Open Letter to the BMJ and RCN on Atos ‘Healthcare’
27 September 2011
Dr Michael ChamberlainChairman, BMJ (British Medical Journal) Group Board
Andrea Spyropoulos, President,Royal College of Nursing
Dear Dr Chamberlain and Andrea Spyropoulos,
Re: Atos Healthcare and parent company Atos Origin
As sick and disabled people, carers and other concerned people, including professionals, we are writing to you to urge the Royal College of Nursing and BMJ Group to immediately end your relationship with Atos, including stopping any advertising of Atos jobs or Atos the company on your websites, and not having Atos at the RCN Bulletin Jobs Fair 13-14 September, or the BMJ recruitment fair 30 September to 1 October 2011 in London.
As you know, Atos currently has a £100m a year contract with the Department for Work and Pensions (DWP) to carry out examinations for disability benefits.
We are outraged that Atos is profiting from denying those of us who are sick or disabled, the benefits we need to survive and maintain our level of health. In May, at the protest outside Atos headquarters, a number of people spoke about our experiences of the examination, being denied benefit and having to appeal to get it back. One woman testified that her brother, who had severe depression, committed suicide after being cut off. See:
The media have exposed more of the dire consequences of Atos’ decisions. In February, the Daily Mirror highlighted the case of a Derbyshire man with a heart condition, found fit for work, who had to go through tribunal to appeal, then was awarded Employment and Support Allowance (ESA) but died of a heart attack the day before his next Atos exam was due.
A Channel 4 News report on 27 July 2011 acknowledged what thousands have been saying: it interviewed the heartbroken partner of a critically ill man whom Atos denied his entitlement on grounds that he was ‘fit for work’ – he died less than three months later. How many more people have died following such cruel and callous treatment? The coverage was prompted by a Parliamentary report from the Work and Pensions Committee of MPs, in which they criticised Atos. Atos the powerful multinational has taken vindictive action against disabled people and carers’ websites where it is criticised, getting sites closed down which isolated people rely on for support.
In August, the Guardian reported that 12 Atos doctors are under investigation by the General Medical Council for improper conduct. The article referred to numerous previous cases and investigations by other bodies.
A nurse in Scotland was so shocked at Atos’s behaviour that she blew the whistle on them. She said that people with serious lung diseases were found fit for work as long as they could sit in front of a computer, and that parents who attend with their children are automatically found fit for work. And Atos is investigating staff, one a nurse, who used their Facebook pages to insult people as “parasitic wankers” and “down and outs”.
According to DWP figures, only 6% of those who have been assessed are placed in the Support Group of Employment and Support Allowance (ESA) which exempts them from the work conditions now attached to benefit. (This 6% includes claimants whom the DWP has already exempted from the Atos examination because their condition is so serious.) http://research.dwp.gov.uk/asd/workingage/esa_wca/esa_wca_27072010.pdf
The Royal College of Psychiatrists and many others have strongly criticised the devastating effect the Atos exam and cuts have had on patients. http://www.guardian.co.uk/society/2011/may/31/incapacity-benefit-cuts-mental-health
GP Margaret McCartney, writing in the BMJ, has questioned the ethics of doctors performing assessments without access to patients’ medical records, and the lack of specialist knowledge of physiotherapists and general nurses employed by Atos. (BMJ 2011; 342:d599. Full article attached.)
Since 1995, when medical assessments for incapacity benefit were privatised and taken out of public services, standards have steadily declined. But Atos has brought this to a new low. While none of the work tests deserve to be called a “medical” as they have no basis in patient welfare, since Atos started carrying out the ESA tests in 2008, there has been a dramatic increase in the number of people with severe illness and disability being assessed as fit for work and denied benefits.
This has been clear for some time. In 2009, ‘Who’s Cheating Who?’, a BBC Scotland documentary, highlighted the plight of June Mitchell who applied for sickness benefit. When examined by Atos, she complained of breathlessness and feeling tired. She was scored zero points and found fit for work. She went back to her GP, was diagnosed with terminal lung cancer and died shortly afterwards.
