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It is not up to GPs to decide which patients are ‘deserving’ or ‘undeserving’

Scottish GPs have come under fire for failing to provide reports for patients to support the appeals process for benefits claimants, but Dr Alan McDevitt argues that GPs are struggling to cope with the new processes

I have spoken a lot about the severe workload pressures in general practice in recent months and the effects of changes to the welfare benefit system have had a huge impact, not just on the workload of practices but on the relationships between doctors and their patients. 

Essentially, by putting patients in a position where they are advised to get additional medical information to support an appeal claim, the Government has placed a requirement on GPs to effectively challenge decisions made by independent medical assessors and determine which of my patients are deserving of their benefit payments.

We need to provide more information

The main area of contention for many appears to come from the requests we get from patients for further medical evidence to support appeals against decisions made by Atos.  This is not information that is required under the terms of our contract or for the initial benefits review process, but instead it’s a ‘suggestion’ that could help the individual’s case when subject to appeal, many of which have been successful.   

In just one morning in my surgery, for example, these requests accounted for three out of 16 of my appointments.  I am in a position where the bureaucratic demands of the welfare system are affecting the time I have to spend on the clinical needs of my patients.  I am sure that all GPs are facing a similar dilemma.

It is absolutely true that none of my patients can afford to have less money, yet employment is arguably one of the best determinants of future health.  The setting of thresholds for benefits is, quite correctly, a political decision and it should be assessed independently, but we GPs are unashamedly biased in favour of our patients; we are not independent in that sense.  Our role in providing evidence should solely be to provide factual information and not to offer an opinion on who should receive benefits, because whoever has that role also says who should not get benefits.  I do not want to divide my patients into the deserving and the undeserving sick and disabled.

The current process puts me in an invidious position.  If I provide further medical evidence only for some people, I am being partial.  I might provide a letter because I am sympathetic to the patient.  We could therefore end up in a situation where my decision to provide additional information – which is private because it is not part of the assessment system - is based on whether I have greater sympathy for one patient over another.  Should I have to decide who deserves an additional medical report that will help them challenge a decision that they cannot have benefits.  For some patients, their doctor may agree with the decision to refuse benefits which could harm the relationship between the doctor and patient.

Therefore if I were to give reports, I would have to give them to everyone.  That is just not tenable, given the numbers involved.  Surely it is fairer for a system where information is provided in a standardised and fair way and where an independent body decides whether a person is entitled to benefits?

The ethical issues

The role and responsibility of GPs has clearly changed as a result of these welfare reforms, but without any genuine discussion from those responsible for the system, yet somehow we seem to be blamed for it going wrong, which is a strange position to be in.

The system should be fair and just – there needs to be a systematic application of a fair way to get medical information.  The process is already there, so change could be easily and immediately achieved – but it is for the politicians and pressure groups to decide how the system works.

As it stands, GPs are expected to prop up a flawed system.  Far too many people are being turned down for benefits and having to go through the appeal process.  That so many appeals are successful demonstrates the flaws in the system and the urgent need for improvement. 

The BMA wants to see improvements where more appropriate and comprehensive information is provided in advance of making a decision on ESA for a patient, because that is the only fair and equitable way for medical evidence to be provided by GPs.

Dr Alan McDevitt is the chair of GPC Scotland and a GP in Clydebank.

Readers' comments (6)

  • David Bush

    How about this for a solution? Develop a nationally agreed template report for DWP (and funded by DWP), giving an appropriate summary of patient's medical history. Embed it into the GP clinical system, so admin staff can run off a copy when requested, much like insurance PMA's.

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  • More bits of paper fro GP's to deal with, no wonder we cannot get appointments!

