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Wednesday, July 2, 2014

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Thursday, March 6, 2014

The truth about Designated Doctors



Re- posted from   http://nzsocialjusticeblog2013.wordpress.com/

DESIGNATED DOCTORS – USED BY WORK AND INCOME, some also used by ACC: The truth about them
 
 
 
 
 
 
1 Vote

DESIGNATED DOCTORS – USED BY WORK AND INCOME, some also used by ACC: The truth about supposedly “independent” Designated Doctors
PART A:
INTRODUCTION:
Over the last couple of years I have been able to collate some highly interesting information from sources like Work and Income (‘WINZ’) clients, advocates, bloggers, certain internet websites, the media and part-time researchers. It includes documents and some other information that could be found by researching past and present media reports, also reports and online manuals from the Ministry of Social Development (‘MSD’) and WINZ websites, through looking at various other websites on the internet, and last not least also by way of Official Information Act (O.I.A.) requests.
The information discloses what the Ministry of Social Development and WINZ have been doing in the areas of medical examinations, assessments and reviews by commissioned “designated doctors”. It includes some valuable other information about medical appeals to Medical Appeal Boards (MABs), and it shows, that the MSD did during 2008 conduct a nation-wide “training program” for the “designated doctors”, who they use for getting second opinions, assessments and recommendations on recipients of, or applicants for, sickness and invalid’s benefits (now called “deferred jobseeker” and “supported living” benefits).
A television “expose” (or documentary) on what has been going on at ACC (’60 minutes’ programme, TV3 on 09 Sept. 2012, available via ‘On Demand’ or ‘You Tube’) showed what appalling strategies were followed there. It was revealed that ACC targeted complex, high cost claimants, by using preferred, hand-picked medical assessors, to prepare reports that favoured ACC. Cost saving appeared to come before proper rehabilitation, treatments and compensation, so they used a kind of “exit strategy” to off-load thousands of such claimants, who in many cases ended up having to apply for invalid’s or sickness benefits. I am afraid that very similar developments have occurred with Work and Income as part of the MSD, leading to former invalid’s beneficiaries having been shifted onto the lower paid sickness benefit, and former sickness beneficiaries been shifted onto the former unemployment benefit.
I wish to provide you with some informative details about the use of so-called “designated doctors”, who are expected to perform similar tasks as ACC assessors in this summary report (with relevant resources).
The information available is somewhat complex, and regrettably requires a bit of study and reading to grasp of what has, still is, and what will continue to be done in the areas of medical assessments, reviews, “designated doctor” examinations, Medical Appeal Board hearings and the likes. But I have attempted to summarise it all to keep it within a reasonable amount of information to digest.
BACKGROUND:
Major social welfare reforms came into effect in July 2013. They have led to some changes of the law and processes. WINZ are continuing to apply an ever more rigorous, yes very questionable approach, as they have already done since at least 2008. With the introduction of the Future Focus policies in 2010 the criteria for being considered sick, disabled and thus incapacitated to do any work, has been tightened substantially. WINZ expect their own Health and Disability Advisors, and the “designated doctors” they regularly use and work with, to now primarily look at what a client CAN DO, rather than what they CANNOT DO! That is of course a bit of a “catchy” but ambiguous phrase, and naturally it can lead to subjective ways of diagnosing and assessing persons, as to what they can individually do or not do when it comes to any work activity.
The MSD has long been concerned about the growth of sickness and invalid’s beneficiary numbers, and hence looked at possible ways to contain the trend of more persons qualifying and going onto these types of benefit. The following extract from a report by Dr Neil Lunt, published in the ‘Social Policy Journal of New Zealand’, from March 2006 (Issue 27), under the section headline ‘The background to reforming SB and IB’, page 82 gives a brief insight, of what moves were made under the then National led government in the 1990s:
“National’s Welfare to Work brand (Player 1994, Ministry of Social Policy 2001) saw a new approach to medical certification for SB and IB. National’s attempts at reform saw the introduction of the Designated Doctor Scheme in September 1995, with designated doctors having responsibility for assessing benefit eligibility, certifying applications for SB at 13 and 52 weeks, and certifying grants for IB, and recommending a possible review (12, 18, 24 months). From 1998, there was an alignment of SB rates with UB rates for new grants and the introduction of the Community Wage in place of UB and SB. In October 1998, the designated doctor review scheme was revised and doctors signing the certificate were able to certify SB for four weeks and then at 13-week intervals. For IB, designated doctors certify the granting of a benefit, with review being recommended by these doctors for two years, five years, or never. During the first part of 1999, there was also the trial of work capacity assessment for those with sickness, disability, or injury. A Phase one trial was undertaken but Phase two was never completed. The work capacity process for IB and SB sought to identify the level of work, if any, a beneficiary was capable of, and to determine what assistance would help them move into paid work (abridged from Wilson et al. 2005:4–5 Table 1.1).”
The National government of that time did plan to introduce “work capacity assessments”, but this was never implemented, as there was another change of government in 1999, thus putting a stop on National’s welfare plans, which were aimed at restricting welfare access, placing much stronger individual responsibilities on persons on benefits, and enforcing more obligations for them to seek and stay in work, or do training.
The same report from Dr Neil Lunt from 2006 described this in the following section (p. 83):
“These approaches sought to narrow the gateway to benefits and to ensure those with work capacity did not avoid the obligations that were at this time being placed on other groups of beneficiaries, including those in receipt of UB and Domestic Purpose Benefit. I would argue that the approach was individualised and an underpinning assumption saw “problems” as located in individual claimants, particularly in their attitudes towards work and unwillingness to meet their obligations.”
It appears therefore that the first use of so-called “designated doctors” – as we now know them – started with the introduction of that “Designated Doctor Scheme” mentioned above. Prior to that separate examinations and assessments for the earlier Department of Social Welfare (DSW, later WINZ) appear to have been made by certain specialist doctors, if there were uncertainties in host (own) doctor assessments. The writer of that report I quoted from, states that the approach introduced by the government then “saw “problems” as located in individual claimants, particularly their attitudes to work…”. This indicates that the reforms introduced then were an attempt to include a somewhat judgmental, yes possibly prejudicial approach, based on the belief, or view, that persons claiming sickness or invalid’s benefits were claiming these, rather for avoiding work obligations, than being seriously sick or disabled, although medical certificates were required by the then ‘Department of Social Welfare’ to prove that the latter applied.