Doctors’ and nurses’ ethics are being corrupted by Atos’ offers of higher salaries and daytime reduced work hours. Some doctors have tried to argue that their duty to patients does not apply when assessing benefit claimants on behalf of Atos. But the General Medical Council has upheld that doctors are always bound by this duty whether seeing patients, employees (when assessing occupational health), benefit and insurance claimants, athletes, among others (see attached response from the Standards & Fitness to Practise Directorate).
As doctors and nurses are enticed into privatisation, and cases of criminal negligence and even murder in hospitals and care homes hit the headlines, patients and their loved ones are increasingly speaking out against the indifference and cruelty they face at the hands of those paid to protect them.
Claimants rightly fear that most Atos assessors are uncaring and prejudiced – they work to targets which have nothing to do with patients’ individual health needs or with the realities of the job market which sick and disabled people are being thrown into. The stress of the Atos examinations has hastened deaths and caused a number of people to commit suicide. For many others, it is exacerbating their already fragile health condition.
Atos kills. Medical professionals who lend it credibility give it a licence to kill. We call on the BMJ Group and RCN to end all association with Atos, and on doctors and nurses to defend patients and uphold our welfare.
We look forward to hearing from you.
Benefit Claimants Fightback: firstname.lastname@example.org
Black Triangle: email@example.com
Defend Welfare network
Disabled People Against Cuts: firstname.lastname@example.org
WinVisible (women with visible and invisible disabilities): email@example.com
And: (full list of signatories at 27 September 2011):
Niki Adams, Legal Action for Women
Peter Ambrose, Visiting Professor in Housing and Health, University of Brighton
Cristel Amiss, Black Women’s Rape Action Project
Arts Against Cuts
Kate Atherton, UK Uncut
Professor Peter Beresford OBE, Brunel University and Chair, Shaping Our Lives
Sue Bott, Director, National Centre for Independent Living
Brighton & Hove TUC Unemployed Workers Centre
Brighton Disabled People Against Cuts
Linda Burnip, Debbie Jolly, Eleanor Lisney, Disabled People Against Cuts (UK)
Sara Callaway, Women of Colour in the Global Women’s Strike
Julia Cameron, Islington Disabled People Against Cuts
Dr Stephen M Carty, GP, Edinburgh
Roderick Cobley, Chair, London Autistic Rights Movement (personal capacity)
Dr Jillian Creasy, GP, Green Party councillor for Central ward, Sheffield
Liz Crow, Roaring Girl Productions
Dr Paul A. Darke, Outside Centre
Rhian Davies, Chief Executive, Disability Wales (and Rhyan Berrigan, Tania Bhutto – member, Maggie Hayes – intern, Paul Swann – policy officer, Independent Living)
Nyami Enyako, Rehabilitation Officer with Visually Impaired People, Sensory Services, London Borough of Lambeth
Kirsten Forkert, University and College Union (personal capacity)
Mat Fraser, actor and writer
Glasgow Coalition of Resistance
Claire Glasman, WinVisible (women with visible and invisible disabilities)
Anat Greenstein, Research Institute of Health and Social Change, Manchester Metropolitan University
Helmut Heib, National Union of Teachers (personal capacity)
Dr Marion Hersh, University of Glasgow
Sarah Hitchings, Lewes Stop The Cuts
Cat Hobbs, Oxford Save Our Services
Islington Poverty Action Group
Michael Kalmanovitz, Payday men’s network
Michael Lavalette, National Convenor, Social Work Action Network
Jill Leigh, BA, CQSW., Dip Counselling.
