Disability assessment medicine

BMJ 1999; 318 doi: http://dx.doi.org/10.1136/bmj.318.7186.2 (Published 20 March 1999)
Cite this as: BMJ 1999;318:S2-7186
  1. Mansel Aylward, chief medical adviser,
  2. Philip Sawney, medical policy manager
  1. Department of Social Security, London WC2N 6HT

    Disability assessment medicine combines aspects of occupational medicine with insurance and social security medicine. Mansel Aylward and Philip Sawney from the Department of Social Security outline its scope


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    Disability assessment medicine is the specialty primarily concerned with the medical assessment of individuals in order to provide objective medical advice to decision makers. These decision makers may be benefit administrators, employers, or “finders of fact” in the insurance industry. Disability assessment is also a key part of advising employers in relation to the Disability Discrimination Act 1995 and local authorities in relation to the provision of community care services.

    In carrying out this function, doctors act as specialist medical disability analysts. The role of a disability analyst differs from the more familiar clinical role of reaching a diagnosis and arranging treatment: the disability analyst's primary function is to make an assessment of how a person is affected by his or her disease or disability and to relate this to the legislative or policy requirements or the specific issues raised by the decision maker. Disability analysts also have an important role to play in educating health professionals and managers about disability issues.

    Decision makers in disability assessment

    Who is a decision maker?

    The decision maker is usually the “finder of fact,” who decides a question (say of entitlement to a benefit or service) by weighing the available evidence in accordance with the relevant legislation or policy specification

    • Benefit adjudicator

    • Insurance officer or claims assessor

    • Insurance ombudsman

    • Employer

    • Pension adjudicator

    • Personal employment adviser

    • Courts and tribunals

    • Local authority officer

    What decision makers expect from a medical report

    The following elements are considered essential:

    • Legibility

    • Absence of medical jargon

    • Consistency - the doctor's comments justify the conclusions drawn, especially when they differ from the client's

    • Based on evidence - opinion alone may be persuasive, but it can never take precedence over opinion based on factual evidence

    Pros and cons of disability assessment medicine

    Advantages
    • Exercises wide range of interpersonal, examination, and analytical skills

    • Uses evidence based approach to achieve consistency and consensus

    • Largely office hours of working

    • Opportunities to work part time - hours can often be tailored to suit caring responsibilities

    • Wide spectrum of pathology seen

    • Varied work with people of all ages

    • Emerging specialty with ample scope for developing quality processes and audit

    • Opportunity for research

    Disadvantages

    • Opportunity to influence, but rarely the final decision maker

    • No direct therapeutic intervention or clinical management

    • Limited number of full time posts available

    • Not perceived as “proper” medicine by healthcare colleagues

    • Conflict between medical and social models of disability

    Impairment and disability

    The two basic concepts of impairment and disability are important in understanding the role of disability analysts. The World Health Organisation defines impairment as “any loss or abnormality of psychological, physiological or anatomical structure or function.” This is largely a medical definition and is usually subject to some form of objective measurement, but it does not provide much information about how a particular individual is affected.

    Disability, on the other hand, is defined as “any restriction or lack (resulting from impairment) of ability to perform an activity in the manner or within the range considered normal for a human being.” The concept of disability requires an assessment not simply of what is wrong with a person but also into what the person is prevented from doing. People with similar impairments may have very different degrees of disability. For example, people with identical leg amputations often have markedly different walking abilities. This largely medical model of disability contrasts with the “social model,” which sees disability more as a function of the environment in which the person operates. The terms activity and participation, with their more positive connotations, are increasingly preferred to the term disability.

    Consistency and consensus

    Consistency of behaviour across functional capacities is a well established clinical principle(1) and is a cardinal feature of disability analysis, particularly of subjective impairments. Impairment of any kind should have consistent effects regardless of the setting. The concept of consensus in this context refers to the need for an explicit recognition of medical opinion, based on research evidence wherever possible, about the clinical pattern of the disease. Rigorous evaluation of different medical opinions about a case, drawing on published evidence, analytical skills, and professional judgment, are the hallmarks for establishing consensus.(2)

    Role of disability analysts

    The role of disability analysts is to help decision makers reach fair and proper decisions, for example, on entitlement to cash benefits and provision of services or environmental adjustments that might be required. They do this by providing advice that is objective, clear, and capable of answering questions posed by a decision maker without compromising any subsequent adjudication process.