With a change in government, and a new approach that was taken from 1999 onwards, more supportive and inclusive ways were being proposed and introduced, largely based on a “social model” for dealing with disability and incapacity. The launching of the ‘New Zealand Disability Strategy’ ‘Making a World of Difference’ (New Zealand Disability Strategy 2001) created a new platform to work from. The Labour government followed a “modern” style welfare policy, with an “investment approach” targeted to assist individual WINZ clients with sickness and disability to achieve better outcomes for themselves, by enhancing employability. “Enhanced case management” was brought in, same as some “Innovative Employment Assistance” initiatives. By about 2005/2006 the then Labour led government decided to follow a yet more “active” approach, which was also somewhat inspired or motivated by new reports and approaches presented in the United Kingdom. I will get to what that meant a bit later. Also were there plans for introducing “single core benefits” from as early as 2007, consisting of one set of rates and one set of eligibility criteria for benefits, but with add-ons to support people who have higher costs such as accommodation or disability-related – whether in or out of work.
Some of these policies were never realised, but trials were run, leading to certain initiatives to be implemented nationally, as this following section from the same report (pages 86-87) mentioned above shows:
“There has long been a concern about gateways into SB and IB and particularly the most appropriate locus of responsibility for certification. This was an area that subsequent National and Labour governments have sought to address. Most recently, the government has allowed local general practitioners and case managers to seek a second opinion where doubt exists about new and continued eligibility for SB, thus pre-empting patient “capture” that is said to result from close or longstanding personal relationships between claimants and their doctors. This initiative was piloted in the Wellington region with national rollout starting from June 2005. There is also enhanced guidance for general practitioners to “improve the management of inflow” onto SB (Maharey 2005b).”
The following chapter from the same report (page 92-93) shows how much the British welfare changes were also given serious consideration by the last Labour government:
“Healthy Welfare”
“Ongoing engagement with the medical profession is likely to be required to clarify general practitioners’ roles of clinician, advocate, and adjudicator in relation to health and wellbeing. Overseas evidence also suggests general practitioners’ views about work sickness depends on a general practitioner’s own personal views, patient characteristics, time available, expertise in occupational health, and views about continuity of care (Mowlam and Lewis 2005). General practitioners often feel pressured and are also inclined to take the wider views of claimants/patients into account, perhaps not wanting to commit them to searches for scarce work or where services are poor (Social Market Foundation 2005). A fuller notion of employability clearly encompasses the supply, demand and matching of labour (Lunt 2006).
It seems likely that prevention and managing long-term sickness-related absence will be increasingly important areas, with medical practitioners encouraged to do more to help workers stay in and retain work.”
From the same report’s “footnotes” on “designated doctors” (page 82) this is quoted:
“Designated doctors assess a person’s medical eligibility for the Invalid’s Benefit. Under current regulations, “Designated Doctors must be registered with the New Zealand Medical Council and hold an annual practising certificate. Designated Doctors must be fully informed about their responsibilities under the Social Security Act 1964”.
And here is the title and link to the quoted report that can be found on the MSD website on the internet (copies can be downloaded in MSD Word and PDF format):
‘Sickness and Invalid’s Benefits: New Developments and Continuing Challenges’
By Neil Lunt, Social Policy Programme, Massey University at Albany
Abstract
The proportion of the working-aged population receiving an Invalid’s Benefit (IB) has increased steadily betw een 1994 and 2004, and numbers on a Sickness Benefit (SB) rose sharply in the early 1990s and have continued to increase between 2000 and 2005. New Zealand has witnessed considerable policy activity in the field of SB and IB, as well as disability policy more broadly. To date, there has been relatively little attention paid by academic commentators to the increased emphasis on working actively with SB and IB clients. This is despite the fact that the new directions signalled for SB and IB constitute nothin g less than a paradigm shift. At the heart of change is the move beyond individuals – beyond focusing on either their disability or their lack of motivation.”
Also of interest is this separate report, which elaborates on the growth of the invalid’s benefit, also mentioning “reforms” and measures taken by governments, involving also the “designated doctors”. Copies can be downloaded in MSD Word and PDF format:
‘Understanding the Growth in Invalid’s Benefit Receipt in New Zealand’
By: Moira Wilson, Keith McLeod, Centre for Social Research and Evaluation, Ministry of Social Development:
“Abstract
This paper reports on research that uses the Ministry of Social Development’s benefit administration data to advance our understanding of the growth in the number of people receiving the Invalid’s Benefit over the decade to 2002. It investigates the growth in inflows of people to Invalid’s Benefit, as this was the main cause of growth in recipient numbers.”
Of interest will also be the “official” WINZ website information on “designated doctors”:
“Work and Income have established a panel of respected medical practitioners to provide second opinions on medical information – designated doctors. The provision of a second opinion assists Work and Income to determine a person’s capacity for work and entitlement to financial assistance. It also assists us with helping people to move towards employment.”
CHANGES TO USE OF DESIGNATED DOCTORS AND INTRODUCTION OF HEALTH AND DISABILITY ADVISORS:
From the above information it can be seen that MSD and WINZ have been using “designated doctors” under both National and Labour governments, and the involvement of these nowadays actually carefully selected medical professionals has fluctuated.
The clear intention was to use them to find ways to gather more information on clients with health conditions and disabilities, but also to offer additional measures to increasingly “assist” or “usher” WINZ clients back into work or training.
Already under the last Labour led government a stronger work focus was gradually adopted for beneficiaries from as early as 2005 on, this leading to introducing some new processes, rules and ways to assess and “assist” applicants, and consequently even more intensive efforts in 2007 and 2008. This was largely based upon the advice of senior policy making staff and management within MSD.
Following reforms under National in the 1990s the number of “designated doctors” reached over 1,000, although only a small number of them would handle most examinations and reviews. Still in 2007 a memo from MSD states they had 1,090 on their books. About then WINZ still had about 115 psychiatrists, a number of other specialists, but only 3 psychologists in their pool. 226 were only on the “general register”, and 224 “designated doctors” were then based in hospitals. The number of “designated doctors” was so high then, because until about that time a “designated doctor” recommendation was usually asked for (by case managers), before any person was granted an invalid’s benefit. Only a much smaller number were used to examine and assess those on (or before being granted) sickness benefits (for “second opinions”). Only barely half of “designated doctors” were then vocationally registered and based in general practice clinics. In 2005 or perhaps 2007 only 41 “designated doctor” GPs wrote 26 per cent of all reports (according do a 2007 memo).
After the Labour government introduced the ‘Principal Health Advisor’ (PHA) and ‘Principal Disability Advisor’ (PDA) positions, which were filled by appointed persons like Dr David Brattand Anne Hawker. Both were then put in charge of overseeing, mentoring and instructing Regional Health Advisors (RHAs), Regional Disability Advisors (RDAs) and Health and Disability Coordinators (HDCs) sitting in the regional offices of MSD and WINZ.