Lesbian Bi Trans Queer in the Global Women’s Strike
Lewisham Anti-Cuts Alliance
Phil Lockwood, Information Co-ordinator & Webmaster, Black Triangle
London Coalition Against Poverty
Nina López, Global Women’s Strike
Adam Lotun, Disability Risk Management & Reasonable Adjustments, Consultant, Workplace Disability Adjustments
Marie Lynam, Kilburn Unemployed Workers Group
Nushra Mansuri, British Association of Social Workers
John McArdle, Black Triangle Anti-Defamation Campaign In Defence of Disability Rights
Gillian McDonald, RMN, NHS Lothian
John McDonnell MP
Denise McKenna, Mental Health Resistance Network
Ronan McNern, Queer Resistance
Cari Mitchell, English Collective of Prostitutes
Dan Morton, Social Work Action Network ( London )
Stella Mpaka, All African Women’s Group
Rev Paul Nicolson, Chair, Zacchaeus 2000 Trust
Notts Save Our Services — http://nottssos.org.uk
Nurses Against Atos
Andrew Osborne, Cambridgeshire Against the Cuts
Anna Owens, secretary, PCS Revenue & Customs branch committee
Redhill Coalition Against Cuts
Ian Sandeman, DLA Help Group
Bill Scott, Manager, Inclusion Scotland (personal capacity)
Dave Sherry, Secretary, UNITE Scottish Housing Branch
Dr Ron Singer, president, Medical Practitioners’ Union, the doctors’ section of UNITE
Dave Skull, South East London Mad Pride
Kim Sparrow, Single Mothers’ Self-Defence
Phil Stevens, Director, Wales Council for the Blind (representing over 63 separate visual impairment groups providing support and assistance to visually impaired people – including list below**)
Russell Stronach, co-Chair, Autistic Rights Movement UK
Peter Tatchell, Peter Tatchell Foundation
The Cuts Won’t Work
Pip Tindall, Brighton Benefits Campaign
Johnny Void, Benefit Claimants Fightback
Welfare Action Hackney
Vin West, Secretary, Arfon Access Group
Alan Wheatley, Green Party TU Group Disability Spokesperson
Alison Wilde, Bangor University
Rick Wilson, Community Lives Consortium, Wales (personal capacity)
Dr Sarah Woodin, University of Leeds (personal capacity)
Dr Felicity de Zulueta, Emeritus Consultant Psychiatrist in Psychotherapy at the SLaM NHS Foundation Trust and Hon. Senior Lecturer in Traumatic Studies at KCL
**Amman Valley Blind Society, Ammanford Blind Society, Bridgevis, Brynamman Blind Society, Carmarthen Area Blind Society, Carmarthenshire County Blind Society, Ceredigion Association for the Blind, Cwmamman Blind Society, In-Sight, Llandeilo Blind Society, Llandovery & District Blind Association, Llandybie Blind Society, Llanelli Blind Society, LOOK, Merthyr Tydfil Institute for the Blind, Monmouth Visually Impaired Club, Mynydd Mawr Blind Society, North Wales Welsh Cassette Service, Partially Sighted Society, Pembrokeshire Blind Society, Radnorshire Association for the Blind, Rhondda Blind Society, Rhuddlan Borough Talking Newspaper, South Wales Talking Magazine Association, Vision Support, Visual Impairment Breconshire, Visual Impairment West Glamorgan, Visually Impaired Merthyr Tydfil, Visually Impaired Children Taking Action
Hamish Meldrum, Chairman of the British Medical Association firstname.lastname@example.org
Dr Brian Keighley, BMJ Deputy Chairman, Scottish Council BMAScotland@bma.org.uk
Margaret McCartney GP email@example.com
Jane O’Brien, Assistant Director of Standards, General Medical Council firstname.lastname@example.org
Response from the General Medical Council
· Jane O’Brien, Assistant Director, Standards & Fitness to Practise Directorate
General Medical Council, 350 Euston Road , London , NW1 3JN
“Edward Cooper is mistaken that the principle of making the care of your patients your first concern does not apply to doctors when they are assessing benefits claimants on behalf of ATOS. Our guidance is for all doctors and in the guidance we use the term ‘patient’ to refer to anyone whom doctors test, treat or assess in their professional capacity as a doctor. This includes amongst others, employees, benefits and insurance claimants, and athletes.
