n Samuel Butler's Erewhon, written in 1872, sick people are punished as criminals. In England in 2013, sick people are punished by Atos, a French firm which holds a contract believed to be worth £400 million from the Department of Work and Pensions (DWP) to carry out work capacity assessments (WCA) on Employment Support Allowance (ESA) claimants. The anti-welfare state touch paper was well and truly lit by Margaret Thatcher in her early days in power, when she talked of the development of an 'underclass' dependent upon the 'benefits culture'.
This belief in the 'deserving' and the 'undeserving', and the imperative to support the workers, not the 'skivers', has leached down over the years to inform and endorse the hounding of 'benefit cheats' in the form of cuts in public spending, loss of entitlement and stigmatisation of social security claimants. Atos Healthcare, appointed by Labour in 2008, represents part of the coalition government's strategy to sort out the 'skivers' from the 'strivers', using the Work Capacity Assessment, which was designed and developed in collaboration with the Department for Work and Pensions (DWP), health professionals, and patient representatives, to 'the highest professional standard'.
Atos employs doctors, nurses and, controversially, physiotherapists to carry out WCAs. However, in press releases and other public statements the organisation is interestingly coy about its use of physiotherapists. A statement for BBC Scotland (25 May 2010) declares 'All of the doctors and nurses employed by Atos healthcare are individually accountable to their own relevant independent regulatory bodies, such as the General Medical Council and the Nursing and Midwifery Council'. Furthermore, in response to widespread criticism about the ability of the WCA accurately to assess people with mental health problems, 'one improvement, in place since May 2011, has been to appoint mental function champions at locations across the UK. They are trained professional doctors and nurses with specialist knowledge of mental health conditions. Their role is to provide best practice advice and support to our healthcare professionals when undertaking work capability assessments' (Atos healthcare 2012). Note 'specialist knowledge of mental health conditions'. And note once again that there is no mention of physiotherapists.
Atos stipulates that all their assessors must have worked for three years since qualifying as a health professional. This means that in theory nurses and doctors who within the NHS structure would be considered still to be in training and supervision for their future specialism, could be employed to assess people with complex physical and psychological health problems. Despite Freedom of Information requests asking how much Atos health professionals are paid, this information has not been forthcoming. Inevitably, this leads to speculation that the pay is extremely generous, with one blogger claiming that the 'ATOS CEO earns £626,000 per year of tax payers' money - enough to pay ESA for 6,849 weekly payments for those 'in genuine need'.
It is widely believed that assessors are required to meet fixed targets. One GP who attended an Atos recruitment fair told the Observer she feared 'doctors could become 'agents of the state' who were de-professionalised by involvement in a system that did not make patient care its first concern' (The Observer, 13 August 2011).
Large numbers of people found ineligible for benefit by Atos assessors are appealing against the decision to find them fit for work. About 40% of those refused support go to tribunal and 30% are subsequently reinstated on benefit. There have been more than 600,000 appeals since the WCA started, costing about £60 million a year. However, Atos assessors are carefully insulated against the outcomes of their decisions. Atos is not penalised, financially or otherwise, when a decision is overturned by the independent tribunal. While many stories abound of dreadful stress and distress to claimants and their families, an Atos trainer is quoted as saying: 'Good thing for us is, even if you made the wrong decision…you never go to the tribunal so, sort of, you won't be blamed' (The Guardian, 27 June 2012).
My own experience of the WCA has been in supporting patients with complex health problems at each stage of the process, from the initial paperwork, to attending tribunals. Atos claims that a paper triage is initially undertaken, so that claimants can be seen by the most appropriate health professional. Unless there are special circumstances (i.e. that a claimant's 'death can be reasonably expected within the next six months'), the claimant is then summoned to an Atos assessment centre, to undergo a face-to-face WCA, which takes around 40 – 45 minutes.
I helped a patient fill out and submit her initial paperwork. Although she had recently been treated for tuberculosis and was HIV+ve, she was suffering from extreme PTSD as a result of being tortured, raped and imprisoned, and her partner killed in front of her, in her country of origin. She had just been granted refugee status, and was on the waiting list to be seen at a specialist psychotrauma institute. We travelled to the assessment centre together and were taken into a consulting room by a very well-dressed young lady. She introduced herself by her first name only. I asked her what her specialist background was, and she said that she was a 'chartered physiotherapist'. I pointed out that my patient was suffering from a severe and enduring mental health problem, and she snapped back at me, 'I have been trained, you know'. I later found out through an FoI request that mental health training for assessors without any psychiatric background consisted of 17 days of paper and seminar-based exercises.
The physiotherapist assessor worked her way through Atos's 'bespoke clinical application', which included testing my patient's patellar reflexes, before asking her: 'Have you ever had PTSD before?' The assessment ended with my patient weeping and distraught at having to recount the causes of her PTSD to a young woman who was plainly out of her depth, and lacking the skills and knowledge to be able to carry out an appropriately sensitive interview with a person suffering from such profound psychological distress.
In fact, the seven questions (11 – 17) on the WCA ESA50 form which claimants have to fill out before they attend the assessment have raised more concern in terms of their ability to capture fully the daily problems people with severe and enduring mental illness experience. The first five questions focus almost exclusively on learning disabilities (e.g. Q11 asks about ability to complete a simple task such as setting an alarm clock), while Qs 16 and 17 ask about coping with social engagement, and appropriateness of behaviour with other people, including 'episodes of aggressive or disinhibited behaviour that would be unreasonable in any workplace'.
Concern about the flaws and failings of the Atos WCA and the ability of their assessors to capture the nuances and difficulties experienced by vulnerable people with complex health problems are widespread. Put Atos into a search engine, and a huge number of anti-Atos organisations and campaigns pop up, from local alliances to web sites such as Atos Victims Group News, the Black Triangle Campaign, advice for claimants from voluntary sector organisations representing a range of disabilities and many articles by concerned GPs picking up the pieces after patients who they know are unfit to work are found fit by Atos, with immediate loss of benefits. As one GP wrote, 'I am fearful that more of my patients will be put at risk of homelessness and suicide by this brutal new system. From my perspective, the most disadvantaged in our society are being punished. Work is good for all of us…But not all of us have the skills to work and some of us are so unwell or damaged by past experiences that they cannot do a job. We should accept that some people, for many different reasons, need supporting' (The Guardian 4th January 2013).
The British Medical Association has called on the tests to be scrapped. The GMC has had to review at least 12 doctors in terms of their fitness to practise following allegations of improper conduct, while at least one doctor was working for Atos even though he did not have a license to practise medicine in the UK. But then, most health professionals would not consider that what Atos employees do is medicine, but rather a ruthless cost-cutting exercise, designed to promote fear and anxiety among vulnerable people.
Atos's contract has been extended to 2015. They have also been awarded the contract to carry out the assessments for the new Personal Independence Payment, or PIP, which is to replace Disability Living Allowance. Recently announced cuts in legal aid will significantly reduce professional support for people wishing to appeal their Atos decision at an independent tribunal
Dr Deborah Colvin, chair of City and Hackney LMC, said each of the 10 doctors at her practice now see three to four patients a week in this situation when it used to be an occasional occurrence.
She said: 'I can't bear seeing patients with major disabilities being told they can go to work when there are no jobs to be had even if they were fit- and they're not. What do they expect us to do? Are we supposed to leave people with nothing?' (from GP Pulse magazine)