    Increasingly, disability analysts are being required to assess functional capacity as much as incapacity. A person's performance may be influenced by the actual loss of function (such as by physical limitation), restrictions on function (such as advice not to perform certain activities), premature termination of activity, and suboptimal performance (possibly limited by pain and fatigue, environment, motivation, and attitude). The approach is increasingly to combine the medical and social models so that, overall, disability is seen to depend not only on bodily or mental impairment but also on performance and behaviour. Thus “ability” may be set by physiological or pathological limits, whereas actual performance is often set by psychosocial limits including the limits set by the person's specific environment.

    Medical and social models of disability

    Medical
    • Disabled people are disadvantaged by their impairment

    • Disabled people are pitied as the victims of personal tragedy (disease or accident)

    • Disadvantage is best overcome through medical treatment or rehabilitation

    Social

    • Disabled people are disadvantaged by society's failure to accommodate everyone's abilities

    • Disabled people are oppressed by current social and economic institutions

    • Disadvantage is best overcome by society adapting itself to everyone's abilities

    Areas of work

    The single largest area of work for disability analysts is in relation to social security benefits, such as state incapacity benefits, industrial injuries disablement benefit, and disability living allowance. Most full time doctors who carry out these assessments are now employed by the private sector, which provides services under contract to the Department of Social Security Benefits Agency. More senior and experienced disability analysts will be responsible for training part time doctors and monitoring the quality of their work.

    Doctors who sit on appeals tribunals are often required to use the skills of the disability analyst, either in carrying out their own assessment of the client or by assessing the information provided by a medical disability analyst. Occupational physicians are often called on to apply the principles of disability analysis when providing advice to employers in relation to management of workplace disability and ill health retirement.

    There is also a substantial and diverse market in insurance work in relation to health claims and long term disability products, pension adjudication, workplace rehabilitation, and disability management.

    Medicolegal basis

    There is a medicolegal basis to much of the work carried out by medical disability analysts whether this be social security law, health and safety legislation, or disability discrimination legislation. Specific training programmes, such as those required by the Department of Social Security before a doctor is approved to perform examinations for state incapacity benefits, cover the legal and procedural context within which doctors are required to provide their advice.

    Career structure

    Most disability analysts carry out this role in a part time capacity, but about 250 doctors are employed full time in the private sector to provide services under contract to the Department of Social Security and the Benefits Agency. A career in disability analysis may be quite different from one in mainstream clinical practice, but it can provide intellectually stimulating work largely within office hours. Doctors choosing to test the career offered by this specialty will discover that they are trained to enhance their ability to analyse medical evidence, to examine patients to medically sound proto- cols, and to write accurate and succinct reports for decision makers.

    Diploma

    Disability analysts come from diverse backgrounds, such as general practice, occupational medicine, and rehabilitation medicine. A current priority for the Department of Social Security and private sector providers is the development of a national training curriculum and quality standards for such doctors. A new diploma in disability assessment medicine (DDAM), sponsored by the Faculty of Occupational Medicine of the Royal College of Physicians and the Department of Social Security, is being developed. The diploma will be awarded by examination, encompassing written and clinical sections, and will be open to any doctor with appropriate experience of disability assessment. The syllabus includes the principles and practice of disability assessment, including clinical aspects; assessment of work and the work environment; principles of rehabilitation; and the principles of assurance medicine. The first examination will be held towards the end of 1999.

    The diploma will provide formal recognition of disability assessment as a distinct medical specialty with its own body of knowledge and skills. Possession of the diploma will also provide externally validated evidence that an individual has attained a standard of excellence in the specialty. Undoubtedly there will also be greater opportunities for research linked to one of the more established specialties such as general practice or occupational medicine.

    Acknowledgments

    The views expressed are those of the authors and do not necessarily reflect the view of the Department of Social Security. We thank Drs Moira Henderson, Carol Hudson, and Peter Dewis for their comments.

    References

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