“The first duty of all doctors is ‘to make the care of your patient your first concern’. But that is not the only duty doctors must observe. Being open and honest and acting with integrity is also an essential part of medical professionalism. Good Medical Practice provides guidance, not a set of rules, so doctors must use their judgement to apply the duties and principles defined in our guidance to the various situations they face as a doctor, whether or not they routinely see patients in a therapeutic or any other role.
Dishonesty in writing reports cannot be justified by reference to the first duty of doctors. Further advice on disclosing information for employment, insurance and similar purposes can be found here: http://www.gmc- uk.org/Confidentiality_disclosing_info_insurance_2009.pdf_27493823.pdf”
Competing interests: None declared
Published 7 March 2011
BMJ 2011; 342:d599 doi: 10.1136/bmj.d599 (Published 2 February 2011)
Cite this as: BMJ 2011; 342:d599
· Medical Work Assessments
Well enough to work?
1. Margaret McCartney, general practitioner Glasgow
Increasing numbers of people previously deemed medically unfit to work are being taken off state benefits after assessments by a doctor. Margaret McCartney investigates the ethics and fairness of the system
A medical degree can open all sorts of doors. One is the brown and tinted glass entrance of the Atos Healthcare offices in Glasgow , where I checked that my name was on the list held by the security guard at the desk. This recruitment evening was for doctors, nurses, and physiotherapists interested in working with this French information technology firm, which is subcontracted to the Department for Work and Pensions to provide work capability assessments.
In November last year Atos announced a three year extension to its contract with the department, worth £300m (€350m; $480m), to “support the UK government’s welfare reform agenda.”1 Atos is the sole contractor, and the medical reports it generates are used to make decisions about eligibility for employment and support allowance. This benefit, which has been replacing incapacity benefit and income support since 2008, is paid to people who are medically unfit to work because of illness or disability. The weekly allowance, once the claim has been verified with an assessment of capability, is worth up to £96.85. The government estimates that 2.5 million UK citizens receive sickness benefits at an annual cost of around £12.6bn to the taxpayer.2
A quick glance at internet discussion forums suggests widespread dissatisfaction from people who have been assessed. The adverts for Atos, however, consist of smiling, badged professionals saying, “Getting home on time has become part of my daily routine.”1 The lack of on-call duties and the 9-5 office hours were also the major advantage plugged at the evening, where nurses and doctors working for Atos helped to promote joining the company.
But what are the ethical issues in performing disability assessments in this way, separate from the NHS and without access to patients’ full medical records? Atos was awarded the assessment contract in 2005 and claims that its reports are “evidence based, clearly presented, legible and fully justified.”3 Are medical assessments accurate enough to make major decisions about people’s ability to work? And is Atos the best company to do them?
The message from the recruitment evening was quite clear. We were told: “You are not in a typical caring role. This isn’t about diagnosing.” And: “We don’t call them patients . . . We call them claimants.” Training is provided for each type of benefit examination. Its length, we were told, depends on experience but is generally up to five days of classroom training, followed by sessions accompanied by a trainer that are audited afterwards.
Full time doctors can earn £54 000 as basic salary plus various benefits including private healthcare. Sessional doctors work a minimum of four sessions a week and are paid “per item”— £35.16 for an incapacity benefit examination and £51.37 for non-domiciliary disability living allowance (DLA) examination, for example . The application forms for sessional doctors state that “10 DLA domiciliary visits cases per week would earn £40 211.60 per annum. Five LCWRA/ LCW [limited capacity for work related activity/limited capacity for work] cases per session, for six sessions per week, would earn £62 883.60 per annum.”
