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Assessing the assessors

The application deadline has just passed for agencies that want to provide medical assessors (MAs) to the Department of Social Protection (DSP).

In August 2013, the Medical Independent (MI) first broke the story that the Department was considering outside providers to carry out medical reviews and assessments of people claiming a social benefit. The news generated some media and political comment. Over the past 18 months, the Department has slowly moved from consideration to action and is now actively seeking agency assessors to fill gaps in the current system.

The role of private agencies in the assessment of benefit claimants has been a source of massive controversy in the UK in recent years. Last summer, private company Atos Healthcare quit its contract with the UK’s Department for Work and Pensions following years of growing criticism of how the company conducted its tests of benefits claimants (see panel).

The role doctors play in the welfare system can often be a tricky one. As the DSP states clearly, medical assessors are qualified doctors whose role is to assess fitness for work and/or the degree of disability. They do not prescribe treatment nor offer advice to those they assess. Their medical role is thus specifically focused on these assessments.

Because of the concerns over private agencies and medical assessments in the welfare system in the UK, this newspaper asked the DSP a series of detailed questions about the exact nature of the work that it is envisioned that outside agency assessors will fulfill here in Ireland.

“The Agency Medical Assessors (MAs) will have the same roles as the MAs currently working in the Department,” a DSP spokesperson tells MI.

“They will work alongside DSP MAs in the Department’s accommodation using departmental systems.”

The DSP is also quick to emphasise that the outside agency staff will work within the parameters of performance targets set by the Department, not by an outside body. This is a concern that some who work with the unemployed have raised.

“The provision of medical opinions by agency MAs will be conducted in-house under the supervision of the Department’s Chief Medical Officer/Deputy Chief Medical Officer,” says the spokesperson.

“And (they) will be subject to the same performance targets and management reviews.

“Appropriate training will be provided and agency MAs will be supervised by the Department’s Chief Medical Officer and Deputy Chief Medical Officer.”

The Irish National Organisation of the Unemployed (INOU) tells this newspaper it believes it is important that agency assessors do not feel “unduly impacted by any drive to meet any prescribed quotas”. The Organisation also feels that measures should be taken to ensure that the recruitment of agency assessors will not impact negatively on the experience of claimants.

“It is important to note that a wide range of social and socioeconomic factors can have a substantial and direct impact on the physical and psychological wellbeing of an individual seeking a disability payment,” says Mr Robbert J Lynch, Manager of the Welfare to Work Section of the INOU.

“In procuring any services from outside agencies, the Department must ensure that any existing practices and safeguards are enabled to ensure such claimants remain protected under existing procedures and are not unduly impacted by any drive to meet any prescribed quotas or targets imposed on the outside agency,” he tells MI.

In procuring any services from the outside agencies, the Department must ensure that any existing practices and safeguards are enabled

The INOU adds that it would like the Department to establish a regular review of the work conducted by agency assessors.

“The INOU would strongly recommend that the Department engage and consult with a number of organisations and groups representing persons with a range of disabilities, both physical and mental, in outlining the outsourcing of these services and provide an opportunity to address any concerns such organisations may have on behalf of their clients prior to any procurement of such outside services,” says Mr Lynch.

“In addition, it would be recommended that the Department would facilitate a review of the outsourcing process over time and would seek to engage with those organisations working in the disability sector in evaluating its role and effectiveness.”

The INOU also adds that it would want to see any outside agency assessors governed by the existing “customer service ethos” of the Department.

“The DSP has a very strong and specific customer service ethos,” says Mr Lynch.

“As part of its ongoing strategic plans, we are aware that the Department have undertaken to develop and improve their customer services and supports over time.

“If the Department seek to procure services from an outside agency, it must seek to ensure that any such service fully commits to any existing customer service plan and fully engages in any future developments.”

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The DSP recently advertised on the Government procurement website for the engagement of a suitable agency for the provision of doctors “to supplement the DSP MA cadre”. The closing date for receipt of tenders has just passed, on 25 March.

“The tendering process is still underway… it is not possible, at this stage, to indicate how many agencies will reply,” the DSP tells MI.

However, we do know that an earlier exploratory notice in late 2013, which tested the waters of interest in an outside agency providing assessors, did generate significant feedback. The DSP has also previously insisted to us that the move towards agency staff was not primarily inspired by budgetary considerations.

In 2013, this newspaper was informed that the DSP originally explored a number of options to increase its capacity to carry out medical assessments and reviews. In late 2013, the DSP published a Prior Information Notice (PIN) to assist the Department in gauging potential interest in contracted medical services and to inform its thinking in that regard.

In August 2013, over 36 organisations, including a number of private agencies and individuals (see panel), were present at an ‘information session’ organised by the Department in relation to the plan.

