The role of GPs in the WCA Process

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Dear Department for Work and Pensions,

In FoI Ref: 285, you have made a series of statements in relation to the WCA and the role you think GPs have to play. I would like to establish precisely how you think they can best contribute to the decision making process and the form this contribution should take :

1. You say “GPs are an important part of the process”, but in the same response you say that you regard them as inadequately trained to assess work capability. Also, GP “fit-notes” are largely disregarded and you have plans to remove GP involvement from sickness certification for people who are employed and receiving sick pay.

Q1: Clearly you do not trust their judgement in this area, so quite what important part do they play? What are they not doing that they should be doing?

Q2: If you are relying on a GP’s clinical expertise, you are then expecting an HCP (who may well be less clinically qualified) and a DWP DM (who has no medical training at all) to accurately interpret the information they provide. This is an obvious recipe for oversimplification, misunderstanding and subsequent error. Please clarify.

2. You say “Additionally, Atos also regularly requests additional medical evidence from GPs in the form of an ESA113.”

Q3: “regularly” implies frequently. In what percentage of WCAs has Atos issued form ESA113 and of this number, what proportion has been returned complete ahead of the WCA?

Q4: Much of form ESA 113 asks the GP to make assessments of a patient’s capability to work, which in the same FoIA response you point out that they are not trained to provide. What then is the point of asking them?

Q5: You seem to be drawing some form of distinction between
• A persons capability to work per se, as viewed by a GP through ESA113 and
• A person’s capability to work in relation to health related benefits payments, as determined by a DWP decision maker.
Please explain how a person can been deemed unfit to work by one criteria, but not by the other.

3. You also describe a GP as an advocate, which is simply a person who acts on behalf of someone else. The Hippocratic Oath required a GP to act only in the best interests of their patient, so if it is in a patient’s best interests to return to work for the physical and psychological benefits it will bring, a GP is of course obliged to say so. You may not regard them as adequately trained to make this call, but this does not stop them from making the recommendation and if they do, DWP accepts it without challenge. You are therefore saying that either:
• GPs are not necessarily working in their patient’s best interest and that a DWP administrator who is not medically trained is better placed to judge or
• In contradicting a GP’s opinion, the DM does not have the patient’s best interests at heart.
Q6: I am afraid it can only be one or the other, so please clarify.

4. “(HCPs) are trained in disability assessment – assessing the functional effects of a person’s condition or disability.”

Perhaps this is true, but how can they understand the limitations a person’s condition might impose if their clinical and diagnostic experience is limited? They could well be faced with a complex condition where they have no experience and which they simply do not fully understand. They cannot rely solely on what they see at a WCA due to condition variability and therefore require far more extensive knowledge than “disability assessment training” would provide.

Q7: Please explain how without this knowledge they can draw a balanced conclusion and recommendation – surely at very least a HCP must be qualified to the same standard as a GP?

Yours faithfully,

J Newman

DWP Adelphi Freedom-of-Information-Request, Department for Work and Pensions

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DWP Adelphi Freedom-of-Information-Request, Department for Work and Pensions

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Dear J Newman

Please see attached response to your FoI request 67

Kind regards

DWP Central FoI Team

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Dear Department for Work and Pensions,

Please pass this on to the person who conducts Freedom of Information reviews.

I am writing to request an internal review of Department for Work and Pensions's handling of my FOI request 'The role of GPs in the WCA Process' as you have not addressed all of the points in full.

Thank you for your reply and I will take your points in turn. There are a few questions and some corrections to what you have said for your information.

However, it is first important to explain to you that a GP’s training is not nearly as narrow as you suggest. As the BMA’s website points out, employers frequently request an occupational health report from an employee’s GP for pre-employment purposes or as part of an assessment of a current employee’s fitness to work, so clearly they are adequately qualified in this area.