Following the appointment of those Principal Health and Disability Advisors, the Regional Health Advisors and Regional Disability Advisors, as well as so-called Health and Disability Coordinators in late 2007 and in 2008, changes were brought in by way of a new medical certificate and by changing the way of using “designated doctors”. They were after then intended to be used rather only for providing “second opinions”, rather than for making initial assessments on potential, new invalid’s beneficiaries, or those being reviewed. Also was the intention to keep and recruit rather vocationally registered practitioners, mostly only GPs, rather than the wider pool of partly not sufficiently experienced and registered practitioners. More balance from region to region was anticipated, and RHAs, RDAs and HDCs were being involved in finding and encouraging GPs – and a few other suitable practitioners – to apply to become “designated doctors”, where there may be a perceived shortage of them. Case managers would also be involved in finding out where shortages existed, and what kind of doctors would be “suitable” for WINZ and MSD.
The result would afterwards be a much smaller pool of “designated doctors”, most of who would though be vocationally registered (and better qualified and experienced). But given the increased coordination and cooperation of the new MSD staff in the roles of RHAs, RDAs and HDCs (all overseen and instructed by primarily Dr David Bratt, and also Anne Hawker) and the medical practitioners, there would be “designated doctors” considered to be the more “preferred” ones for WINZ. Naturally certain “designated doctors” would be found to have a reputation to deliver certain outcomes, that senior MSD and WINZ staff would consider “helpful”, so it can be concluded, that an unofficial, but understandable “selection” would occur, where a small core of doctors out of the total pool of the “designated doctors” would end up with the larger work-load, given their “preferred expertise” or desired “output” in recommendations.
There appears to have been a somewhat new “culture” within MSD and WINZ in regards to the handling of medical examinations, assessments and reviews, that started to develop under the auspices of Dr David Bratt, who came to the Ministry after having worked as a kind of consultant at the Capital and Coast DHB. He is also known to have done work for ACC, same as a Dr David Rankin, who also worked for MSD.
It was in 2008 also certainly noticeable that there was a kind of media campaign that the National Party opposition appeared to be running, or at least was heavily promoting and driving, and Judith Collins was as their “welfare spokesperson” a main driver behind it, actually “feeding” media with endless National Party “press releases”. There had already been ongoing criticism by certain politicians and some others (likely with ulterior motives) about the fact that the number of persons on the sickness benefit had been increasing under Labour, while unemployment was as low as it had not been for over 16 years.
Various media reports, also from the NZ Doctor magazine, then claimed that there were many incidents of “doctor bullying”, where apparent drug addicts and some sickness beneficiaries were putting undue pressures on GPs to sign off medical certificates, so they could claim a benefit for health reasons. Apart from a questionable “survey” the actual number of such incidents was never clearly established, and there was never sufficient evidence provided, that this was ever serious, wide-spread behaviour. “Drug addicts” were thrown together with “sickness beneficiaries”, as if they belonged into the same “drawer”. Also was there never any proper information on what particular reasons may have been behind cases, where some behaviour perceived as “pressure” may have had occurred. No consideration was given to the possibility that some felt unfairly treated by doctors, some of whom could well have been working as “designated doctors” for WINZ.
One blog entry and comment thread on ACC Forum did then actually cover these media reports, and the following link does lead you to that one:
From the ‘NZ Doctor’ magazine on 02 July 2008 Lucy Ratcliffe was quoted as reporting: “Just over a third of GPs polled say bullying is a serious concern for them and drug addicts and sickness beneficiaries are most likely to be the culprits.
The latest New Zealand Doctor/IMS Health faxpoll finds a third of GPs (33 per cent) say they’ve been bullied two to three times during their career in general practice, and just over a quarter (26 per cent) say it’s happened four to five times.
Eighteen per cent say they’ve been bullied more than 10 times and 6 per cent say it’s happened so many times they’ve lost count.”
It becomes clear that this “survey” asked “loaded” or ambiguous questions, so doctors referred to incidents “during their career”, which is likely to cover very many years in most cases!
Dr David Bratt did though appear to take up that issue with some passion and added his own comment to certain media reports on incidents, which were only quoting very few GPs. It will not surprise those who know more about Dr Bratt and his clearly biased views that the rounded survey result would later show up in many of his “presentations” that he regularly gives to GP conferences, other medical professional gatherings, to medical trainers and trainees, which are full of such hand-picked, insufficiently proved statistics.
Designated Doctor Training
Under Dr Bratt (a common GP from Wellington, with specialisation in obstetrics), who has been Principal Health Advisor since late 2007, WINZ and MSD soon even started “training” the so-called “designated doctors” that WINZ relies on for giving second opinions and conducting reviews of applicants’ and sickness and invalid’s beneficiaries’ health conditions.
In a memo from T. Mulvena, ‘National Manager Strategic Projects’ at MSD and Work and Income, and Steve McGill, ‘National Manager Health, Disability and Financial Outcomes’, dated 27 June 2008 and addressed to ‘Regional Commissioners’, in which a “designated doctor” training program was proposed, it was stated, that Work and Income has never provided training for designated doctors in the past.” Dr David Bratt as PHA and Dr David Rankin as ‘Senior Advisor’ were mentioned as supporting the move for “training”.
Officially this “training” was supposed to be “neutral” and “objective” and only intended to “assist” designated doctors to understand the WINZ and MSD system and certain administrative and other requirements, but there is sufficient information showing, that the very resolutely “work ability focused” Dr David Bratt has used presentation- and apparently also “training” material, which clearly has a strong, underlying bias to it. In another memo from 27 March 2006 Dr Rankin had already proposed to the ‘Working New Zealand – SDD’ department within MSD, that the role of “designated doctors” needed to be refined. He recommended in one points under his summary:“Designated doctors should be engaged through a robust selection process and be involved in regular training and education.” In other memos, like one from 05 June 2007, Dr Rankin suggested other changes, raising issues with the then present use and selection of “designated doctors”, and how a “robust” new GP Second Opinion service program should be rolled out. In this the roles of RHAs and RDAs (working under protocols and oversight by the PHA and PDA) were described, how they should be involved in client referrals to “designated doctors”.
Training sessions were held during late 2008 all over New Zealand, and the clear intention was to “train” all “designated doctors” that MSD and WINZ could reach. The new Health and Disability Coordinators (HDCs) were involved in supplying materials, contacting doctors, and so forth. “Training scenarios” and other material were used by Dr Bratt and Dr Rankin, who conducted the training, and looking at those shows that especially the “scenarios” and some “presentations” contained quite “biased” case scenarios and other information, which portrayed sick and disabled beneficiaries as tending to be dishonest, untrustworthy, shirkers, malingerers or exaggerators. Participating doctors were offered “medical education credits”, an “education fee” of $ 150 for participating, possible help with “travel arrangements”, and in some cases even with “accommodation”.
