WORK ABILITY ASSESSMENTS DONE FOR WORK AND INCOME – A REVEALING FACT STUDY: PART I


There are two studies I found, which appear to prove that it is a person’s usual general practitioner (GP) that is best placed for providing a reliable assessment on that person’s work ability, at least in the first instance, to provide a basis for further examinations and assessments:

STUDY I:

Work ability assessed by patients and their GPs in new episodes of sickness certification

http://www.ncbi.nlm.nih.gov/pubmed/10758076

Reiso H1,Nygârd JF, Brage S, Gulbrandsen P, Tellnes G.

Fam Pract.2000 Apr;17(2):139-44.

Abstract

BACKGROUND:

Sickness certification legislation demands that work ability is reduced due to disease or injury. Most sickness certificates are issued by GPs. Assessment of work ability might introduce conflict in the doctor-patient relationship.

OBJECTIVES:

The aim of this study was to compare the level of work ability assessments by patients and their GPs in new episodes of sickness certification, and to explore how medical conditions and work demands are associated with the assessments.

METHODS:

Forty nine GPs supplied data about 408 patients certified sick <8 days before questionnaires were filled in. A total of 268(66%) patients completed corresponding questionnaires. Patients and GPs independently answered the following question using a five-point scale: “To what degree is your (the patient’s) ability to perform your (his or her) ordinary, remunerative work reduced today?”

RESULTS:

Work ability was assessed by patients as very much or much reduced in 66%, moderately reduced in 23% and not much or hardly reduced at all in 11% of the cases. Corresponding assessments made by GPs were 71, 27 and 2%. Patients and GPs agreed well on their assessments (+/- 1 answer category) in 81% (216/266) of the cases. The patients assessed work ability asmore reduced the more stressful or physically strenuous their jobs were, and the older their GPs were. The GPs assessed work ability as more reduced the more their assessments were based on clinical findings.

CONCLUSIONS:

The agreement between work ability assessments made by patients and GPs was high, despite patients’ assessments being associated with work demands and GPs’ with medical conditions.

PMID: 10758076 [PubMed – indexed for MEDLINE]”

STUDY II:

How primary health care physicians make sick listing decisions: the impact of medical factors and functioning.’

http://www.ncbi.nlm.nih.gov/pubmed/18208594

Norrmén G1,Svärdsudd K, Andersson DK

BMC FamPract. 2008 Jan 21;9:3. doi: 10.1186/1471-2296-9-3

Abstract

BACKGROUND:

The decision to issue sickness certification in Sweden for a patient should be based on the physician’s assessment of the reduction of the patient’s work capacity due to a disease or injury, not on psychosocial factors, in spite of the fact that they are known as risk factors for sickness absence. The aim of this study was to investigate the influence of medical factors and functioning on sick listing probability.

METHODS:

Four hundred and seventy-four patient-physician consultations, where sick listing could be an option, in general practice in Orebro county, central Sweden, were documented using physician and patient questionnaires. Information sought was the physicians’ assessments of causes and consequences of the patients’ complaints,potential to recover, diagnoses and prescriptions on sick leave, and the patients’ view of their family and work situation and functioning as well as data on the patients’ former and present health situation. The outcome measure was whether or not a sickness certificate was issued. Multivariate analyses were performed.

RESULTS:

Complaints entirely or mainly somatic as assessed by the physician decreased the risk of sick listing, and complaints resulting in severe limitation of occupational work capacity, as assessed by the patient as well as the physician, increased the risk of sick listing, as did appointments for locomotor complaints. The results for patients with infectious diseases or musculo-skeletal diseases were partly similar to those for all diseases.

CONCLUSION:

The strongest predictors for sickness certification were patient’s and GP’s assessment of reduced work capacity, with a striking concordance between physician and patient on this assessment. When patient’s complaints were judged to be non-somatic the risk of sickness certification was enhanced.