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  • Joint Response by DPAC and Black Triangle on Dr Phil Peverley’s Shameful Comments published in Pulse Magazine, The Daily Mail and The Daily Telegraph Posted on August 5, 2013

    http://blacktrianglecampaign.org/2013/08/05/joint-response-by-dpac-and-black-triangle-on-dr-phil-peverleys-shameful-comments-published-in-pulse-magazine-the-daily-mail-and-the-daily-telegraph/

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  • Leading doctors protest at ‘cruel’ disability assessments ~ Letter

    Black Triangle Campaign Anti-Defamation Campaign in Defence of Disability Rights


    info@blacktrianglecampaign.org

    1. Doctors’ Letter

    TEXT

    On 24th June last year at the BMA’s Annual Representative Meeting (ARM) doctors from every discipline voted overwhelmingly to demand that the DWP-Atos Work Capability Assessment end ’with immediate effect’.

    Through their Medical Adviser, the patient-led Black Triangle disability rights campaign originated the motion which became BMA national policy. Part (iii) of the ARM motion called upon the BMA to engage with disability groups to change public policy. To date, the only ”official” communication their campaign has received has been a short statement via Facebook.

    As doctors on the front line witnessing daily the enormous avoidable suffering of many of our most vulnerable patients caught up in this Kafkaesque system of ‘disability assessment’, we find this failure to meaningfully engage unacceptable. More critically, we fully share in the dismay with which sick and/or disabled people have greeted the failure of the BMA’s leadership to give any meaningful effect to the unanimous wishes of its members: that this dreadful assessment régime should be immediately terminated.

    The GMC’s own publication ‘Good Medical Practice’ states that:

    ‘… a doctor must (overriding duty or principle) take prompt action if he feels that “patient safety is or may be seriously compromised by inadequate… policies or systems.’

    ESA Regulations (2013) 29 & 35 deal with flagging up a substantial risk of harm to patients if they were to be found ‘fit for work’ or to have ‘limited capability for work’ and placed in the Work-Related Activity Group (WRAG) where:

    ‘the claimant suffers from some specific disease or bodily or mental disablement and, by reasons of such disease or disablement, there would be a substantial risk to the mental or physical health of any person if the claimant were found not to have limited capability for work.’

    Regrettably, it remains the case that only DWP and ATOS staff are aware of these regulations whilst GPs remain ignorant of their existence and those performing the WCA and DWP Decision Makers continue to make complex risk assessments based on grossly inadequate patient information.

    Until the current system is entirely revised, there remains no safety protocol for the assessment of risk and the avoidance of harm to patients. There are no formal reporting mechanisms for GPs to report significant adverse events such as self-harm and suicides which many of us have witnessed.

    Black Triangle have led the way in campaigning for the uptake of Regulations 25 and 31 and their legal Counsel has advised that they should be applied in every case where harm would be more likely than not to occur as a result of erroneous DWP decisions regarding patients’ fitness for work.

    We are also fully aware of the fact that numerous conflicts of interest exist between the ethical versus contractual duties placed upon GPs arising out of the DWP-Atos contract. In balancing a doctor’s duty of care to provide supporting information for Tribunal appeals and contractual conflicts with the DWP over the issue of fees and workloads, we submit that the only ethical solution must be the one that causes the least harm to patients.

    Black Triangle’s simple campaign for the appropriate application of these regulations utilising one side of A4 has proved highly efficacious in this respect. It has saved General Practitioners a substantial amount of time and expense and has meant that unnecessary, costly and stressful tribunal appeal hearings have been rightly avoided.

    We now call upon the BMA leadership to urgently publicise and make known to every GP in the country the existence and lawful application of these regulations without any further delay in order to prevent further avoidable harm to our patients. Any failure to do so would in our opinion amount to negligence.