Another internal MSD memo I have seen is from Debbie Costello and Barbara-Anne Stenson as Programme Managers, addressed to Dr Bratt, T. Mulvena and two others, and dated 23 January 2008. It outlines proposed measures, resources and approaches to take in the planned “Designated Doctor Training”, and on page 5 also says rather openly under ‘Costs will include’:“Food and non-alcoholic drinks would be provided on arrival, or to assist social networking after the formal presentation.” On page 3 the same memo states that: “Attending a training course should be compulsory for a doctor to remain a designated doctor.”
In yet another memo dated 19 November 2008 Dr Bratt wrote to Mike Smith, ‘GM Strategy and Service Development’ at MSD, that the fees paid to “designated doctors” doing examinations and giving recommendations on WINZ clients should be reviewed and “adjusted”. It appears that training session attendees expressed dissatisfaction with the way MSD would pay them for the assessments they provided. He refers to an established list of contract “Designated Doctors”. Clearly the WINZ “designated doctors” had expressed their concerns about the time required to complete assessments, which in 1995 was estimated to take only about 30 minutes, but which now was closer to 45 minutes per client. Also did Dr Bratt raise that “designated doctors” had experienced losses in revenue from assessments, as invalid’s benefit applications and reviews were now no longer regularly requiring reports from them. Dr Bratt did thus suggest that MSD increase the standard fee paid to “designated doctors” be increased to $ 180 per examination and report, plus an extra $ 60 for such a doctor for requesting an additional report from a client’s host or own doctor. Dr Bratt argued that GPs generally and on average earn (or charge) $ 250 an hour. Also did Dr Bratt state that over the 6 months until October 2008 DD reports asked for by WINZ increased by 60 per cent, due to the new approaches taken. I have no information on what increase was ever agreed to, but it must be concluded, that a significant increase occurred, as at one stage I heard of $ 136 per report being paid a few of years ago.
There are also memos and other information showing that Dr Bratt proposed training for ‘Medical Appeal Board’ members. The information shows that Dr Bratt was concerned about board members not focusing strictly and firmly enough on only medical conditions and relevant information on these, and on how health issues impacted on the ability to work. Some other concerns were about the selection of appropriate members, and that panel members were not supposed to “diagnose” or “examine” appellants, only question them and examine medical records and other relevant information to make decisions.
QUESTIONS ABOUT THE INDEPENDENCE OF DESIGNATED DOCTORS:
According to MSD’s “official” policies and principles, and certainly according to the law, designated doctors doing reviews under the old sections 44 and 54B (3) and (4) of the Act (now sections 40C, and also 88E (4) and (5)), are supposed to be INDEPENDENT medical professionals providing only truly INDEPENDENT opinions, assessments and advice. Yet, how “independent” would such designated doctors be, while they get “trained”, “hosted” and paid by the very agency asking them to provide “independent” opinions on clients and applicants dependent on welfare support from that agency?
This somehow goes down badly with the principles of natural justice and the law, does it not?
Information obtained under the O.I.A. discloses that almost all designated doctors are nowadays simply common GPs (general practitioners). There was in early 2011 NO psychologist available as a designated doctor, while the Social Security Act does in old sections 44 and 54B (3) and (4) (now ss 40C and 88E (4) and (5)) provide for a “choice” (with good reasons) between a medical practitioner (a specialist doctor, registrar, psychiatrist or GP) and a PSYCHOLOGIST (to presumably examine mental health or psychological conditions and disabilities).
There were in 2011 also only 10 psychiatrists listed nationwide as designated doctors, which hardly meets the needs of sick and disabled with mental health problems, who would be spread across the whole of New Zealand. With about 30 to 40 per cent of invalid’s and sickness beneficiaries at least partly having psychiatric, psychological and/or addiction issues, it is a rather dismissive approach by MSD, to rely largely only on common “generalist” doctors like GPs, when the vast majority of them have NO (or totally insufficient) expertise and qualifications in psychology or psychiatry.
I have been given information by persons affected, who were asked by WINZ case managers to undergo a review by a designated doctor. The Act does offer an affected client or applicant some input, because s 44 and s 54B (3) and (4) (now 40C, and also 88E (4) and (5)) speak of an agreement between WINZ and a client to be attempted on who to see as such a doctor. Yet in at least some (I dare to presume very many) cases, the client is NOT offered any choice and input, and rather gets told by a case manager who to see! That is a breach of the law. Only if there is no agreement at first between an affected client and WINZ, then can WINZ case managers (usually in consultation with a Regional Health or Disability Advisor) propose and appoint a particular “designated doctor”. In many cases a client is only presented a short list of selected designated doctors to pick from, again not offered any sufficient input. In any case, it appears that MSD and WINZ have their preferred designated doctors, which I presume is, because they are more likely to make the decisions WINZ would prefer! A doctor I spoke with confided to me that he knows a colleague who does a very high number of reviews for WINZ. MSD have themselves records, proving that a small percentage of designated doctors handle a very large volume of examinations (assessments) for WINZ.
Also have there been issues with the appointments to so-called Medical Appeal Boards, who under old section 53A (now new s 10B) hear appeals by the former invalid’s and sickness benefit recipients (now ‘Supported Living’ and ‘Jobseeker’ benefits), or applicants for those benefits. Applicants and benefit recipients can appeal against decisions by WINZ staff, that are based on a “designated doctor” recommendations, with which a client may disagree.
There is no further appeal possible after such a board makes a decision. Strangely also many “designated doctors” again sit on such boards, although not the same ones who conducted the disputed assessment or review. Members of such a board are appointed by MSD “medical appeals coordinators”, who are placed in their regional offices.
This is going on under the regime of MSD and their new Principal Health Advisor Dr Bratt, who believes that work is the best kind of “medicine” to assist sick persons on benefits to get well again. Since at least 2010, Dr Bratt appears to have felt very emboldened by the new approach under the new National led government towards social security – and welfare policy in general. He has shown this in the many “presentations” he has since then given, and comments he has made to the media and in public forums.
There is a presentation that Dr Bratt, in that instance “officially” together with his colleague Anne Hawker, that is called ‘Ready, Steady, Crook Are we killing our patients with kindness’, which was given to a GP conference in Christchurch in 2010. IN it he makes bizarre statements like this one on page 13:
“Why these cases?
● in both a patient requested a specific “service”
from you – and these have clinical or health
consequences/outcomes – both positive and
negative
● did you react the same way to each? – the
drug seeker and the benefit seeker?