PMID: 18208594 [PubMed – indexed for MEDLINE] PMCID: PMC2266928”

Own Comment:

These are just summaries of the reports, which are available on-line and found via the provided links. But it appears sufficiently convincing that persons’ own GP’s medical reports and certificates should be relied on more than those from WINZ’s own chosen designated doctors, and clients’ own GP’s reports must also definitely be given due consideration besides of any reports from the newly contracted “work ability assessment” providers, who mostly seem to have a rehabilitation treatment focus.

ANOTHER STUDY OF SOME OTHER RELEVANCE TO WORK ABILITY ASSESSMENTS:

Here is another report from Sweden, presenting various issues that can arise when different professionals and officials are involved in the “work ability assessment” of sick and disabled social security benefit recipients:

‘Swedish Rehabilitation Professionals’ Perspectives on Work Ability Assessments in a Changing Sickness Insurance System’

http://www.diva-portal.org/smash/get/diva2:311071/FULLTEXT01.pdf

Christian Ståhl, Tommy Svensson, Gunilla Petersson and Kerstin Ekberg;

Christian Ståhl (corresponding author)

Linköping University Post Print

The following shows larger extracts from the study:

Abstract

Purpose: Changes in the Swedish sickness insurance system shifts focus from return-to-work to labour market reintegration. This article analyses Swedish rehabilitation professionals’ perspectives on how the changed regulations affect practice, with a special focus on work ability assessments.

Methods: Two groups of representatives (n=15) from organizations involved in rehabilitation and return-to-work met at seven occations. The groups worked with a tutor with a problem-based approach to discuss how their practice is influenced by the changed regulations. The material was analysed inductively using qualitative content analysis.

Results: The new regulations requires developed cooperation between insurance, health care, employers and occupational health care; however, these demands are not met in practice. In work ability assessments, several flaws regarding competence and cooperation are identified. An increasing number of people previously assessed as work disabled are required to participate in labour market reintegration, which puts demands on professionals to engage in motivational activities, although this is perceived as hopeless due to the group’s lack of employability.

Conclusions: The possibility for employers to sidestep their responsibility has increased with changed regulations. The overall lack of cooperation between relevant actors and the lack of relevant competence undermine the ambitions of activation and reintegration in the reform.”

(See page 2)

Introduction

In recent decades, policy development on disability and sickness insurance has converged in most European countries, and there has been a shift of focus from passive compensation to active work reintegration (1), a development actively promoted by international actors such as the European Union (EU) and the Organisation for Economic Co-Operation and Development (OECD) (2-5). As a consequence, the concept of work ability has become increasingly important, because the criteria for eligibility for sickness benefits are commonly related to remaining abilities rather than diagnoses. However, there are a variety of methods for assessing work ability in the different national settings, and there are differences in who is responsible for the assessments and the criteria for making assessments (6).

To be eligible for sickness benefits from Swedish sickness insurance, a person must have a medical condition that implies work disability. After an initial waiting day, the employer is responsible for paying sick-pay for the first two weeks, whereafter the cost is taken over by the Social insurance Agency. The agency assesses the worker’s work ability based on a medical certificate issued by a physician, most commonly in primary health care.

In 2008, the government introduced several changes to the sickness insurance system. The most prominent feature of the reform involve a fixed time schedule for work ability assessments (the Rehabilitation Chain) which describes how work ability should be assessed in increasingly broader terms as time passes (see table 1), which affect eligibility for sickness benefits. After 180 days, the process is shifted away from the employer to the labour market at large, i.e. from return-to-work to labour market reintegration. At this stage, the Public Employment Service assists the sick-listed worker with vocational guidance. An ending-point to sickness benefits was also introduced, where benefits after 365 days are only to be granted in cases of severe illness. Further, a system of temporary disability pension for people with more long-term diseases was abolished to direct the sickness insurance system more towards labour market reintegration. Sickness benefits have also been reduced from 80% to 77,6% of wages1.

