reported conclusion on their unsubstantiated “opinion”.

This is a perfectly reasonable approach to a difficult situation.  It does however introduce certain associated issues:
1)      The HCP must have all the relevant information in advance with sufficient time to study it in detail.  DWP however does very little to explain the importance of this to claimants ahead of a WCA.  The Atos appointment letter for example concentrates only on means of identification.  
2)      It significant expands the clinical expertise needed to perform a WCA.  It requires a far greater understanding of diagnosis, treatment options etc. which will often be beyond the experience of a nurse or physiotherapist.  It is all very well claiming that for a WCA, diagnosis and history are largely irrelevant, but they most certainly are not in this context.

The problem is that:

1)      Atos HCPs do not fully understand this requirement.  This is down to Atos to ensure it is adequately emphasised to its staff.
2)      Atos internal QA does not understanding it either so would not detect such a flaw in an ESA85 report.
3)      DWP Decision Makers do not understand it either.  Despite the fact that they have no medical training, they should still be able to spot reporting omissions of this nature.

If the dilemma is not properly resolved DURING the WCA, it cannot be dealt with retrospectively.  The only fair action to take therefore is to:

·         Reject the report and do not pay Atos for its production + add a penalty for such a fundamental, inexcusable omission – it would then quickly be sorted out. 
·         Apologise to the claimant and rearrange another WCA asap.
·         Leave ESA payments unaffected until the results of the repeat WCA are known. 
·         If finally the Atos error caused any additional cost of any kind to taxpayers it should be recharged to Atos.  This could include ESA payments made that prove to have been unnecessary.  We certainly would not want to pay them twice for the same job.

All perfectly reasonable and “do-able”, if of course there is the will !!!!  in the meantime, grounds for appeal without doubt.

The WCA – GPs are not well enough trained it seems (2)

This post is a continuation of http://tia-junior.blogspot.co.uk/2012/04/wca-gps-are-not-well-enough-trained-it.html as my reponse to the latest feedback is too long to post as a "comment"
Thanks for the comment and my apologies for the lengthy response.
Basically I agree.  My own belief is that GPs are perfectly capable and best able to assess work capability with at best a slight change in the way they approach it, at worst a tiny amount of “training”.  There are as you have touched on a number of relevant issues that HAVE to be addressed for this to work effectively from everyone’s point of view that the Government has so far avoided.
·         I accept that some GPs may have been a bit “soft” in the past, but they have had no real guidelines to work to and there have been no consequences to this approach.  They are paid a great deal of money and adopting the view that the only answer it to place the task elsewhere just adds to cost and reduces effectiveness – there has been no corresponding saving through taking this away from GPs and like it or not, cost-effectiveness whilst not the first consideration is still A consideration.
·         To devise a WCA without defining the “W” is ridiculous. The only commercial analogy I can think of is a QA test for light bulbs that only checks they light up, rather than to the correct brightness – inconceivable that such a meaningless test would be deployed.  Am I being passed fit as a steeplejack or bank clerk – absurd to say it is irrelevant!
·         It is the general demands of working that is so seriously missing from the WCA – being forced into the same daily disciplines when one’s condition is highly variable, perhaps hour to hour as well as day to day.  If there was a good supply of work that recognised the inevitable constraints of a disability, the situation would be different.  So not only has the Government placed the cart before the horse (introduced the test, before providing suitable jobs), it has taken a further step backwards in its approach to Remploy.
·         The issues of condition variability and levels of pain are without doubt the hardest areas to accurately assess in a single session, whether it lasts 10 mins or 10 hours.  There are also other complex issues to do with the ‘cocktail’ effect of multiple prescriptions as well as their combined side effects.  These can ONLY be evaluated by a HCP who has adequate clinical training an experience, which means a doctor, not a nurse or physio (with all due respect to both).  The assessor should be familiar with the full range of treatment options, risks and potential outcomes so that they can at least establish if a person’s condition falls within a generally accepted range and if not, through the assessment establish why.  Again, beyond the experiences of nurses and physios.
·         Then there is the matter of one’s career or profession.  The Government pretends it recognises this but does not with its concept of “general work”.  I believe that they should first consider a return to one’s profession if at all possible, but could quite reasonably put a time limit on it.  If one’s heath (sadly) will not allow a return, quite reasonable that alternatives need to be considered and this is where support would be of real help.
·         As an aside, the Government’s justification for dumping people who are less than fully able into the “normal” job market is also rubbish.  It claims that equality legislation has been so effective that they are no longer at any kind of disadvantage in the workplace or when applying for a job.  This hugely flawed theory has also allowed them to manipulate/eliminate descriptors using the same assumption, when clearly the only motivation has been to cut points.
·         [Of course this is all doubly compounded by the fact that we are in a recession]
Finally, the BMA should out of principle be fighting hard to get this work back in the hand of GPs.  They should regard it as a huge insult to suggest they are incapable or hide behind the “patient trust” nonsense.
·      If working is in my best interests, my GP should be telling me – he has signed the Hippocratic Oath for Christ’s sake.  If I disagree, we will have a debate and reach the best answer – one of us will convince the other or we will sensibly compromise.  The point is that we AGREE.  By contrast, the current system is adversarial being based on mistrust so hardly surprising it generates conflict.  Conflict requires resolution = delay + cost that adds no “value”.  At no stage does anyone currently ask me what I would like to do.  Far better to reach agreement early on then everything afterwards runs smoothly.  Substitute the concept of ‘appealing ‘with the occasional need to seek a second opinion – quite easy in my GP’s surgery – he just has to ask the bloke next door.
·      If my GP explains why working would be good for me, I am far more likely to accept it than when it comes from a DWP administrator I will never meet and who will not entertain a debate.  The trust between me and my GP is an advantage to build on, not a disadvantage to steer around.
DWP has to split hairs over who does what and introduce spurious levels of demarcation not because they are justified, but simply to support the ‘model’ it has adopted. 
1.    Atos cannot be seen to make ESA decisions – they are not within the public sector.
2.    Decision Makers cannot be seen to be making medically based decisions because they are not medically trained.
So my as yet unanswered question to DWP is:
“My ESA payments are wholly dependent on my ability to work – if I am deemed fit to work the payments stop, if I am not they continue.  So the REAL decision is about FFW which then dictates ESA or no ESA.  So who decides if I am FFW (which is of course a medically based decision)? 