    Dr Stephen M. Carty, GP and Medical Advisor, Black Triangle Campaign.
    Dr John Budd, GP Edinburgh Access Practice
    Dr Roy Robertson, GP Muirhouse, Honorary Clinical Reader
    Dr Ian McKay, GP Rose Garden Medical Practice, Leith
    Dr Oliver Aldridge, Edinburgh
    Dr Guy Johnson, GP Sighthill Health Centre, Edinburgh
    Dr Helga Rhein GP, Sighthill Health Centre, Edinburgh
    Dr Elizabeth Morton, GP Challenging Behaviour Practice, Edinburgh
    Dr Kate Burton, Public Health Practitioner
    Dr Margaret Craig, GP, Allander Surgery, Possilpark, Glasgow
    Dr Nick Treadgold, GP, Pollok Health Centre, Glasgow
    Dr Christine Grieve, GP Drumchapel Health Centre Glasgow
    Dr Chris Johnstone, GP Paisley
    Dr Donald MacIntyre Consultant Psychiatrist Edinburgh
    Dr Sarah Houston GP
    Dr Ros Wight GP
    Dr Robert Young, Glasgow
    Dr Nora Murray-Cavanagh GP Medical Education Fellow
    Dr David Nicholl, Consultant Neurologist, Birmingham
    Dr Jonathon Tomlinson, GP The Lawson Practice N1 5HZ
    Dr Anita Roy, GP, Yorkshire
    Dr George Farrelly, GP, London
    Dr Peter English, Consultant, London
    Dr Robert Cheeseman, Ophthalmology Registrar, Liverpool
    Dr Ray Noble, Medical Ethicist, UCL Institute for Women’s Health
    Dr Margaret McCartney, GP , Glasgow


    2. Supporting Letter from Trade Unions and Civil Society


    TEXT

    As trade unionists, organisations and campaigners from across civil society who collectively represent millions of citizens we write in support of the letter by doctors in the British Medical Association about work capability assessments.

    We firmly believe the current assessment régime is unfit for purpose and poses a real risk to the health and lives of disabled people and those with life threatening conditions. This is because the government’s regulations, which ask whether substantial risk or harm would be caused if the claimants are found ‘fit for work’ or with limited capacity for work, are not being applied consistently.

    Information obtained through freedom of information requests shows that between January and August 2011, 1,100 claimants died after they were put in the work-related activity group – the equivalent of 30 deaths a week.

    We are hopeful for a successful outcome to discussions between disabled people’s organisations and the BMA, following its conference decision last year to call for the current assessment régime to be scrapped.

    We send our solidarity to these groups and the BMA and hope you will join us in a united campaign to bring an end to the disgraceful treatment of ill and disabled people.

    John McArdle, David Churchley and Dr. Stephen M. Carty Black Triangle Campaign

    Linda Burnip Disabled People Against Cuts DPAC
    Mark Serwotka General Secretary Public and Commercial Services Union PCS
    Len McCluskey General Secretary Unite the Union
    Christine Blower, General Secretary National Union of Teachers NUT
    Bob Monks, General Secretary of United Road Transport Union URTU
    Sally Hunt, General Secretary of University and College Union UCU
    Michelle Stanistreet, General Secretary National Union of Journalists
    Phil Gray, Chief Executive, Chartered Society of Physiotherapy
    Richard Evans, Chief Executive Officer Society of Radiographers
    Bill Scott, Manager, Inclusion Scotland
    Gordon McFadden, Policy Director, Limbcare
    Dr Simon Duffy, The Centre for Welfare Reform
    Dan Moreton, Social Work Action Network (SWAN) and SWAN (London)
    Mary Olaniyi Coordinator/Family Adviser Lewisham Mencap
    John McDonnell MP (Lab, Hayes and Harlington)
    Deborah King Co-founder Disability Politics UK
    Paul Smith – Founder Atos Victims Group
    John Burgess Branch Secretary Barnet UNISON
    Gill MacDonald Psychiatric Nurse Lothian NHS

    http://blacktrianglecampaign.org/2013/05/05/leading-doctors-protest-at-cruel-disability-assessments-letter/

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  • Come on, Doctors! SPEAK OUT!

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  • On a technical point, the medical history isn't as important as your opinion on the patient's likely difficulties with activities of daily living. GPs shouldn't be asked to decide fitness for work once Atos are involved.

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