[Table 1 about here]

The new time schedule have changed the conditions for sick-listing, and in particular work ability assessments. Before the changes, there were no set time limits in the system. A more narrow time perspective put higher demands of purposeful cooperation between relevant actors in the processes of rehabilitation and return-to-work. Therefore, it is of interest to study how officials (i.e. the gatekeepers) within the authorities that are responsible for these processes perceive that the changes affect their practice.”

(Pages 3 to 4)

Aim

The aim of this study is to explore how officials from different organizations involved in rehabilitation perceive that the changes in sick-listing regulations affect their practice and cooperation, with a special focus on work ability assessments. The study aims to answer the following questions:

* What factors are taken into account when work ability is assessed?

* How do the representatives perceive that the new sickness insurance regulations affect their cooperation in work ability assessments?

* How do the representatives perceive that the new sickness insurance regulations affect return-to-work and labour market reintegration?

In this article, the term cooperation is primarily used to indicate cooperation between professionals from different organizations, e.g. cooperation between health care workers and social insurance officials. The term is thus to be understood as referring to interorganizational cooperation rather than cooperation between professionals within a specific organization.

Methods

This is a qualitative explorative study in which the experiences and attitudes of representatives of officials from different public services are investigated. …”

(Pages 4 to 5)

Results

The participants’ discussions in this study concerns two distinct phases in the sickness insurance system: the early return-to-work oriented phase, and the later labour market reintegration phase.

The return-to-work phase: work ability assessments as a public affair

Because work ability is a central concept for decisions on eligibility for sickness benefits, these assessments must be performed accurately. However, there are several ways of assessing a person’s work ability, incorporating a different number of factors (e.g. medical, psychological or social). Work ability assessments are performed by health care and the Social Insurance Agency, and different definitions of the concept may prevail.

At the initial phase of a sickness insurance case, a physician assesses the individual’s functional ability, most commonly in primary health care. In the medical certificate, the physician also suggests whether the functional disability will decrease the person’s work ability, for which the physician needs to have an idea of the characteristics of the person’s work tasks. The following quote illustrates how this may be complicated, because one occupation may have very different working conditions.

Health care coordinator: “That there is someone on the person’s surroundings who asks “describe your work, how is it done”, because you are surprised. We had one; this guy who filled a hundred kilos a day, and that was his only task as a painter. “What do you do as a painter?” “I fill.” And he filled this sand fill, a hundred kilos a day, and he had such terrible pain in his shoulder. Another guy who was a painter, “what do you do when you paint”, and “I only paint bases”. He was on his knees all day painting bases. Well, of course your knees hurt.”

This example illustrates how difficult it is for health care workers to assess whether a person is able to continue their work or not, based only on a short visit to a health care centre. Because the health care workers cannot observe the individual at work, the assessment is dependent on their ability to ask the right questions, and that they can trust the individual’s description of their working conditions.

In a strict sense, health care is only supposed to assess the individual’s level of functioning, which is then formally transferred into an assessment of work ability by the Social Insurance Agency. However, the physician’s medical certificate is the basis for this assessment. It is thus interesting to ask who has the competence to assess work ability. The following quote indicates that the Social Insurance Agency officials do not consider that they have enough competence to do so.

Social insurance official: “We have to translate this certificate to what work ability it generates. And it’s not sure that the physician, it’s not the physician’s task to describe that, it’s us who are supposed to consider on the basis of the certificate if there is a work ability or not. And it’s not easy for us laypersons to do.”

The official in the quote speaks of herself as a layperson in assessing work ability, and yet it is this person who has the formal task of performing this assessment. Apparently, the officials at the Social Insurance Agency are given a task they do not feel competent enough to fulfil.

Social insurance official: “As an official, I’m not supposed to ask the physician if the person has a work ability. I’m only supposed to ask, “what is the functional ability?”. Then it’s my role – because it says so in our profession – to assess on the basis of the physician’s description how it decreases the work ability. And it becomes, it gets ambiguous. Because I don’t really have the competence to assess work ability.”