● and why?“
In the same presentation Dr Bratt then does in further comments on pages 20 (see reference to “opiates”), 21 and 35 link the medical certification for benefit purposes to promoting drug use – with the risk of causing addiction. It culminates in this extreme comparison:
“• the “benefit” – an addictive debilitating drug
with significant adverse effects to both the
patient and their family (whānau) – not
dissimilar to smoking
• and NZ GPs write 350,000 scripts for it every
year!“
On page 30 of that presentation (like others that followed) Dr Bratt lists the doctor patient relationship and patient advocacy as “barriers” to “managing health and work issues”!
Dr Bratt has since then continually linked benefit dependence to drug dependence, or made bizarre comparisons between the two. Also has he presented disputed, unproved statistical information, like that about “30 per cent” of GPs “had experienced a sense of threat and intimidation”! This appears to be based on questionable surveys conducted, like the one by ‘NZ Doctor’ magazine, asking ambiguous or too unspecified questions. He repeatedly claims that being on a benefit is as bad for your health as smoking 10 packets of cigarettes a day, and more dangerous than working in the most dangerous jobs (e.g. on an oil drilling platform in the North Sea).
Furthermore has Dr Bratt drawn substantially on supposed “findings” from UK “research”, like the ones conducted by the ones of Professors Gordon Waddell and Mansel Aylward, who both worked for the ‘Unum Provident’ sponsored ‘Centre for Psychosocial & Disability Research’, based at Cardiff University in the UK. Other similarly inclined “experts” like Wessely and Burton also get quoted. Financed by the highly controversial (and repeatedly convicted) US insurance giant, Aylward and Waddell prepared reports that serve as supposed “scientific” evidence, to prove that open employment is both “good for a person’s health” and even “therapeutic”.Much of the research is based on other reports and on statistics that appear to simply have been used selectively to prove a pre-conceived point and message. Their adopted position is that many mental illnesses, same as musculo-skeletal conditions that people suffer from, are mostly only “illness belief”, and therefore medically “unproved”. This “research” has been used by the Department of Work and Pensions in the UK, which was during Mansel Aylward’s employment there as Chief Medical Officer also repeatedly “advised” by the same insurance company, and which then led to disastrous consequences of welfare reforms there, resulting in over 1,100 deaths of those affected in 2011 alone. There is evidence of Professor Aylward’s long relationship to Unum Provident, and he was later appointed as the director of the mentioned “research centre”.
It is not surprising then to find references to those “findings” and other selected “research” in Dr Bratt’s many presentations, interviews and speeches. In this year Dr Bratt has even now started using presentations together with Professor Mansel Aylward, like one which was given to the annual ‘Rotorua GP CME’ in June 2013. Both spoke there and at some other conferences, and held a joint media interview with ‘NZ Doctor Magazine’. Both appear to be working closely together; and Professor Aylward has been advising MSD and the present government on welfare reforms, especially on how to assess and treat sick and disabled.
Below are some links to a presentation and some You Tube videos that show what “presentations” Dr David Bratt made to the Welfare Working Group Forum in 2010:
‘Benefit Sunshine’, PDF presentation by Dr Bratt, see this link:
(this is the more “moderate version” in circulation, there is a longer presentation with more drastic “information” at the end of it!).
For U TUBE Clips and the rest of the article see:
http://nzsocialjusticeblog2013.wordpress.com/2013/12/28/designated-doctors-used-by-work-and-income-some-also-used-by-acc-the-truth-about-them/