which takes us straight back to the dilemma between 1) & 2) above. 

DWP will not relinquish power easily, but it is less of an issue for everyone if it is to public sector colleagues in the NHS rather than an outsourced private outfit – at least that’s my view.

Wednesday, 18 April 2012

The Measurement Myth (again)



This is a follow on from http://tia-junior.blogspot.co.uk/2012/04/wca-no-measurement-no-targets-no.html in the same theme:-  even if the Government was seriously trying to improve ESA decisions and even if it was being successful, it would have no way of knowing and how stupid is that?

On Page 68, paragraph 273 in the publication “Social Justice: transforming lives” (http://dwp.gov.uk/docs/social-justice-tr...) Iain Duncan-Smith states that one of the cornerstones of success will be to “agree clear parameters for success”.  So I asked DWP what they are. 
So far they are still trying to blame the previous administration- they cocked it up so we can too.   It will be interesting to see what ID-S has in mind . . . . . .

Tuesday, 17 April 2012

The WCA – GPs are not well enough trained it seems

The WCA – GPs are not well enough trained it seems

Requests for information under the Freedom of Information Act can be a useful way of forcing an admission from DWP or any other Government agency.
They can work both ways – an admission that they do something or an admission that they don’t.  I sometimes just ask for the evidence (information) to support something a Minister has said on the news the previous day.  Quite often (surprise, surprise) there is none and using the Government's own evidence-based philosophy, if there is no clear evidence, whatever it is doesn't exist.  There always has to be evidence of existence.
They don’t have a great deal of respect for the letter of the law let alone its spirit, so there is a certain knack to phrasing requests in a way that does not allow them to easily side-step a legitimate question.  You also have to be patient and accept that you may have to make several passes at the same issue from slightly different directions to circumvent general prevarication and extract what you are looking for.  The final value lies in the fact that the words come from their own mouths and therefore cannot be contested on the basis of supposition, misinterpretation etc.
The Act is about revealing recorded information, so set your expectations accordingly.  There is no point in chasing information they say they do not have, even if you think they should have it.  They will not simply offer comment nor become involved in anything that looks like a debate or discussion and will not express an opinion.  At least in theory, if it has been recorded you can have it, if there is no record that is all they will say.  However, this “negative confirmation” can be useful on the basis of assuming that logically if something has not been recorded it cannot be “official” and vice versa.
This particular request can be found in detail at http://www.whatdotheyknow.com/request/gps_are_not_well_enough_trained
It arose out of the repeated claims by DWP that GPs are not equipped or authorised to perform a WCA correctly.  They attempt to attribute this largely to lack of appropriate training and expertise although they have admitted here that they have no basis for saying this.  More importantly, the legislation has been deceitfully constructed to exclude them, as explained in my closing annotation.  DWP (with the help of Atos and other private companies) has created an artificial new branch of medicine for which it has defined the training and qualifications needed to become a practitioner.  This allows them to control the resources as they wish and change the rules as they wish. 
Note that Atos is does not fall within the remit of the Care Quality Commission, so there are serious questions about how medical standards can be maintained.  As it is, DWP/Atos audit themselves, although they continually say that this is done by independent experts, but as in other areas DWP has its own dictionary allowing it to use words that do not have the meaning you would expect.
This information will not directly help you with your WCA or your ESA claim.  However, by giving you a bit of insight into the hidden agenda and the lengths to which DWP will go to fulfil its aims you might just be better prepared for what is ahead of you.  Remember, if it smells fishy and looks fishy, it is probably a fish.  Within DWP, the end justifies the means, regardless of the collateral damage.