More specifically, the officials at the Social Insurance Agency state as problematic their lack of knowledge of working conditions and how the different factors that limit work ability can and should be weighed. According to the regulations, the officials are to limit their assessment to medical factors as the only valid cause for limitations, although there may be other, more socially oriented factors that influence an individual’s situation. Since physicians in general tend to include a broader set of factors in their certificates, the Social Insurance Agency officials have to deal with sorting out the factors that permit or deny eligibility to sickness benefits. In doing so, they may consult insurance medicine counsellors, but they are in turn even further detached from the individual’s working conditions because they do not meet the individual.

Social insurance official: “… it’s tricky. Then you hope to get help from the insurance physician, the insurance medicine counsellor to clear it up, to help you find out what’s what.”

Tutor: “Is that where you go for advice?”

Social insurance official: “Exactly, when I want to get to the bottom of it, the medical and to be able to decide what to do.”

Tutor: “Help with not seeing all the other things?”

Social insurance official: “Exactly, yes.”

(Pages 9 to 11)

Cooperation needs in the return-to-work phase

Since the sickness insurance system only focus on return to the previous workplace during the first 180 days, cooperation with employers and occupational health care is an important issue to make return-to-work possible within this time frame. However, these actors are perceived as disinterested as long as the public system cannot offer financial incentives for participation. There is a general view among the participants that employers can easily escape their responsibility for rehabilitation. Employers only need to state that they have no possibilities of returning their employee to work, after which there are no further opportunities for the Social Insurance Agency to act.

Social insurance official: “…it’s enough [for an employer] to state in a meeting that they’ve done what they can and that there’s nothing else, and then we can submit a note and that’s enough for us.”

Health care coordinator: “So the employer doesn’t need to declare what they’ve done?”

Social insurance official: “No, well, they probably do in the meeting, but they don’t have to. […]”

Employment service official: “My take on that is that it’s too easy for employers to get rid of people. You need a clearer, deeper account of what actually has been done to save someone’s job.”

Tutor: “Are there too little demands on the employers?”

Employment service official: “That’s my experience.”

Lack of cooperation between the public authorities and employers is perceived as the weak link in the process of rehabilitation and return-to-work, and possibilities of workplace adjustments are easily missed due to comunication failures. Similarly, there is a lack of communication between primary health care and occupational health services, where secrecy is perceived as a hindrance for cooperation.

Health care coordinator: “The problem is that the occupational health services don’t have physicians in the way they used to. If they [people on sick leave] have their certificates from [the occupational health service], then we [in primary healthcare] don’t have any information on them. And we’re also supposed to take those who come from psychiatry, and we have to refer them back since we don’t have access to their journals. There’s a level of secrecy that we cannot get around. …..”

(Pages 11 to 12)

The labour market reintegration phase

After 180 days on sick leave, the worker’s work ability is to be assessed in relation to the labour market at large, which implies that the focus is shifted from return-to-work to labour market reintegration. In this phase, the earlier assessment of work ability may prove to have little in common with employers’ demands. Basically, this may be seen as a transfer from work ability to employability: employers may not want to hire a person, even though he or she has been assessed as able to work, if the person lacks relevant competence. Both these concepts are highly interrelated to the situation on the labour market; in bad times, there are fewer jobs, which makes the competition tougher.

Health care coordinator: “And then the development on the labour market. I’m thinking about those I’ve met who had been odd-jobbers more or less, in a workplace, sweeping the floors, carrying mail, watering flowers, this and that. And the social competence was perhaps not the best. But it worked there, in that small family business where you believed in them. But as soon as they got kicked out of there they were toast, because in our groups where we were to test their work ability, they really made a mess. […]”

Employment service official: “Yeah, I’m thinking about this with employability. I mean, it takes – an important thing is that there is an employer who is willing to pay for what this person can do. I think that’s where it’s at. If someone’s willing to pay me for standing on the street playing my lip, well then I guess I’m employable for that.”