Some employers do (perhaps in addition) commission the services of someone else, but this person is familiar with the workplaces relevant to the particular employer and make their assessments accordingly on an individual basis. They do not make generalised assessments with no indication of what the work is and what the work entails. They also consider the broader context of work – for example, the reliability an individual’s condition allows them to offer, problems travelling to and from work etc. again all on a case by case basis.

You are therefore wrong to say that GPs are inadequately qualified to make FFW judgements.

Q1: Your response does not answer the question. You have an experienced doctor trained over 7+ years and highly qualified providing information to (potentially) a much less qualified HCP and an administrator. Clearly they simply will not understand a good proportion of it.

Q2: You are wrong. An Atos HCP might be no more than a Physiotherapist who is NOT regarded as clinically qualified. Also, in other FoI responses you have stated categorically that Atos HCPs DO NOT NEED TO BE CLINICALLY QUALIFIED (in your opinion) – a complete contradiction of what you have said here.

Q4/Q7: GPs are all trained in the same way to the same standard, so in acknowledging some have this expertise you must also accept they all do. In contrast here and elsewhere you have suggested none of them do and your entire process reflects this false assumption.

Q5: In deciding entitlement to ESA, a DM is also deciding my fitness to work. However you word it, an administrator with no medical training is making decisions involving potentially complex medical conditions. There is no other example where this absurdity would be allowed to take place – rather like your GP’s receptionist being given responsibility for prescribing your medication.

Q6: Let me re-phrase. Do DWP’s policies and imperatives anywhere clarify to a DM that their first priority is always a claimant’s health and well-being? Despite its obvious importance, I have been unable to find it in any of the references you have sent me.
Also, a GP’s behaviour is largely dictated by the Hippocratic Oath. As DMs are able to countermand a GP’s opinion, you would expect them to have signed-up to something identical. What and where is it? Again, there is nothing of this nature in the references you have supplied to date.

A full history of my FOI request and all correspondence is available on the Internet at this address:
http://www.whatdotheyknow.com/request/th...

Yours faithfully,

J Newman

DWP Adelphi Freedom-of-Information-Request, Department for Work and Pensions

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DWP Adelphi Freedom-of-Information-Request, Department for Work and Pensions

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Dear J Newman

Please see attached response to your FoI request IR 93

Kind regards

DWP Central FoI Team

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Dear Department for Work and Pensions,

Please pass this on to the person who conducts Freedom of Information reviews.

I am writing to request an internal review of Department for Work and Pensions's handling of my FOI request 'The role of GPs in the WCA Process'.

Although I took the trouble to explain the reasons behind my requests (in the hope it would make it easier for you to answer), it seems you have still not read my IR request correctly. For the avoidance of doubt, I DO NOT WANT A DISCUSSION. I want whatever RECORDED INFORMATION you have in the areas I have questioned (repeated below, albeit reworded). Only Q1 & Q6 require responses. If there is no information, all you have to do is say so. The context I have described previously is still valid for your reference:

Q1: What evidence do you have that proves GPs are insufficiently trained to correctly assess work capability? An example would be patients who had been signed-off work by their GP, but were able to find and sustain employment. I have presented you evidence available that indicates they ARE adequately trained, so I expect you to be able to more than contradict it.

Q2: You regularly contradict yourselves over the level of clinical expertise an Atos HCP needs, which in itself provides the answer to the question. No further response needed.

Q4/Q7: as with Q1, you are unable to address this issue and in any way support your proposition over GP shortcomings. No further response needed.

Q5: Observation – you are prepared to station HCP with DMs to help them but cannot accept that this just shows the wrong person is making the decision. No further response needed.

Q6: GPs sign the Hippocratic Oath and in countermanding a GP’s recommendation, a DM assumes the GP’s accountabilities and potential liabilities. Do DWP’s policies and imperatives anywhere clarify to a DM that their first priority is always a claimant’s health and well-being? Despite its obvious importance, I have been unable to find it in any of the references you have sent me. It is however important enough to be documented somewhere I am sure.