Throughput is a clear focus. The average morning or afternoon session should consist of five assessments, and it was made clear at the recruitment evening that clinicians who did not achieve this regularly would be picked up quickly on audit trails and speed of work addressed.
Nurses and physiotherapists do effectively the same job as doctors in the centres, but do not see people with neurological conditions such as stroke or multiple sclerosis. Otherwise people are seen on a first come, first served basis. One nurse in the audience asked about training in mental health, as she had had little training in this area and would not feel competent to assess it in a fitness for work setting. The reply was that health professionals were “very thoroughly assessed” at interview for their abilities; however, general nurses were often taken on and given training. Is a relatively short training course thereafter enough to ensure the assessments are medically accurate and fair?
Duty of care
Atos chose not to be interviewed by the BMJ , although the Department for Work and Pensions referred me to the organisation for questions about recruitment, training, and audit that it couldn’t answer.
However, from the recruitment evening it was clear that the medical examination consisted of a computerised form to be filled in by choosing drop down statements and justifying them. For example, you could say “able to walk with ease” if you witnessed this or the patient told you this.
The professional role of the doctor is very different from that in the typical NHS. Paul Nicholson, chair of the BMA Occupational Medicine Committee, says that working in this environment brings specific difficulties. “Notwithstanding a contractual obligation to provide a report to a government department, I still have a professional duty of care to the patient and to make the care of the patient my first concern.”
The Faculty of Occupational Medicine publication Good Occupational Medical Practice reinforces the General Medical Council’s position that, good medical care “must include adequately assessing the patient’s conditions, taking account of the history (including the symptoms, and psychological and social factors), the patient’s views, and where necessary examining the patient; providing or arranging advice, investigations or treatment where necessary; referring a patient to another practitioner, when this is in the patient’s best interests.”4
In other words, it expects doctors to adhere to the same professional conduct as they would in any other role.
Does it work?
So is the current method of assessment fit for purpose? There is a queue of people who think not. The Citizens Advice Bureau Scotland , in a report last year, noted “the vast majority of complaints and advice queries stem from the Work Capability Assessment.”5 This includes both the result of the assessment as well as the manner in which it was carried out, it said. “Citizens Advice Scotland (CAS) is extremely concerned that many clients are being found fit for work in their Work Capability Assessment despite often having severe illnesses and/or disabilities. Our evidence has highlighted the cases of many clients with serious health conditions who have been found fit for work, including those with Parkinson’s disease, multiple sclerosis, terminal cancer, bipolar disorder, heart failure, strokes, severe depression, and agoraphobia.”
The report noted that under the previous incapacity benefit system, 37% of claimants were being found fit for work, whereas work capability assessments are finding 66% fit to work. It also gave examples where advice from people’s general practitioners that they were not fit to work was disregarded. The report found that clients often “felt hurried in their assessment and that the healthcare professional was ignoring the answers they were providing to the questions in the assessment. There was a general feeling that the assessor made little eye contact with the claimant and spent most of the assessment entering information into their laptop.” This tallies with the recruitment evening, when it was made clear that efficiency with entering details into the computer system was a stipulation of employment.
The Department for Work and Pensions says, in response, that “It’s unfair to suggest that the system isn’t working.” However, published statistics of the 600 000 new claims for employment and support allowance from October 2008 to May 2010, show that 39% were assessed as fit for work. Around a third of these people appealed this decision, 40% of whom won.6 The department says, “If a decision is overturned at appeal, it does not necessarily mean that the original decision was inaccurate—often, customers produce new evidence to their appeal.” However, this doesn’t really deal with the problem that the healthcare professionals doing the assessments are not, therefore, forwarding sufficient evidence to enable reliable decisions.