Employability is a context-bound concept, depending on what employers need at a certain place at a certain point in time. This has little to do with how the Social Insurance Agency assesses work ability: when assessing work ability after 180 days, social insurance officials are expected only to consider the medical function and are not allowed to take age, education, place of residence or working life experience into account.

The ultimate goal for the rehabilitation process, according to policy, is that the individual shall return to work with full work ability within the time frame of the Rehabilitation Chain. However, the participants in this study expressed concerns about whether this is feasible for all individuals. Those who are not able to finish their rehabilitation in time lose their sickness benefits and are transferred to the Public Employment Service where they have to compete with people with full work ability. In addition, the policy changes were introduced shortly before the financial crisis of 2008, which resulted in a dramatically deteriorated labour market with increasingly tough competition over jobs. This situation causes the participants in the study to question the goal of the rehabilitation process.

Social welfare official: “…if there’s no job for this ability, then I feel that we’re fooling people, to fire them up and be positive and work with them, and then there’s no possibilities.”

The participants see few practical possibilities and no actual end point for rehabilitation of the more complex cases. In the quote above, the participant expresses that it feels like they are fooling the individual when arguing for a goal that is not possible to accomplish. This involves the risk of backlash, where the individual falls back into sickness.

Health care coordinator: “I have a man with a troublesome past, a drug addict who prior to that worked as a welder for twenty years and got a disk displacement, went to sick leave, alcohol abuse, depression following that. Then in some way he changed his life, got off his addictions and has found a 75% work ability. And he’s so proud of his job, he’s a wood worker, and enjoys it. So he’s really succeeded. But then there’s no employer to hire him, and what will happen to him? The last thing he told me was “the social welfare office, I’ll never set my foot there”. It was humiliating for him when being assessed as having a 75% work ability; he has no unemployment insurance, what will happen to him? He can tip back over night.”

Employment service official: “That’s a great example. That’s the biggest dilemma we have to face. […] There’s something missing, a “what happens next?”. […] When you come to this, when you’ve worked up an ability and motivation to pull from and you’re so close to the goal, you’re finally “normal”. Finally, but too bad. So close, but there was no employer to hire you.”

Most participants expressed that there are no alternatives for those who are not able to cope with the competition on the labour market. For instance, those who due to the changed regulations have had their temporary disability pension withdrawn generally have decreased work ability. The participants express a wish for more alternative employment structures, such as sheltered workshops or other forms of subsidized employment. The participants generally claim that the availability of these alternative forms of employment have decreased considerably in recent years.

Employment service official: “That’s a clash I’ve been thinking about since last time. When we assess sheltered employment, for instance. There’s no such thing. You’re put in a queue for something that’s not available, because you assess by old rules. Sometimes we get documents where someone has assessed sheltered employment, and the person has been waiting for fifteen years or something. But they will never get there, and we still get these indications to do these assessments, put them in line. It doesn’t feel realistic for me to do so.”

The participants in the study experience an increasing gap between the sickness insurance system and the labour market, especially concerning those with low work ability who are not work disabled enough to receive a disability pension. The participants expressed concerns that the introduction of the Rehabilitation Chain implies that these individuals will not be able to provide for themselves when they lose their sickness benefits.”

(Pages 13 to 16)

Discussion

A prominent feature of the reformed sickness insurance regulations is the shift of focus from return-to-work to labour market reintegration. From a political perspective, the idea behind the reform was to speed up the return-to-work process and to promote activation through an earlier focus on job mobility. This study shows that employers are regarded as passive and non-contributing in this process. Employers have through the new regulations gained an opportunity to sidestep their responsibility for returning workers by staying passive for 180 days, after which the system has the full responsibility for the person.

