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EDITORIALS: Jos Verbeek and Frank van Dijk Assessing the ability to work BMJ 2008; 336: 519-520 [Full text]

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...and what about the simulators index

Luiz Philippe Vasconcellos   (9 March 2008)

Is the ‘disability’ label always helpful?

Anthony N Williams   (11 March 2008)

Occupational communication.

William G. Pickering.   (12 March 2008)

Receipt of Incapacity benefit does not equate with being unable to work.

Richard D Colman   (21 March 2008)

...and what about the simulators index 9 March 2008
Luiz Philippe Vasconcellos, Medical Legal Expert ( Rua Satélite 80, Jundiaí, S. Paulo State, Brazil Send response to journal: Re: ...and what about the simulators index	It's welcome any guide to evaluate the prognostic of the return to work. Unfortunelly, all over the world are de smarts, the mallingerants, the hipocondriacs and the lawers servers that are really confounders people. For them, we need another kind of semiology and propedeutics, not new rules. Competing interests: None declared
Is the ‘disability’ label always helpful? 11 March 2008
Anthony N Williams, Consultant Occupational Physician Working Fit Ltd, PO Box 389, Temple Ewell, Dover CT16 9BF Send response to journal: Re: Is the ‘disability’ label always helpful?	Verbeek and van Dijk (1) are rightly critical of the lack of robust evidence behind the criteria used to assess eligibility for incapacity benefits. They suggest it is important for doctors to understand the essential difference between ‘having a disease and having a disability’. Do doctors, and society in general, understand the current way in which disability is assessed? For incapacity benefit, where there is no ‘factual evidence’ available, the assessment is based entirely on what the claimant states in a questionnaire, and how they perform on the day of the assessment (2). In other words, they have an incapacity if they say they do and if they perform appropriately. The Disability Discrimination Act 1995 (DDA) defines disability as ‘a substantial impairment in normal daily activities that is long-term’. The disability can either be physical or mental, but the need for the mental impairment to be related to a recognised medical condition was removed in the 2004 amendment to the Act mostly as a result of intense lobbying by the then Disability Rights Commission. Currently, therefore, an individual can be regarded as disabled if they believe they are disabled, and behave as if they are, for a period of a year. There is no requirement for them to have any reason to be disabled in the sense that they have an underlying disease process or obvious physical or mental impairment. Illness behaviour such as this frequently leads to inappropriate prescribing and treatment as well as long-term unemployment, all potentially harmful. Certifying that an individual is eligible for incapacity benefit or is disabled under the DDA will reinforce such illness behaviour and therefore contributes to any harmful consequences. Verbeek and van Dijk state that ‘subjecting the topic to scientific evaluation might be too confrontational or politically risky because the results might fundamentally challenge current practice’. Any evaluation is likely to focus on secondary gain and illness behaviour. What evidence there is suggests that these could be factors in as many as 75% of incapacity benefit claimants (3) and therefore likely to be factors in a significant proportion of individuals who believe they are disabled under the DDA. This would inevitably raise major questions about the DDA itself. While these may be issues for government and society to tackle, doctors should be asking more challenging questions about the harmful effects such a liberal approach to defining disability and incapacity can have. (1) Verbeek J, van Dijk F. Assessing the ability to work. BMJ 2008; 336:519-20. (2) Henderson M. Transformation of the personal capability assessment. Department of Work and Pensions, 2007. www.dwp.gov.uk/welfarereform/tcpa.pdf. (3) Waddell G. Models of disability, using low back pain as an example. London: Royal Society of Medicine Press. 2002. Competing interests: None declared
Occupational communication. 12 March 2008
William G. Pickering., Doctor NE3 4AL Send response to journal: Re: Occupational communication.	Occupational communication. Doctors Verbeek and van Dijk, and Dr Williams, all helpfully sketch the well-known tracks which criss-cross the field of occupational health and disability [1,2]. They may agree sickness-absence management is also a component of this landscape. One wonders if there is often too much doctor and too little decision -making by management or human resources — ‘unload the employee to the medics then we’ve covered ourselves’. Lay initiative and decision is frequently eschewed in favour of passing the buck and medicalisation. The trickiest cases to assess are often those with subjective unmeasurables (e.g. backs, ‘stress’). Management are more wised-up on the employees than doctors. Head to head discussion between doctor and management therefore, is essential to get near the correct decision. Communication, however, is more and more by letter – in which candour and insight are less easy to articulate (these wary days). Nowhere is this more evident than in local authorities and state services. Videoing certain suspicious cases (not all!) has produced spectacular results some companies have found. An employee on long term sick-leave videoed lifting rubble, driving a taxi, or on the 18th hole, then made accountable, is an excellent deterrent to would-be malingerers or fraudsters. It bespeaks the fallibility of medical decisions too. Doctors should point this out clearly to their OH clients and not foster a view of omniscience (however lucrative). The contrast between apparently ‘incapacitating’ conditions (mental and physical) that some self-employed persons overcome, and the rapid cave -in of some salaried employees with lighter burdens, also shows medicine’s limitations and urges the maximum-communication approach. Alongside, doctors are continually struck by what some people have to put up with at work. Occasional teachers, for example, seem to have to cope with fractious, abusive pupils below, and apparently indelicate management above. Just how some employees, of all sorts, often with a medical condition which others in an easier job might exaggerate to prompt sick-leave or ill-health retirement, can endure difficult employment without becoming ill, is often much more unfathomable than why others flee early through the available medical exit. William G Pickering (AFOM) wgpi@hotmail.com 12.3.08 References: 1. Verbeek J, van Dijk F. Assessing the ability to work BMJ 2008;336:519-520 2. Williams A N. Is the ‘disability’ label always helpful? http://bmj.com/cgi/eletters/336/7643/519#191892, 10 Mar 2008 Competing interests: None declared
Receipt of Incapacity benefit does not equate with being unable to work. 21 March 2008
Richard D Colman, Occupational Physican N Yorkshire Send response to journal: Re: Receipt of Incapacity benefit does not equate with being unable to work.	There is much misunderstanding about the meaning of being in receipt of Incapacity benefit. What it means is that the recipient has accumulated enough points via a screening test to be awarded the benefit. However many with sufficient points for the benefit do and are capable of working. It denotes the accumulated degree of disability that society via the government is prepared to pay as compensation. I repeat it is not an objective test of capability to work. Unfortunately the bar was set too low. Competing interests: None declared