Work Capability Tests Based on Flawed Researcch

MEDICAL AND WORK CAPABILITY ASSESSMENTS – BASED ON THE CONTROVERSIAL BIO PSYCHO-SOCIAL MODEL

reprinted from http://nzsocialjusticeblog2013.wordpress.com/

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MEDICAL AND WORK CAPABILITY ASSESSMENTS – BASED ON THE CONTROVERSIAL BIO PSYCHO-SOCIAL MODEL, AIMED AT DISENTITELING AFFECTED FROM WELFARE BENEFITS AND ACCIDENT COMPENSATION: THE AYLWARD – UNUM LINK
‘An article summarising comprehensive, revealing research results’
Introduction:
Media revelations during 2012 exposed a kind of “exit strategy” that ACC has apparently been using to off-load complex and costly claim cases by using in at least some cases highly questionable practices and medical assessors.
(see YouTube links: http://www.youtube.com/watch?v=DNkN3DW1W6s andhttp://www.youtube.com/watch?v=55LzKcivWuM from Sept. 2012).
Following this, recent developments in the social security system in New Zealand now also give rise to immense concern, as work capability assessments will be applied to virtually all disabled and seriously ill, suffering degrees of incapacity.
On 15 July 2013 fundamental changes to the New Zealand social security system were introduced. Most in the public only learned that 7 former benefit categories would be merged into 3 new categories, that beneficiaries caring for children now have to fulfil certain social obligations, that jobseekers may face sanctions if they do not pass a required drug test, and that benefit recipients facing a warrant for arrest, could lose their benefit, if they would not comply with new rules.
A certainly much more significant set of changes also came into force, which have hardly been taken note by the media and the public. This includes the new, extremely stringent approach by Work and Income (WINZ) to require sick, disabled and incapacitated beneficiaries, to comply with greater work expectations. All former sickness beneficiaries were transferred onto the new Jobseeker Support category, and they will face new, different re-assessments for their capacity to work or train.
Work capability will no longer solely – or primarily – be determined by information on medical certificates issued by medical practitioners or other authorised health professionals. There will be new additional measures, including expected, “self assessments” (on pre-designed forms), additional interviews with Work and Income staff tasked with finding ways to refer sick, injured or disabled back into some form of work on the open market. Further medical examinations by WINZ-trained and paid “designated doctors” can also be required, to assess what work a client can do.
Few will comprehend the magnitude and significance of the new approach, which, when compared with similar, earlier changes introduced in the United Kingdom, can only be described as the biggest attack on the social security system of New Zealand since at least 1991. The new changes under the ‘Social Security (Benefit Categories and Work Focus) Act 2013’, are nothing but a relentless drive to force many sick, disabled and incapacitated to look at least for part time work. The claims by the government and Ministry, that the intention is to “help” people, who are “locked in” benefit dependence, are nothing but cunning, misleading statements to disguise the true intentions and agenda. The goal of that agenda is above all: Reducing the number of persons on welfare benefits, and by doing so – COST CUTTING!
Already with the introduction of the ‘Future Focus’ policies in 2010 did Work and Income introduce a new approach following one used by the ‘Department of Work and Pensions’ (DWP) in the United Kingdom (UK), to rather look at what clients “can do” than what they “cannot do”. From 15 July 2013 a new ‘Work Capacity Medical Certificate’ is being used, which puts the emphasis on assessing what obstacles a client faces, to return to work, before the actual health conditions are being looked at.
Virtually ALL beneficiaries, including those on the new Supported Living Payment, onto which mostly former Invalid’s Benefit recipients have been transferred, will have to attend interviews and assessments for determining capacity to at least attend work preparation obligations, when being asked to do so.
On page 40 (of 48) on the new application form for the ‘Supported Living Payment’ – under “obligations” and “privacy” it says:
“2. Work preparation obligations if you have a health condition,
disability or injury
I understand that while I get this benefit I’ll have an obligation, when asked, to:licants
• attend and participate in interviews to determine if I have the capacity to have work preparation obligations
I understand that if I’m assessed as having the capacity, I’ll have the following work preparation obligations to:
• attend and take part in work preparation interviews, where Work and Income ask me to
• attend and take part in work related activities or programmes such as a work assessment, a programme or seminar to increase particular skills or enhance motivation where Work and Income ask me to
• attend and take part in any other activity that Work and Income require me to (including rehabilitation but not medical treatment, voluntary work or activity in the community).”
It says on page 39 (of 48) on the new application form for the Jobseeker Support benefit – under “obligations” and “privacy”:
“3. Work obligations if you have a health condition, disability or injury that
stops you working full time
I understand that while I get this benefit, if I have a health condition, injury or disability that
means I can only work part-time, I have the following part-time work obligations to:
• be available for and take reasonable steps to get a suitable part-time job
• take any offer of suitable part-time or temporary work, or work that is seasonal or subsidised
• attend and take part in any suitable job interviews Work and Income ask me to
• take and pass any drug test potential employers or training providers require
• attend and take part in interviews with Work and Income as required
• work with Work and Income to plan how I’ll find a suitable job
• take part in any other activities that Work and Income refer me to, such as attend any job
training courses, seminars, work experience or work assessments (including rehabilitation, but not medical treatment) that will improve my work readiness or help me get work
• let Work and Income know how I’m meeting my work obligations as often as Work and Income reasonably requires.
I understand that while I get this benefit, if I have a health condition, injury or disability that
means I am unable to work or can only work less than 15 hours a week, I will not be asked
to meet work obligations until my situation changes and in the meantime I will have the
following work preparation obligations to:
• take reasonable steps to prepare and plan for work
• attend and take part in work preparation interviews, where Work and Income ask me to
• attend and take part in work related activities or programmes such as a work assessment,
a programme or seminar to increase particular skills or enhance motivation where
Work and Income ask me to
• attend and take part in any other activity that Work and Income require me to (including
rehabilitation but not medical treatment, voluntary work or activity in the community).”
It says on page 40 (of 48) on the new application form for the Jobseeker Support benefit – under “obligations” and “privacy”:
“6. Work ability assessment
Where I’ve been asked to I’ll have an obligation to attend and participate in a work ability
assessment.”
Applicants andartners
“7. Working with a Contracted Service Provider
Where I’ve been asked to work with a Contracted Service Provider I’ll have an obligation to
co-operate with them and to:
• attend and participate in any interview with them
• report to them on how I’m meeting my obligations
• complete assessments with them.“
Link for downloading form:
http://www.workandincome.govt.nz/documents/forms/jobseeker-support-application.pdf
Links to a sample Work Capacity medical certificate and additional information – from the website of the ‘Royal NZ College of General Practitioners’:
http://www.rnzcgp.org.nz/assets/WI-Medical-Certificate-Sample.pdf
http://www.rnzcgp.org.nz/assets/Work-Capacity-Medical-Certificate-HDS017W.pdf
http://www.rnzcgp.org.nz/changes-to-the-benefit-system-on-15-july/
Link to law change requiring WINZ clients to work with contracted providers:
http://www.legislation.govt.nz/act/public/2013/0013/latest/DLM4750153.html
With news and other reports about the new approach in establishing work capability for sick, injured and disabled, the name of a Professor Sir Mansel Aylward, as well as names of other members of a core group of medical and health “experts”, many linked to the ‘Unum Provident’ funded ‘Centre for Psychosocial and Disability Research’ at Cardiff University, Wales, UK, have repeatedly been mentioned.
Also have there been frequent references to the so-called “bio psycho-social model” (BPS model), which is strongly associated with, and promoted by Professor Mansel Aylward and their school of thought. He and others have been strongly recommending this model for the diagnosis and treatment of diseases and illnesses that lead to degrees of impairment and incapacity to function – or to do work.
It has been said and written in UK based media that Mansel Aylward was given a “golden parachute” by the ‘Unum Provident’ insurance company, after he finally resigned from his position as ‘Chief Medical Officer’ for the ‘Department of Work and Pensions’ (DWP) in April 2005. ‘Unum’ offered substantial funding for a newly established ‘Research Centre for Psychosocial and Disability Research’ at Cardiff University in 2005 – that would be led by Professor Aylward.
Aylward’s name has repeatedly surfaced here in New Zealand, and it was reported last year, that he met with Social Welfare Minister Paula Bennett, and also with members of a ‘Health and Disability Panel’, set up by the Ministry of Social Development (MSD) to “advise” on “medical” matters, on the way medical assessments, possible rehabilitation and enhanced work referrals, could be further developed as part of the wider social welfare reforms.
Aylward furthermore held speeches at various conferences and meetings with groups of medical professionals here in New Zealand, and he has been accepted by the ‘Counties Manukau District Health Board’, the Ministry of Social Development, certain general practitioner- and other health professional organisations, and Social Welfare Minister Paula Bennett, as an advisor on health and welfare matters.
To understand who Mansel Aylward is, and what supposed “expert” advice he presents, we can look at readily available information on the internet. It will become evident that Professor Aylward, with his version of the “bio psycho-social model”, and with the strong private health- and disability-insurance sector lobbies, and also government backers behind him, has with his efforts achieved that the medical professions have almost been seized upon. The professions have been inundated with reports, speeches, campaigns and policy releases supporting a new, controversial doctrine – or at best theory! It is time to shine light on what is behind the resolute drive to gradually disentitle sick, disabled and incapacitated from support they were traditionally ensured by way of insurance payments or welfare benefits.
In the following 13 parts of this article and analysis I will present a wide range of available, factual, revealing information that is backed up by plenty of resource material, which can be found via the internet and in other accessible sources.
For the rest of the article  see: http://nzsocialjusticeblog2013.wordpress.com/2013/09/02/medical-and-work-capability-assessments-based-on-the-controversial-bio-psycho-social-model/