At the meeting, I asked how it was possible to know the variation in symptoms that a patient may have during a one-off assessment. I was told that this could be “difficult” but this “wasn’t an occupational health service.” Instead, it was a “functional assessment.” Despite being told that the decision to award benefits or not rested with a layperson within the work and pensions department, the reports were often referred to as “judgments” where making decisions may be “not always clear cut . . . but as long as you can say, on balance.” For example, you could watch someone walking into the room and ask how he or she got to the assessment centre in order to judge mobility. One assessment, which initially reported a woman was fit to work, reported as evidence that her mental health was reasonable that she “did not appear to be trembling . . . sweating . . . or make rocking movements.”7
Other countries rely more on general practitioner assessments of fitness to work. For example, in the Republic of Ireland , general practitioners mainly certify patients and a doctor acting for the Department of Social Protection reviews around 12% of cases as a control mechanism. In Sweden , a certificate from your general practitioner does not automatically entitle you to sickness pay. However, the certificate asks for a description of how illness affects work capacity and a time frame. Just 3.5% of claims are turned down, and about 10% of these are overturned at appeal.
So what is the optimal system? Malcolm Harrington, emeritus professor of occupational health at the University of Birmingham , reviewed the work capability assessment system last year8 and is currently writing a second review. He wrote: “The pathway for the claimant through Jobcentre Plus is impersonal, mechanistic and lacking in clarity. The assessment of work capability undertaken for the DWP by Atos Healthcare suffers from similar procedural problems. In addition, some conditions are more subjective and evidently more difficult to assess. As a result some of the descriptors may not adequately reflect the full impact of such conditions on the individual’s capability for work. The final decision on assigning the claimant to one of the three categories theoretically rests with the Decision Maker at Jobcentre Plus but, in practice, the Atos assessment dominates the whole procedure. This imbalance needs correcting.”
His view is that “the Jobcentre Plus Decision Makers do not in practice make decisions, but instead they typically ‘rubber stamp’ the advice provided through the Atos assessment.” The Citizens Advice Bureau shares this view and says it wants “better accuracy” in reports. But how can this be achieved when funding is devolved to Atos with no routine access to detailed specialist or general practice based information and opinion? Professor Harrington says this “results in the Atos assessment driving the whole process, rather than being seen in its proper context as part of the process.” And so, as things stand, how sure can Atos doctors be that they doing their professional duty?
Cite this as: BMJ 2011;342:d599
· Competing interests: The author has completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from her) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
· Provenance and peer review: Commissioned; not externally peer reviewed.
Atos. UK government Department for Work and Pensions agrees BPO medical services contract with Atos Origin. Press release, 16 Nov 2010.www.atosorigin.com/en-us/Newsroom/en-us/Press_Releases/2010/2010_11_16_05.htm.
Commons Select Committee. Support to incapacity benefits claimants through Pathways to Work. 2010.www.parliament.uk/business/committees/committees-a-z/commons-select/public-accounts-committee/news/committee-of-public-accounts-support-to-incapacity-benefits-claimants-through-pathways-to-work-/.
Atos Origin. Lima —evidence based medicine in action. 2006.www.uk.atosorigin.com/NR/rdonlyres/57A2ACB1-CF8D-4414-9157-FBFE1E586957/0/AO_AD_CaseStudy_EBM.pdf.
Faculty of Occupational Medicine. Good occupational medical practice. 2010. www.facoccmed.ac.uk/library/docs/p_gomp2010.pdf.
Citizens Advice Scotland . The work capability assessment. 2010.www.cas.org.uk/Resources/CAS/Migrated Resources/Documents/CR Work capability assessment.
Department for Work and Pensions. Employment and support allowance: work capability assessment by health condition and functional impairment: official statistics. 2011.http://research.dwp.gov.uk/asd/workingage/esa_wca/esa_wca_25012011.pdf.
Mind. New benefit will fail to spot illness and disability. 30 March 2010.www.mind.org.uk/news/3166_new_benefit_test_will_fail_to_spot_illness_and_disability.
Harrington M. An independent review of the work capability assessment. 2010. www.dwp.gov.uk/docs/wca-review-2010.pdf.