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 21^st 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.

#ESA Appeals - clause 99 of the Welfare Reform Bill

http://www.theyworkforyou.com/pbc/2010-11/Welfare_Reform_Bill/22-0_2011-05-17a.6.0

Again, some propaganda from Chris Grayling, who we already know cannot be trusted.

However he tries to explain the motivation behind this clause and the limited use he has in mind, it gives DWP the authority to determine which appeals can be heard by the Tribunals Service, which is an infringement of the principles on which our legal system is based and should be resisted by all means possible.  Yes, some wholly spurious appeals reach the TS that waste time & money, but this is the small price we pay for democracy and basic human rights and something we should not give up.

In addition, some of what he says is not true:

1.       The current process already requires DWP reconsideration of a decision on appeal before it passes on to the TS.  Although sensible to filter out any obvious gaffs, the reality is that the second DM invariably comes up with the same decision as the first DM – what else would you expect?

2.       It makes sense to ask straight away for any more evidence if there is any, but I doubt if it will get a fair hearing within DWP and the original decision without it will simply be upheld.

3.       It would help to be more informative about what “additional evidence” could comprise and list it on the front page of the ESA50.  Do not regard a fit-note from your GP as in itself an indication of his opinion.  Better to have a letter from him/her explaining more fully why you are not fit for work if that is the case.

4.       Yes, sometimes the TS finds itself with more evidence than the DM had, but a LOT of the time this is not so – it is simply that whilst the DM had it, they decided not to use it.  I know this happens, because it happened to me and the DM admitted it.  This is not just hearsay – reports produced by the TS prove it is the case.

DWP/ESA/WCA Appeals - Welfare Reform Act

From DWP under FoI Act:  Interestingly in their response, they did not challenge the 40% or 70%.

The proportion of ESA decisions "fit for work" that are reversed on appeal is generally quoted as 40% overall, 70% for claimants with representation.  Whilst there could be several reasons why this is the case, how low would this % have to be (approximately) before

1.       DWP would stop ESA payments during the appeal period and

“there have not been any final decisions for removal of the ESA ‘pending appeal’ awards.”

2.        consider dropping the appeals process in its current form altogether?

“there are no plans whatsoever to remove the right of appeal.”

3.       What are the targeted reductions in these percentages over the 6 and 12 months that would cause the Government to regard its planned improvements as successful - clearly without targets success will be impossible to judge? .

“We do not have a target in the sense you suggest. All the Secretary of State can do is ensure that his decisions makers can make the best possible decision they can. One that can be defended at a tribunal hearing with confidence. As you say above a tribunal may disagree for all manner of reasons. “

Welfare reform Act Clause 99 concern

To quote:

Subsections (2) and (3) of clause 99 amend section 12 of the Social Security Act  to enable the Secretary of State to make regulations setting out the cases or circumstances in which an appeal can be made only when the Secretary of State has considered whether to revise the decision.

The concern with this is that it grants DWP powers to decide which WCAs can be taken to appeal and which cannot - kind of poacher & gamekeeper combined and it is only ever the poor prey that suffers.  There is a partial debate on this link, but it seems Chris Grayling talked his way around the question, so the proposed amendment was withdrawn.

Every concern CG expresses is valid but their combined significance is dependent upon two assumptions he is making, but not declaring – I’m not even sure he realises himself.

Firstly, that everyone is on the fiddle and will exploit whatever loopholes exist.

Secondly, that the appeal rate will be high, so the cost could be high, but this is a reflection on the quality of the WCA.

He cannot see the straightjacket he has created for himself through the “model” he insists on sticking with.  He has positioned the WCA responsibility in a place where our democratic standards demand a formal appeals process through the judiciary system.  Position it somewhere and this need can be largely removed. 

When my doctor tells me something, I do not generally argue or take his decision/advice to appeal.  I basically trust him and his judgement – I might just on odd occasions ask for a second opinion.  This is the framework on which WCAs should be arranged.

The worrying thing about clause 99 is that Grayling and DWP cannot be trusted not to exploit and abuse the powers it gives them.  They have already demonstrated this year that seemingly innocuous phrases in the WCA specification can be twisted into results with huge consequences and they will undoubtedly  do the same here.

To have a situation where DWP itself decides what goes to appeal and what doesn’t is untenable within a democracy and one step closer to totalitarianism.  The odd frivolous referral is the price you have to pay for maintaining civil liberty.

One of the oddities in Prof Harrington’s earliest work is that he took the Atos model for granted without any explanation as to why.  He produced something akin to a PID (project initiation document) where a project’s framework is normally described, but oddly it contained no comprehensive list of inclusions/exclusions or assumptions, which is normally de rigueur for such a document.

If this goes through, we will all be for a far tougher time – declared fit for work with a very limited right to appeal at best.

There is also an interesting question over responsibilities – if DWP says I am fit for work against my wishes and my GP’s advice and my health suffers badly, who is accountable?

PS:   I really do believe that forcing home the issue of accountabilities at a personal level is one of the best way of prompting a reconsideration – the fact that I personally could be in the firing line is a very sobering realisation.

http://www.theyworkforyou.com/pbc/2010-11/Welfare_Reform_Bill/22-0_2011-05-17a.6.0