The larger number of appeals with successful outcomes relate significantly to disability payments

The original PIN estimated that the number of assessment cases contracted out could range from 25,000-to-75,000 per annum. It is not known how the recent fall in unemployment levels may have affected these numbers, and this week the Department was reluctant to speculate on exact figures, insisting that the numbers may vary.

“Agency MAs will work alongside existing DSP MAs and be subject to the same performance targets and management reviews,” says the DSP.

“MAs provide medical opinions across a range of illness, disability and invalidity schemes. The times involved and the numbers completed vary, depending on the scheme involved.”

Last year saw a drop in the total number of social welfare medical assessments compared to 2013, according to figures collated by the Department and provided to this newspaper. This continues a downward trend since 2011.

There were a total of 92,786 assessments last year compared to 102,395 in 2013, 120,285 in 2012 and 143,488 in 2011.

“The figures represent total numbers of assessments and it is difficult to determine the actual numbers of persons, as there could be more than one assessment associated with one person, eg, initial claim assessment, a review assessment, an appeal assessment,” adds the DSP spokesperson.

“It is also very difficult to determine which decisions were reversed following review.”

While recognising this important proviso, these figures may seem like a cause for celebration — a reflection of the lowering unemployment percentage, perhaps? Why would the DSP need to employ more assessors when the number of assessments is dropping?

However, the Department insists this is the very reason why new MAs are needed, because the fall in numbers is actually caused by a lack of MAs in the system.

“The fall in the amount of medical assessments has been mainly caused by a lack of MA resources due to retirements,” says the spokesperson.

“This has resulted in backlogs and delays.”

Those who work on the front line of the long social welfare queues report that concerns arising out of medical assessment verdicts is a significant issue.

“One of the most frequent reasons clients in receipt of, or seeking to claim, disability payments contact the INOU’s Welfare Rights Information Service regarding medical assessments relates to refusal of a claim following a medical assessment,” says Mr Lynch of the INOU.

“As such, the right to appeal a decision made by the DSP is hugely important for both social welfare claimants and the social welfare system itself.

“The number of appeals being lodged with the Social Welfare Appeals Office can act as a barometer as to the state and nature of the social welfare system at any given time and highlight any issues arising within the welfare system itself.

“Annual reports from the Social Welfare Appeals Office over successive years have shown that the larger number of appeals received by their offices relate to decisions refusing disability payments such as disability allowance, illness benefit and invalidity pension.”

The INOU tells this newspaper that it believes that there is a “strong case” for a review of the medical assessment currently deployed by the DSP.

“The larger number of appeals with successful outcomes for the appellant relate significantly to disability payments,” says Mr Lynch.

“By virtue of the fact of the number of appeals taken, and particularly the number of successful appeals related to disability payments, a strong case for a review of medical assessment criteria used by the Department could be made.”

Cases of individuals who have been refused payment following assessment are also regularly raised by opposition politicians in Dáil questions.

Including the posts of Chief Medical Advisor and Deputy Chief Medical Advisor, who are both officially regarded as assessors, there are currently 23.4 (full-time equivalent) MAs employed by the Department. This total figure represents an increase from late 2013, when there were only 19 MAs working for the Department.

Doctors had previously voiced concerns over the Atos-run WCA scheme in the UK. In 2012, the GP Committee of the BMA voted unanimously to scrap the WCA

Following the current recruitment of agency workers, it is envisaged that a core of “at least five whole-time equivalent, on-site, suitably-skilled agency MAs” will supplement the Department’s Medical Review and Assessment Service (MRAS).

According to the DSP, the recruitment of an outside agency is not the only route it is taking to find the much-needed MAs.

“A Medical Assessor recruitment competition has recently been completed by the Public Appointment Service and DSP,” says the Department.

“A new panel of permanent DSP MAs has subsequently been established and offers of appointment are in progress.”

But direct recruitment by the DSP has not garnered enough assessors to fulfill the need — thus the turn to outside agencies.

“However, due to the time involved in the recruitment process and the delays in appointments following retirements, there is a need to supplement the numbers of permanent MAs,” says the spokesperson.

“The provision of agency MAs will increase capacity, provide greater flexibility in deploying resources for specific reviews and give cover for periods of normal and extended leave.”

The appointment of agency MAs is a new departure for the DSP and many interested parties in the social welfare system will be carefully assessing the assessors over the coming months and years.

A cautionary tale of controversy from the UK

In March 2014 it was announced by the UK government that Atos Healthcare had left its contract to deliver work capability assessments (WCA) for the country’s welfare system.

This announcement ended years of growing controversy over the service provided by the company. Appointed by the previous Labour government and with their approximately £100 million per year (€135 million per year) contract initially extended by the subsequent coalition government, the company faced growing criticism from activists and politicians.

The Guardian noted last March that “there has been mounting evidence that hundreds of thousands of vulnerable people have been wrongly judged to be fit for work and ineligible for government support”.

Reports and reviews into cases of alleged callousness and bullying towards claimants, and reports of threats to Atos staff, meant that the contract ended with a welter of criticism and controversy.

Doctors had previously voiced concerns over the Atos-run WCA scheme in the UK. In 2012, the GP Committee of the BMA voted unanimously to scrap the WCA.

At the time, Dr Laurence Buckman, Chair of the BMA’s GP Committee, told The Guardian: “When 40 per cent of appeals against the assessments are successful at tribunal hearings, something is clearly very wrong with the system.

“Being in work is good for people’s overall health and wellbeing, but GPs are seeing too many patients who genuinely need to be on incapacity benefit coming in very concerned and confused by the system.

“The government needs to look again at the whole assessment process and replace it with one that is fit for purpose.”

A spokesperson for the DSP tells this newspaper that it has “no” relationship with Atos Healthcare or any other private/outside agency in its current provision of medical assessments.

 

Facts and figures

The figures outlined below are of the overall numbers of medical assessments carried out in the respective years, according to information supplied by the DSP. It indicates a fall in assessments, a fact attributable to the low number of MAs working in the system rather than any fall in the unemployment figures, a DSP spokesperson tells MI.

Year

Number of

medical

assessments

2011 143,488
2012 120,285
2013 102,395
2014 92,786

 

Who are the assessors?

“Medical Assessors are fully qualified and experienced practitioners who provide a second opinion to that of the person’s own doctor,” said Minister Joan Burton in the Dáil recently.

The Minister added that MAs are required to be medical practitioners who are on the General Register of medical practitioners.

“They must have at least three years’ satisfactory experience in the practice of medicine since registration. Many of the Medical Assessors have specialist postgraduate qualifications and three have mental health/child and adolescent psychiatry qualifications or experience.”

All MAs have received special training in human disability evaluation. They also have special training in disability assessment.

“The MAs have an ongoing commitment to continuing medical education to ensure that standards are maintained and enhanced,” she added.

“The MAs also work in a collegiate way to ensure that best practice and professional expertise are shared and applied across all of the cases that are reviewed by them.

“This includes daily case conference meetings and a Medical Research Unit to actively engage in the update of the body of medical knowledge and evidence-based practice.”

What is an assessment?

Medical assessments take place in the cases of illness benefit claims. Illness benefits include disability allowance and carer’s allowance, among other payments.

“The outcome of these assessments are medical opinions, which were provided to deciding officers to be considered by them, together with other criteria in deciding eligibility to particular schemes,” says a DSP spokesperson.

According to the DSP website, the purpose of an assessment is to “provide a second medical opinion as to your eligibility for benefit”.

“Applications for disability allowance, carer’s allowance and domiciliary care allowance are normally assessed by Medical Assessors at desk level on the basis of medical evidence submitted,” said Minister Burton in the Dáil recently.

“Medical eligibility is determined by the severity and expected duration of the medical condition. Each case is individually assessed on its own merits and in accordance with the Department’s evidence-based medical guidelines and protocols.”

Their assessments conform to the ethical conduct and behaviour guidelines of the Irish Medical Council, added the Minister.

 

A meeting of minds

In August 2013, over 36 organisations and individuals were present at an ‘information session’ organised by the Department in relation to the plan to appoint agency medical assessors. The following were among those present at the information session, according to the DSP.

  • Alpha Primary Care Ltd
  • An Garda Síochána
  • Boyd Occupational Health Services Ltd T/A (Occupational Health Ireland)
  • Capita Health & Wellbeing (Capita Business Services Ltd)
  • Central Occupational Health Services
  • CPL Healthcare
  • CPSU (Civil Public Services Union)
  • Department of Defence
  • Department of Social Protection
  • Employment Health Advisers Ltd
  • Fitzwilliam Medical Centre
  • Fusion HR
  • Grafton Medical Practice
  • Impact Trade Union
  • Injuries Board
  • JSJ Medical Services Ltd T/A Partner Health
  • Locum Express
  • Mediserve Homecare Ltd
  • Medmark
  • MPHC Mallow
  • Park Medical Centre
  • Pertemps Medical Ltd
  • Primacare Health Professionals Ltd
  • PSEU — Public Service Executive Union
  • Rigney Dolphin
  • Roseberry Clinic
  • Saffron & Blue Medical Centre
  • Servisource Healthcare Ltd
  • Stanwood Medical Services Ltd
  • Telefónica Ireland Ltd
  • The Keogh Practice
  • The Meridian Clinic Group
  • Vhi Corporate Solutions

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