Thursday, 12 April 2012

Double Standards & Hypocracy - ESA & Tax Avoidance

The Government has constructed the entire WCA/ESA process around the basic premise that generally speaking, anyone claiming benefits cannot be completely trusted, so they can take no direct part in it and will simply have to live with the outcome that is decided by people who can be “trusted”.  Essentially they are guilty until proven innocent.  If they have nothing to hide, they have nothing to fear.
Then there is the question of tax returns and tax avoidance, where the same principles must be applied.  The perpetrators cannot of course be trusted to follow the letter let alone the spirit of the law.  They too must be treated as guilty until proven innocent and likewise if they have nothing to hide, they have nothing to fear.  If new legislation goes too far initially and penalised perfectly honest people, tough luck - they will be able to appeal but it might take a year or so to resolve.
A sad reflection on society perhaps, but at least even-handed.  If you cannot hide behind privacy laws with one, you cannot with the other.  We are after all in it together.

Tuesday, 10 April 2012

WCA - No measurement, no targets, no interest, no compassion, no ethics.


This is an extract from a very straightforward Freedom of Information exchange with DWP over something pretty basic.

Me:
Messrs Grayling & Harrison are agreed that the overriding priority is to ensure that WCA decisions are right first time and it is normal business practice to establish the parameters through which progress can be objectively measured.
1) Long term, once the process has settled, what error rate does DWP regard as acceptable and by when?
2) What are historical and current error rates?
3) What milestone dates has DWP set itself to reach the long term acceptable error rate?
DWP:
 At present, DWP does not collect data in relation to WCA Decision Making. It is not therefore possible to provide current or historical information.
Me:
Although the answer here is clear, it is impossible to believe that no Government Minister and no senior civil servant regards this statistic as indispensible. If you do not monitor it, what statistics do you use to track process performance and accuracy?
DWP:
Having concluded my review, I am satisfied that we responded correctly to your original request for information.
So next time you hear someone say that things are getting better, you now know that they really have no idea.
SOURCE:


Monday, 2 April 2012

Important ESA payment decision

An important ESA tribunal service decision to note acheived by someone far cleverer than me.

"I have just won at the First Tier Tribunal in Norwich on the 15th March 2012 with regards a decision about ESA that may have consequences on a national level. I argued that applicants who have not had an ATOS medical assessment within the 13 week assessment period are entitled to the work related activity component (“WRAC”) from the end of week 13 up until a Decision Maker finally finds the applicant fit for work (if this being the case) as a result of finally attending an ATOS medical. The conditions for payment of the WRAC are in Section 4(5) of the Welfare Reform Act 2007. Firstly my client had not been deemed to have limited capability for work related activity under Reg 30 ESA Regs as he merely supplied a GP’s sick note in order to claim ESA.The assessment phase is described in Reg 4(1)&(2) of the ESA Regs. The DWP argued the assessment phase continues indefinately (past 13 weeks) until an ATOS medical is carried out and a decision is made. I argued Reg 4(1) needed to be followed (13 weeks only) as reg. 4(2) was not engaged as my client had not attended an ATOS medical within the 13 weeks and was deemed to have limited capability for work under Reg 30 ESA, therefore 4(2)(a)&(b) were not engaged! The Tribunal found in my favour and instructed the DWP to make the WRAC payment from week 13 onwards even though my client had not attended an ATOS medical. Quite simply the DWP cannot keep clients waiting month after month for an ATOS medical and therefore be financialy penalized through no fault of their own. Obviously we await the posibility that the Sec of State will wish to appeal this decision"