The two phases in the rehabilitation process put different demands on all of the involved actors. The participants in the study raise a number of concerns regarding these two phases, where the most emphasized are the lack of competence to assess work ability, the lack of cooperation with employers and occupational health care, and the limited possibilities for work disabled people to compete on the labour market.

It is notable that the social insurance officials do not feel competent in assessing work ability. It is also notable that the officials do not make contact with employers or occupational health services, who could provide the information that is necessary to make reasonable assessments. Instead, they rely solely on physicians’ medical certificates, which are based on medical status rather than working conditions. Thus, the basis for decisions of eligibility for sickness benefits is weak, which is troublesome from a legal perspective.

As the OECD notes in a report, the sick-listing process focuses more on eligibility to benefits than on activation and return-to-work (13). The new policy framework, further, “requires good cooperation and continuous information exchange to continue” (13, p. 42); this study indicates that this is not the case with regard to the assessments in the return-to-work phase of sick leave. According to Loisel et al. (14-15), work disability management need to take into account the situation at the workplace as well as personal and medical factors and the compensation system for the return-to-work process to be purposeful. The sickness insurance reforms have primarily targeted the compensation system in controlling in- and outflow from sickness benefits, while the importance of involving the workplace arena has been disregarded.

What is disregarded in work ability assessments?

In current practice, work ability assessments are based on physicians’ initial assessment of functioning in medical certificates. This assessment is in turn based on the definition of functioning in the International Classification of Functioning (ICF) given by the WHO (16), which, as noted elsewhere (17), offers a broader definition than the one used by the Social Insurance Agency. ICF, for instance involves social and contextual factors which the insurance system are not expected to take into consideration. Because the definition of functioning, and subsequently work ability, differs between the actors, this is a possible cause for conflict within the process of assessing work ability.

The broader perspective on work disability suggested by Loisel et al. (14-15) is to a large extent in line with Nordenfelt’s analysis of work ability, in which he distinguishes between a number of factors that together make up a person’s ability to work on a specific task, such as personal competence, motivation and health status (18). Nordenfelt concluded that a person’s work ability needs to be assessed holistically, involving the context of sickness insurance as well as the person’s qualifications and the characteristics of the work task. The results of this study suggest that the biomedical perspective prevails in the sickness insurance system, which implies that other factors that may contribute to a person’s work ability are disregarded.

When comparing the Swedish sickness insurance regulations to those in other countries, the focus on medical factors for work disabilty is notable. As Hedborg notes, it is uncommon that a system disregards other factors as thoroughly as the Swedish does (19). The other Nordic countries (i.e. Norway, Denmark and Finland) permits long-term benefits for other reasons than strictly medical, where the possibilities for the indidivual are taken into account, including factors such as education, working life experience and age (19).

The return-to-work phase: is it possible to involve employers and occupational health care?

There is scientific evidence that well-functioning cooperation between health care, employers and the compensation system is effective for shortening the sick-leave period and for facilitating return-to-work (20-21). However, in the Swedish sickness insurance system there is a general lack of clarity regarding the responsibilities of the employers and occupational health services. This study highlights this ambiguity by elucidating flaws in the cooperation between the public system (the Social Insurance Agency and primary health care), employers and occupational health services in return-to-work due to the lack of regulations on employer responsibilities, which leaves them outside the cooperation domain. …”

(Pages 16 to 18)

The labour market reintegration phase: a Sisyphean task?

As discussed, the current system promote a fast shift of focus from return-to-work to labour market reintegration. In the labour market reintegration phase, the relevant actors change, as does the relevant competencies and needs for cooperation. Where the return-to-work phase required communication with employers and knowledge of working conditions, this later phase put more demands on the officials’ therapeutic and motivational skills and their knowledge in vocational training and guidance. Here, the Public Employment Service replace the employers in trying to bring the sick-listed worker back to the labour market. In this phase, the officials at the Social Insurance Agency are not allowed to take into account the worker’s age, education or working life experience when assessing work ability, which implies that most people will be assessed as able to work and hence lose their benefits.