Wednesday, February 12, 2014

The Health Benefits of Work?

Open Letter to Royal Australasian College of Physicians




Dr John O'Donnell FRACP

New Zealand President

Royal Australasian College of Physicians

PO Box 10601

WELLINGTON



Dear Dr O’Donnell



On behalf of the members of my Union branch and all affected by the influence your prestigious college exerts, I write to you a matter of grave concern to us all. What concerns us is evidence that the advocacy of one of your constituent faculties, the Australasian Faculty of Occupational and Environmental Medicine (AFOEM), is having consequences it may not have foreseen and which in the current economic climate and under the current political regime could have adverse health effects which far outweigh any benefits it seeks to bring about. This being so, we think it incumbent on the RCAP to issue a public statement criticising the unbalanced position of the AFOEM and the opportunistic use the government has made of it, and bring this to the attention of the government, opposition MPs and the media.



The adverse consequences I have referred to follow from the use made by the present government of the AFOEM’s Position Statement (1) on the health benefits of work. The statement is quoted on Work and Income's application form for work assessment (2) in a blatant attempt to influence G.P s to disqualify applicants from the Supported Living payment. Moreover, one of our supporters (who, for understandable reasons wishes to remain anonymous) reports having obtained under the Official Information Act evidence that WINZ 'designated doctors' are being indoctrinated in the converse of the 'health benefits of work', viz. the allegedly adverse health consequences of living on a benefit. The idea is even being propagated that benefit dependency is an addiction! (2).



It is no secret that the government's benefit reforms are intended to reduce the number of beneficiaries by tens of thousands: 40,000 has been mentioned as a target.

If these reforms were genuinely promulgated as a public health measure, we would expect the government to say so publicly, and to back its words with deeds by ensuring there were jobs available for job-seekers to apply for. The fact that they have done neither surely indicates firstly that they know such a claim could not withstand the storm of criticism it would be bound to provoke, and secondly (when considered in conjunction with other employment-related legislation) that the real purpose is altogether different: A predictable consequence of throwing tens of thousands more onto the labour market at a time of global and local recession is intensified competition for scarce jobs, resulting in greater stresses on individuals - many of whom have mental and/or physical ailments- and downward pressure on wages. The latter effect will certainly be seen as desirable by employer friendly government keen to restore business profitability, and the measures taken to achieve it signify that it considers the inflicted stresses worthwhile. Any such government would naturally be delighted if its harsh measures could be represented as beneficial from the point of view of health, and would welcome such advocacy as the AOEFM's with open arms.

It would be truly shocking if the AFOEM foresaw and approved of this consequence of its advocacy, but not so surprising if any corporate interests it may serve (such as insurance companies) did so. This possibility is further discussed below.

Meanwhile New Zealand's appalling childhood poverty rates have finally been getting the media attention they deserve, as has the link between poverty and illness. We find it remarkable that despite what it says in your admirable Public Health and Policy Statement (3) about 'complex interactions between social and economic factors', nowhere on your website can be found any reference whatsoever to any link between poverty and illness, such as is ably described in the following article in NZ Herald of 23rd Oct 2013. (4) As a specialist faculty of RCAP, it is somewhat more understandable that the AFOEM should in its Position Paper omit discussion of poverty as a more direct causative factor in illness than unemployment.

We would, however, expect a scientific investigation to consider alternative hypotheses to the one advanced, and to acknowledge that statistical correlation is not evidence of direct causation. Even less is it ‘compelling’ evidence, especially when the evidence of an alternative explanation of the data is so strong.

