From Views & Reviews, The British edical Journal, 8 August 2012. Review by Dr Margaret McCartney, general practitioner, Glasgow.
Two recent television programmes made public what doctors and patients already know: fitness to work assessments being conducted in the UK by the private firm Atos are unfit for purpose and damaging. Why are doctors involved in this farce, asks Margaret McCartney
Atos Healthcare carries out disability assessments on behalf of the Department for Work and Pensions. When I tried I failed to find out about the content of assessments, their evidence base, and the training and auditing of assessors.1 2 I wanted to know basic things. What medical criteria were used in assessments? How could the assessor—having no access to medical notes, test results, clinical opinions, or history—make a valid decision about whether the person was fit, or not, to work? Despite Atos’s services costing the taxpayer £100m (€125m; $155m) a year, commercial confidentiality is given as the reason why the veils are persistently and firmly drawn.
The general practitioner Steve Bick thwarted this tangled web by going undercover as a new recruit, filming his training sessions for Dispatches. It made for painful viewing. Incapacity benefit is being converted to employment support allowance, with the intention that every claimant would have a medical reassessment—the “work capability assessment.” This is a medical examination carried out by a nurse, physiotherapist, or doctor. The tests—peak flow, limb movements, pushing a box around, pressing a button—are clearly unable to distinguish someone who can work from someone who can’t. Points can be awarded in several categories and are forwarded to the decision maker, a Department for Work and Pensions assessor, for judgment. The box ticking to achieve enough points to be granted employment support allowance was ludicrous.
The doctor who trained Bick explained the distinctions. Oral chemotherapy or hormone therapy, say for prostate cancer, doesn’t get points; intravenous chemo does. When Bick asked why, he was told, “That’s the legislation.” Disabled claimants were assessed as though they were using a “hypothetical” wheelchair. Having one hand or one leg is not enough to generate points; you must have no use of either of a pair of limbs to get a tick. This was described as “almost unachievable.” The assessment bears no resemblance to real life. Why are doctors involved in such a farce? Atos has been allowed to take over the assessment of the most vulnerable people in society without proper scrutiny. The many successful appeals, which cost the taxpayer £50m a year to administer, shows the system’s failure, and we do not know how many others do not appeal. Why are we not acting on the human cost of stress and anxiety caused by the assessments?
One man was declared fit to work while awaiting heart surgery—and died shortly afterwards. No system will be perfect, but this system fails serially. Disabled people are left to deal with an often insensitive round of assessments, failures, appeals, successes, and then, in a circular fashion, reassessments. People who had worked all their adult lives feel humiliated in asking for benefits and then being turned down. This is no way to treat sick or disabled people. Yet we do.
Citizens Advice, which helps people with appeals, has had its funding cut by an average of 10% from local government and reported last year that it was able to help 7% fewer people.3 A video recently created by Her Majesty’s Courts and Tribunals Service for appellants, which gave tips that might increase the chances of success, has been withdrawn after Chris Grayling, employment minister, complained about the “tone.” Grayling went on camera for Panorama to deny that there were targets for assessment results, describing the push to get people off benefits as “tough love.”
So, how does this work with, say, assessments of people not working because of mental illness? Panorama showed a man detained in hospital under the Mental Health Act who was pronounced fit to work. How do the assessors make judgments without recourse to notes or third party information, knowledge of stressors, patterns of illness, chronicity? What evidence does Atos have to show that its assessments are fit for purpose? The variety of backgrounds of the health professionals doing the assessments means that some may have no clinical experience of mental illness. Their only training may be that from Atos. Is this enough?
Having professionals on board lends legitimacy to Atos’s process. Yet the potential for deprofessionalisation in this environment is overwhelming. Malcolm Harrington has written three independent reviews of the work capability assessment for the government and has asked for substantive changes, including improvements in the assessment of mental illness and to transparency of the process. He told Panorama that the assessments needed human medical judgment to work. At the Atos recruitment evening I attended we were told that there were no targets; there were, however, averages, and if you fell beyond these you should expect close auditing. This was confirmed by Dispatches, but the derivation of these averages is unknown. So there was no room for medical judgment or nuance. One health professional explained that she felt awful for scoring a man with prostate cancer as fit to work. No wonder Bick’s trainer explained that this was a “toxic” job: “That’s why I don’t do overtime.”
The question of how we got ourselves into this mess is one thing. How we get ourselves out is another. Fear of losing their jobs, and the confidentiality agreements, means that few Atos Healthcare staff speak out. Bick was told, by a doctor who assessed a patient he had never met, to alter his examination findings. This should be intolerable. The BMA’s conference of local medical committees in March passed a motion saying that the work capability assessment was unfit for purpose.
The evidence for the processes that Atos uses needs immediate public scrutiny, and the harms of this system must be examined urgently. We should support and protect health professionals who work for Atos and want to speak out. We have allowed medicine to be made responsible for a dreadful process. We need to work together to make it clear that it cannot be.
Cite this as: BMJ 2012;345:e5347
Disabled or Faking It?
A Panorama programme first shown on BBC Two on 30 July 2012
Britain on the Sick
A Dispatches programme first broadcast on Channel 4 on 30 July 2012
McCartney M. Well enough to work? BMJ2011;342:d599.
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McCartney M. Atos and changes to disabled people’s benefits. BMJ2012;344:e1114.
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Citizens Advice. Cuts in CAB funding leaving thousands with nowhere to turn for help. 6 Sep 2011. www.citizensadvice.org.uk/press_index/press_20110906.htm.