The participants in the study notes how the changed regulations imply that an increasing number of people who previously were considered work disabled now are required to look for jobs on the open labour market. Since the possibilities for placing these people in subsidized or alternative employments are scarce, the task of motivating these people is perceived as hopeless due to their lack of employability. Motivating them to look for jobs is not considered realistic, nor ethical.

One consequence of the changed regulations is that an increasing number of people reaches the new ending point in the sickness insurance system (365 days). In a report on where these people have gone, it is concluded that after six months only 2,5 % have a regular job on the labour market; 7 % have subsidized or supported employments; 41 % returns to sickness insurance after a waiting period, while the rest are either unemployed or not identifiable in the statistics (28). Taking this into consideration, it is reasonable to assume that the disenchantment expressed by the participants is valid.”

(Pages 20 to 21)

Conclusions

The Swedish sickness insurance system has undergone dramatic changes over the last years, with a shift of focus from return-to-work to labour market reintegration through a fixed time schedule as the most prominent feature. This study highlights how these changes put new demands on cooperation between social insurance, primary health care, occupational health care and employers, and that these demands are not met in practice. Employers are perceived as passive in this process, and the possibility for employers to sidestep their responsibility has increased.

An increasing number of people previously assessed as work disabled are according to the new regulations required to participate in a labour market reintegration process. This puts demands on professionals to engage in motivational and therapeutic activities for this group, although this is perceived as a hopeless task due to the group’s lack of employability.

The results of this study also show that officials at the Social Insurance Agency do not consider themselves competent in assessing work ability, which implies that decisions rely heavily on medical certificates issued by physicians. Because of a general lack of communication and cooperation between the public system (the Social Insurance Agency and primary health care), employers and occupational health services, these certificates are based on assumptions rather than actual observations of the individual at work.

In sum, the lack of cooperation between relevant actors and the lack of relevant competence undermine the ambitions of the reform.”

(Pages 22 to 23)

OWN COMMENTS ON THIS SWEDISH STUDY

Although this explorative and limited study based on participating groups of professionals and officials in Sweden may only have some limited value, because it is about social, health and employment service frameworks and settings in a different country, it does clearly present a range of serious issues relating to work ability assessments. The study shows how difficult it is to apply new systems and approaches in moving sick and impaired social security benefit recipients with disabilities into suitable work. At least some of the issues raised in the study are also relevant to the approaches tried by MSD and their department Work and Income here in New Zealand.

The Swedish study does not research and analyse particular medical conditions and under what criteria they may be considered as impairments affecting ability to work, thus leading to disability. It is rather focused on examining, analysing and making conclusions on general systemic approaches based on recent changes in how work ability assessments are increasingly being used to provide support to sick, injured and disabled into employment, whether back into positions the affected held before, or otherwise into alternative kinds of jobs on the market.

MSD and WINZ claim that they are not working with clients to rehabilitate and refer them into suitable work within tightly set time frames. But the started use of outsourced, contracted, private “mental health employment service” providers, same as some other similar service providers, does encourage the providers to deliver anticipated outcomes for clients within specified periods. The existence of contracts containing a graded fees structure does reward contracted service providers to place WINZ clients into jobs as soon as possible, at least within a 12 month period. That will of course mean, they will communicate expectations to the clients they deal with, and this will put great pressure on the beneficiaries that WINZ refer to them, to accept jobs that may be deemed suitable, whether they are or are not so. Hence there is a similar situation as to the one in Sweden, where sick and disabled beneficiaries are expected to make use of available rehabilitation and other services, and thus prepare themselves to take on previously held – or alternative work. If this does not result in (lasting) employment, and especially if they are seen as not being “cooperative”, they may lose benefit entitlements, or face other forms of sanctions.