What is ironical is the position paper’s acknowledgement, albeit without any discussion of its significance of two observations that conflict with its primary hypothesis. Firstly that for a certain stratum of society the possession of wealth is a sufficient prophylactic against the allegedly adverse health effects of idleness! Secondly, the inclusion of children in the statistics adduced in support of the 'health benefits of work' hypothesis is 'compelling evidence' (to use a phrase AFOEM has used and the government is fond of quoting) not of the health benefits of work (unless the AFOEM attributes childhood illness to idleness!), but of the adverse health effects of poverty. And let us not forget that increased poverty is the inevitable consequence of the benefit reforms. For the government to acknowledge the latter would be fatal to one of its main policy platforms. Hence it's state of denial.

The noted omissions would be explicable if the AFOEM's research was 'commissioned research and, as such, pre-disposed towards ideologically determined outcomes' (to quote Prof Alison Ravetz' appraisal of similar research done in the UK).

What is particularly disturbing is evidence of the influence on the AFOEM of Sir Mansel Aylward. (5) Aylward was formerly Chief Medical Adviser, Medical Director and Chief Scientist at the UK Department of Work and Pensions, and is now HOD in an academic chair sponsored by Unum, the world's largest disability insurer. (6) Not only has Unum been thoroughly discredited for the scale on which it has attempted to evade payouts (California Insurance Commissioner John Garamendi has state that is is 'an outlaw company...that for years has operated in an illegal fashion.' (7) A Yale University research paper commented that, with regards to Employee Retirement Income Security Act (ERISA) and other cases, Unum was, 'engaged in a program of deliberate bad faith denial of meritorious claims'; (8). Moreover Unum has according to one disability researcher from Leeds University 'demonstrated an interest in taking over the UK welfare system' (9).

It was Aylward who devised the Personal Capability assessment (PCA) to which British claimants are subjected, the administration of which is contacted out to a private sector firm ATOS. Amongst the charges levelled against the sponsors of Aylward's academic chair by the insurance commissioners of a number of U.S. states (7) is 'excessive reliance of in-house medical professionals.' If Aylward does not fit that description, he comes perilously close to it. The RACP should be seriously concerned for its reputation for scientific impartiality.

Aylward’s version of the bio-psycho-social-model of illness differs from that of the RACP’s public policy statement in its emaciated interpretation of the social dimension, which conveniently (for the purposes of such as WINZ and Unum) restricts it to the immediate circle of the client’s family, employer and caregivers, and excludes capital, income distribution and such redoubtable social institutions as, governments, universities, professional associations, trans-national insurance companies etc. Moreover it lends itself to interpretations that stigmatise the infirm and disabled, as has happened in the UK. (10)

The United Kingdom is further down the path of work-focused welfare reform than is New Zealand, and the results it has achieved- little published in New Zealand, are truly alarming, and include the ‘ruthless pressurising (of) the sick and disabled into work’ and thousands dying while on work-related activity placements. (11)

Insofar as the success claimed by the government in reducing expenditure on welfare is a consequence of AFOEM's advocacy, one consequence of that advocacy is increased financial stress on beneficiaries disqualified from receipt of the supported living payment without any guarantee of employment (12) It is precisely when the income loss affects ability to meet expenses for healthy food, accommodation, power and doctors bills that the 'complex interactions between social and economic factors' referred to in your Public Health and Policy Statement take effect.

In summary, it bears repeating that the government has reasons for reluctance to acknowledge the reality of a link between child poverty and illness, is totally reliant on unregulated and demonstrably unreliable market forces to eradicate poverty and is evidently therefore profoundly grateful for such advocacy as is offered by AFOEM which, supported by the continued silence of the RACP, diverts blame for a disgraceful state of affairs from the policies which perpetuate it onto the victims. There are grounds for suspecting that in issuing its Position Statement the AFOEM has been manipulated by corporate interests into lending its prestige as a professional body toward endorsing goals that have nothing to do with health and everything to do with profit-making.

The most shameful episodes in the history of the medical profession have been when in the name of science it has given ideological support to slave-owning oligarchs and fascists. Greater vigilance is evidently required to ensure nothing like that ever happens again.

Yours sincerely

D.K. Henderson

Honorary Secretary

Waitemata Branch of Unite Union



Footnotes: ___________________________________________________

(1) AFOEM Position Statement: http://www.racp.org.nz/i ndex.cfm?objectid=F07790EC-0F2D-D1EB-4298E5D44500162A

Consensus Statement: http://www.racp.org.nz/index.cfm?objectid=57063EA7-0A13-1AB6-E0CA75D0CB353BA8

The fact that WINZ erroneously attributes a quote from AFOEM's position statement to its consensus statement could signify that it has not even studied the evidence that it blithely quotes as being 'compelling.'

(2) http://www.nzherald.co.nz/simon-collins/news/article.cfm?a_id=135&objectid=10898616

(3) We wholeheartedly approve of RACP's excellent public health and social policy statement, which can be seen in full at:

http://www.racp.org.nz/page/policy-and-advocacy/public-health-and-social-policy

However it should not be taken to endorse Aylward's (and the AFOEM's and WINZ's retrograde version of bio-psycho-social medicine).

(4) Child Poverty http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11168848

http://www.scoop.co.nz/stories/PO1312/S00111/unicef-nz-statement-on-child-poverty-monitor.htm

http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11144397

(5) http://www.racp.org.nz/page/racp-faculties/australasian-faculty-of-occupational-and-environmental-medicine/realising-the-health-benefits-of-work/may-2010-video-presentation-professor-sir-mansel-aylward/

(6) http://www.corporatewatch.org.uk/?lid=2940

(7) http://www.austinmehr.com/about-us/articles/articles-austin-mehr/103-unum-life-insurance-fined

(8) A Yale University research paper commented that, with regards to Employee Retirement Income Security Act (ERISA) and other cases, Unum was, 'engaged in a program of deliberate bad faith denial of meritorious claims'

(9) http://disability-studies.leeds.ac.uk/files/library/FROM-BRITISH-WELFARE-STATE-TO-ANOTHER-AMERICAN-STATE-2013-3rd-edit-FINAL.pdf

(10) ) http://blacktrianglecampaign.org/

(11) http://www.newstatesman.com/politics/2008/05/work-benefit-claimants-reform;

http://www.dailymail.co.uk/news/article-2180899/Flawed-disability-tests-send-genuinely-s ick-unable-work.html

(12) Benefit Cuts http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11144397 http://www.scoop.co.nz/stories/PO1401/S00024/changes-to-invalids-benefit-sees-beneficiaries-income-drop.htm