A full history of my FOI request and all correspondence is available on the Internet at this address:
http://www.whatdotheyknow.com/request/th...

Yours faithfully,

J Newman

DWP Adelphi Freedom-of-Information-Request, Department for Work and Pensions

This is an automated confirmation that your request for information has
been received at the DWP Central FoI Team.

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Department who will respond to you direct. 

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P. Smith left an annotation ()

Hope you don't mind me posting an annotation on here - I would like to know what the BMA's opinion is about this situation. I would like to see copies of all / any representations made by the BMA to the DWP on this matter.

DWP Adelphi Freedom-of-Information-Request, Department for Work and Pensions

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Dear Mr Newman,

Please see attached response to your Internal Review request.

Kind regards,

DWP Central FoI Team

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Dear DWP Adelphi Freedom-of-Information-Request,

Thank you for your reply, although there is a slightly intollerant and annoyed tone to it. I did make it clear where I did not require a response, so there was no need to reprimand me.

For the record, although you sometimes insist you have answered questions and/or provided information previously, this is often actually not the case. The clue is in the fact that the question gets asked again, which would of course be unnecessary if you had already answered it.

With respect, I think you sometimes confuse providing information that explains a question or its context with answering it. Also, you frequently provide links to reports etc. that do not contain the information you say they do. It would be a good idea if someone could read these references before circulating them.

If I can offer any further feedback please let me know.

Yours sincerely,

J Newman

DWP Adelphi Freedom-of-Information-Request, Department for Work and Pensions

This is an automated confirmation that your request for information has
been received at the DWP Central FoI Team.

We will forward your request to the relevant information owner within the
Department who will respond to you direct. 

Should you also have any further queries in connection with this request
do please contact us.

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please click on the link below.

[1]http://www.dwp.gov.uk/freedom-of-informa...

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J Newman left an annotation ()

I have closed this, but will leave a summary here so save other people time. This is actually a very important issue:

1)Although DWP “has no recorded information”, it is still insistent that GPs are not equipped to assess capability to work. It can produce no evidence to support this and cannot see that it is at best ‘opinion’, certainly not fact.

2)It has now to maintain this unsubstantiated position otherwise it undermines the whole outsourced HCP/DM concept. It is not well known for admitting mistakes.

3)It says this despite the fact that GP training includes this very subject and the BMA promotes the occupational health skills of its members to industry, the result being that many GPs are retained by companies for exactly this purpose.

4)The clue is maybe in the DWP phrase “according to legislation”, which tends to imply that it has been drafted to sit outside of a GP’s expertise. Firstly, I do not think this is the case – GP’s are perfectly well qualified. Secondly, if you can teach it to an HCP in a few weeks, you could teach it to GP’s too in probably less time with must better results.

5)GPs engaged for occupational health advice will become very familiar with the working environment of their clients and be able to meaningfully compare individual capabilities with known work situations. By contrast DWP believes that there is something called “general work” although it cannot define what it is or define its characteristics. It can however deem people fit to do it without knowing what “it” is.

6)DWP still disingenuously maintains that a DM only makes an administrative decision over ESA payments. It has to say this because DMs have no medical expertise. It also cannot allow Atos to be seen to be making benefit decisions, so it has created a hole for itself. The ESA decision is a direct result of ability to work – once you have established the latter, the former is obvious. So who decides fitness for work – DM? (not medically equipped) or HCP? (outside of the public sector). DWP talks around this question, but cannot/will not answer it.

7)It (DWP) will not state that its overriding priority is patient well-being. This is a grave concern. It tries to suggest that the ESA decision means the same thing, but of course it does not. This is precisely the difference vs. The NHS.

8)It will not admit it has a duty of care. In countermanding my GPs opinion, the DM must assume the responsibility my GP accepted and never contested i.e. for my health & well-being. If my health suffers as a result of the DM’s decision, he/she is culpable, without doubt.