There are clearly issues around appropriate, essential competency of professionals conducting work ability assessments, like who should be doing them, and how assessments should be done. There are separated responsibilities that professionals from the various groups have, that work with social security clients around assessment and rehabilitation. Medical practitioners play a role, so do rehabilitation professionals, and in a very different way administrators like case managers, who are working for state social security service agencies. A lack of cooperation and coordination between parties involved can create problems, and one must expect the same to happen here in New Zealand, as it did in Sweden.

Generally it will first and foremost be medically diagnosed sickness, injury and disability that will be crucial for any assessment. Some environmental factors and possibly psychological aspects will also be of varying importance. It is my firm view, that in general, the client’s long term medical practitioner (GP) will have the best ability to assess work ability, given the familiarity with the patient’s medical history and also social and other environmental circumstances. While specialists can provide more particular information on certain health conditions, they will often only see patients/clients for short periods. Any occupational or other rehabilitation therapist may be able to develop familiarity with the patient, but without prior assessment by a GP there will be risks of them failing to see the whole picture.

Traditionally WINZ case managers make the final decisions about a client’s work capacity in relation to benefit entitlement, and so forth, but they do follow recommendations by the Ministry of Social Development’s internal Regional Health Advisors and Regional Disability Advisors. They work under the supervision of the Principal Health Advisor (Dr Bratt!) and the less prominent Principal Disability Advisor. All these advisory professionals do again rely on either a client’s own GP’s or specialist’s medical diagnosis and certification, or on WINZ’s own “designated doctors”, and now also on new private “work ability assessment” providers.

WINZ case managers do usually not have any relevant medical, rehabilitation or other health qualifications, which may enable them to make their own assessments. So they will have to rely on the various other professionals involved in processes they have in place, and given the different focus on criteria for work ability, there will inevitably be differing assessments and recommendations. WINZ case managers and health and disability advisors will feel to have some extra “responsibility” to meet expectations by their employer (MSD), who of course has an interest to reduce benefit claimant numbers. Clients’ own doctors will feel that they know their patient best, but may also feel that they need to be extra careful, to avoid making risky or wrong assessments. Designated doctors and new work ability assessment providers will be paid by MSD and be bound by contracts they entered with the Ministry, so they can due to that not be seen as totally independent. There are forms of conflict of interest at play here.

It is clear that it is never easy for any sick and disabled beneficiary to compete with those without such handicaps on the competitive job market; hence they will always face extra challenges. Employers will mostly be hesitant to take on any new employee with lasting health conditions, injuries or disabilities, given the risks and potential costs associated with hiring and employing them. So in absence of any extra measures, to involve and “incentivise” employers, and to also offer alternative employment in special work-shops or on subsidised schemes (that will not exposed clients to the same market pressures), any measures to move sick and disabled into work will in most cases be difficult and risk prone endeavours.

Sadly it seems, with the flawed approach now adopted by MSD and WINZ in New Zealand, we have a huge experiment being conducted, that exposes many, particularly mentally ill, to some risks to suffer harm, due to potentially wrong, inappropriate, flawed assessments – and decisions based on them.

Christian Ståhl, Tommy Svensson, Gunilla Petersson and Kerstin Ekberg;

Linköping University Post Print

Link to download site:
http://www.diva-portal.org/smash/get/diva2:311071/FULLTEXT01.pdf
“Swedish Rehab. Professionals WAAs Perspectives, 2011, FULLTEXT01, d-load 20.05.14.pdf” (601.23K):

See attached a PDF file containing the full study report mentioned above:
Title:Swedish Rehabilitation Professionals’ Perspectives on Work Ability Assessments in a Changing Sickness Insurance System:

Swedish Rehab. Professionals WAAs Perspectives, 2011, FULLTEXT01, d-load 20.05.14

Advertisements
  1. Leave a comment

Leave a Reply

Please log in using one of these methods to post your comment:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: