Tag Archives: John LoCascio

Found: The book that helps the government smear the sick as ‘malingerers’

 

Denied benefit: This is the late Karen Sherlock. Her illnesses included chronic kidney disease, a heart condition, vitamin B12 deficiency, anaemia, high blood pressure, high cholesterol, underactive thyroid, asthma, diabetic autonomic neuropathy, gastropaeresis, and diabetic retinopathy. She died on June 8, 2012, of a suspected heart attack, after the Department for Work and Pensions stopped her Employment and Support Allowance. John LoCascio would describe her as a malingerer. Considering the list of her illnesses, how would you describe him?

Denied benefit: This is the late Karen Sherlock. Her illnesses included chronic kidney disease, a heart condition, vitamin B12 deficiency, anaemia, high blood pressure, high cholesterol, underactive thyroid, asthma, diabetic autonomic neuropathy, gastropaeresis, and diabetic retinopathy. She died on June 8, 2012, of a suspected heart attack, after the Department for Work and Pensions stopped her Employment and Support Allowance.
John LoCascio would describe her as a malingerer. Considering the list of her illnesses, how would you describe him?

Some of our least favourite people contributed to a book entitled Malingering and Illness Deception in 2003, that seems to provide much of the ammunition used by the current government to demonise claimants of disability and incapacity benefits.

One of the relevant chapters is ‘Malingering, insurance medicine and medicalization of fraud’ by John LoCascio of the criminal American insurance giant Unum, that has been heavily involved in British social security work since the 1990s.

The other is ‘Origins, practice and limitations of Disability Assessment Medicine’ by Mansel Aylward, the Unum puppet who was formerly chief medical officer at the Department for Work and Pensions.

These are the two charmers who put forward a perversion of Professor George Engels’ biopsychosocial theory that calls an individual’s illness into question, rather than treating it, to the then-Department of Social Security back in the 1990s.

The assertion that it was a tool to reduce claimant numbers can be proved by the fact that Mr Aylward was asked to change the test used to determine whether a claimant deserved benefit, in order to reduce the flow of claimants with mental health problems. When politicians ask for specific results, you know impartiality has gone out the window!

Look at the title of the book: It labels incapacity and disability claimants as “malingerers”, defined in the book’s first chapter as those who engage in “the intentional production of false or exaggerated symptoms motivated by external incentives” – in this case, the desire to receive state benefits.

This fits with what we know of the Unum-influenced benefit system already – that claimants are to be treated as if they are trying to cheat the system, unless they can prove to a state-provided official (not necessarily medically-trained) – who has been briefed to find ways to prevent them receiving the benefit – that they are unwell. Their own doctor’s reports are ignored.

Let’s look at LoCascio’s chapter. He starts by suggesting that “disability-related programmes in both the public and private sectors are faced with increasing numbers of disability claims despite improved health care and job design (the disability paradox).”

Already we are in the realm of fantasy as he fails to mention the logical reasons for these increases, which include poor implementation of health and safety measures in the workplace under ‘light touch’ regulation, and the discovery of new medical conditions whose causes are unknown and which require protracted study before they are understood – all made possible by the “improved health care” to which Mr LoCascio refers.

Amusingly, LoCascio also claims that the commercial insurance industry “is neither medically nor legally driven. It is driven by societal imperatives”. What a whopper! Commercial insurance is driven by the desire for money. That is why his company has a criminal conviction to its name – it changed its medical procedures to make it almost impossible for anyone to claim successfully that their Unum health insurance policy had matured.

Much of the remainder of his chapter attempts to convince the reader that the lack of data available – to support claims that a medical patient is “malingering” – should not be used as evidence that they really are ill. He asks the reader to believe that three questions should be asked: Did the patient understand the medical issues? Are the patient’s reported and actual behaviours consistent through time and across observers? And are the functional capacities in question (the patient’s abilities) well-defined?

What a cheat.

It seems perfectly likely that any patient will understand the medical issues informing their condition. However, in a Work Capability Assessment it is common for the assessor to have a completely different opinion of what those issues are. This discrepancy allows the assessor to find fault with the benefit claim.

The second question supports evidence of those who have read assessment reports claiming that patients did not display the behaviours expected of a person with their condition – one famous example was that the patient was not “rocking back and forth”. The simple reason for this was that their condition did not display in that manner but the assessor – who was not an expert in this field of medicine – did not know that because the only advice available was a biased screed from the Unum-influenced DWP.

The final question – are the functional capacities in question well-defined? – can be defeated with a simple, two-word counter-question: By whom?

Also of interest is the concept of ‘Functional Capacity’ (FC). LoCascio argues that a person should not be expected to be incapable of any type of work, just because they are incapable of one. His example is that a person limited to typing for 20 minutes due to forearm pain may be able to play piano for an hour. This is entirely possible but contradicts one of the quotations Mr LoCascio uses four pages previously: “The question of disease—that and nothing more—is the one for the physician to determine” (Drewy 1896). It is not the assessor’s job to dream up functions a claimant might be able to carry out and then discount a claim for benefits on the basis of that possibility. That is not evidence; it is fantasy.

All of the above questions are also rendered pointless by the simple fact that a claimant’s condition may be variable. LoCascio acknowledges this! However, he then goes right off the rails: “I favour a series of three questions: ‘Please describe a bad day. Please describe a good day. Please tell me how many good days and bad days you have in an average week.’ Armed with this knowledge about any particular symptom and the corresponding reduction in an FC, the medical resource can proceed to analyse the consistency of the history against the medical or observational data.”

That is an inaccurate assumption. When you are ill with (for example) fibromyalgia, there can be a huge range of difference between days. Sometimes Mrs Mike has seemed able to function almost normally (she can never walk far without suffering a huge amount of pain in the following days, as an example of why she only seems more able); other times she has been confined to the sofa for days on end in terrible pain for which medical science currently has no alleviation. At other times her condition may be anywhere between those extremes. Asking for a description of a good or bad day, or how many of these take place in an average week, is not only pointless – it hinders understanding of the condition.

“In conclusion,” LoCascio writes, “the most important product of the medical consultant is clear, credible, and defensible
documentation.” It seems strange, then, that the most clear, credible and defensible documents – those written by the patient’s doctor – are the first to be ignored in any Work Capability Assessment.

What we have here is a propaganda screed, riddled with inconsistencies and running against reason, that has been used to support the government’s position on sickness and disability benefits. As an argument in favour of current policy, it is worse than useless. In fact, it should be a tool for campaigners to use against that policy.

It tells us why a claimant who lives in agony every day should be outraged when assessors use LoCascio’s nonsense to explain away their pain.

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Unum, Atos, the DWP and the WCA; Who gets the blame for the biopsychosocial saga?

Mansel Aylward, former chief medical officer at the Department of Work and Pensions, now director of the (UnumProvident) Centre for Psychosocial and Disability Research at Cardiff University: Architect of misery?

Mansel Aylward, former chief medical officer at the Department of Work and Pensions, now director of the (UnumProvident) Centre for Psychosocial and Disability Research at Cardiff University: Architect of misery?

If we know anything at all about the Work Capability Assessment for sickness and disability benefits, we know that it doesn’t work. In fact, it kills. There is a wealth of evidence proving this, and if any readers are in doubt, please take a look at the other article I am publishing today, MPs tell their own Atos horror stories.

Much has been made of this fact, without properly – in my opinion – addressing why it doesn’t work. The apparent intention is an honourable one – to help people who have been ‘parked’ on disability benefits back into work, if it is now possible for them to take employment again, and to provide support for those who cannot work at all. What went wrong?

Let’s start at the beginning. The WCA is, at least nominally, based on the biopsychosocial model developed by George Engel. He wanted to broaden the way people think about illness, taking into account not only biological factors but psychological and social influences as well. He contended that these non-biological influences may interfere with a patient’s healing process.

The idea has been developed to suggest that, once identified, the non-biological factors inhibiting healing would be neutralised via a variety of support methods. Stressful events in a person’s life or environmental factors are acknowledged as having real effects on their illness, and it can be seen that this confers a certain amount of legitimacy on symptoms that are not currently explainable by medicine.

Engel stated, in 1961, “Many illnesses are largely subjective – at least until we as observers discover the parameters and framework within which we can also make objective observations. Hyperparathyroidism… was a purely subjective experience for many patients until we discovered what to look for and which instruments to use in the search.” He also warned that people engaged in research should “see what everyone else has seen and think what nobody else has thought” – as long as they don’t automatically assume that their new thought must be correct.

The Engels theory forms the basis of the system of insurance claims management adopted by US giant Unum when its bosses realised that their profits were being threatened by falling interest rates – meaning the company’s investments were losing value – and a rise in claims for “subjective illnesses” which had no clear biological markers – Myalgic Encephalomyelitis (ME), also known as Chronic Fatigue Syndrome (CFS), Fibromyalgia, Chronic Pain, Multiple Sclerosis, Lyme Disease, even Irritable Bowel Syndrome (IBS).

As I wrote on Wednesday, Unum adapted the biopsychosocial model into a new medical examination that stripped it of its ‘bio’ and ‘social’ aspects in order to concentrate on the ‘psycho’ – with a relentless emphasis on an individual claimant’s beliefs and attitudes.

The new test aggressively disputed whether the claimant was ill, questioning illnesses that were “self-reported”, labelling some disabling conditions as “psychological”, and playing up the “subjective” nature of “mental” and “nervous” claims.   The thinking behind it was: Sickness is temporary. Illness is a behaviour – all the things that people say and do that express and communicate their feelings of being unwell. The degree of this behaviour is dependent on the attitudes and beliefs of the individual, as well as the social context and culture. Illness is a personal choice. In other words: “It’s all in the mind; these people are fit to work.” (as I mentioned in When big business dabbles with welfare; a cautionary tale)

Already we can see that this is a perversion of Professor Engel’s theory, using it to call an individual’s illness into question, not to treat it. Yet this is the model that was put forward to the Department of Social Security (later the Department of Work and Pensions) by its then-chief medical officer, Mansel Aylward, in tandem with Unum’s then-second vice president, John LoCascio.

Together they devised a new ‘All Work Test’ that would not actually focus on whether an individual could do their job; instead it would assess their general capacity to work through a series of ‘descriptors’. Decisions on eligibility for benefit would be made by non-medical adjudication officers within the government department, advised by doctors trained by Mr LoCascio. Claimants’ own doctors would be marginalised.

When New Labour came to power, Mansel Aylward was asked to change the test to reduce the flow of claimants with mental health problems. In came the ‘Personal Capability Assessment’, which again focused on what a person was able to do and how they could be supported back into work.

It is at this point that US IT corporation Atos Origin (now Atos Healthcare in the UK) became involved. The task of administrating the PCA was contracted out to a company which was taken over by Atos, meaning its employees – who had no medical training – could now assess claims for sickness and disability benefits, using the company’s Logical Integrated Medical Assessment tick-box computer system. These evaluations proved unreliable and the number of successful appeals against decisions skyrocketed.

So in 2003 the DWP introduced ‘Pathways to Work’, in which claimants – now labelled ‘customers’ – had to undertake a work-focused interview with a personal advisor. If they weren’t screened out by the interview, they would go on to mandatory monthly interviews where they would be encouraged to return to work and discuss work-focused activity. I can assure readers, from personal experience with Mrs Mike, that this activity remains a prominent part of the DWP’s sickness and disability benefit policy.

Mansel Aylward is no longer at the DWP, though. In 2004 he was appointed director of the UnumProvident Centre for Psychosocial and Disability Research at Cardiff University (it has since dropped the company title from its name). Was this as a reward for services rendered in getting Unum and its practices into the heart of the UK government?

Let’s have a look at some of the ‘descriptors’ that are being used to determine a claimant’s – sorry, customer’s – fitness for work in what is now called the ‘Work Capability Assessment’. I am grateful to Helen Goodman, Labour MP for Bishop Auckland, who provided this information during yesterday’s debate on the Atos WCA in the House of Commons. She said a person who…

“Cannot mount or descend two steps unaided by another person even with the support of a handrail”;

“Cannot, for the majority of the time, remain at a work station, either…standing unassisted by another person…or…sitting…for more than 30 minutes, before needing to move away in order to avoid significant discomfort or exhaustion”

“Cannot pick up and move a one litre carton full of liquid”;

“Cannot use a pencil or pen to make a meaningful mark”;

“Cannot use a suitable keyboard or mouse”;

“Is unable to navigate around unfamiliar surrounding, without being accompanied by another person, due to sensory impairment”;

“Is at risk of loss of control leading to extensive evacuation of the bowel and/or voiding of the bladder, sufficient to require cleaning and a change in clothing, not able to reach a toilet quickly”;

“At least once a month, has an involuntary episode of lost or altered consciousness resulting in significantly disrupted awareness or concentration”;

“Has an epileptic fit once a fortnight”;

“Cannot learn anything beyond a simple task, such as setting an alarm clock”;

“Has reduced awareness of everyday hazards leading to a significant risk of…injury to self or others; or…damage to property or possessions such that they frequently require supervision”;

“Cannot cope with minor planned change” such as a change to lunchtime;

“Is unable to get to a specified place with which they are familiar, without being accompanied by another person”

… is “fit for work”.

A person in the following category is also deemed fit for work, if: “Engagement in social contact with someone unfamiliar to the claimant is always precluded due to difficulty relating to others or significant distress experienced by the individual.”

Kate Green, Labour MP for Stretford and Urmston, added: “My constituents told me categorically last week that they believe that the whole system was deliberately designed and operated to trick them — to make them incriminate themselves and to catch them out.

“They firmly believe that the system is deliberately designed, not to assess and then help them into work if they are fit for it, but simply to stop paying benefits wherever possible.

“There are far too many instances of trickery and misleading people and of distorting what they have done, said and reported and drawing conclusions from that. That is happening far too often.

“It is an absolute disgrace that we should run a public assessment process in such a discredited way.”

It seems to be a result of Professor Aylward’s work that the main influence on government welfare reform has been a perversion of a perversion of a theory that has not been shown to work. Authentic evidence is disregarded by those in power, who clearly continue to persecute the sick while feeding the profits of private concerns.

I wonder what he would have to say, if he were to be confronted by the evidence of what his policies have done to the sick and disabled of this country – as spelled out, in the House of Commons, by MPs from many parties.

Afterthought: It should be noted that Professor Aylward is on record as having expressed doubts about the Work Capability Assessment and the current system, as run by the government, with the caveat that he has not been involved for several years.

He told the Black Triangle Campaign: “I will make myself aware … but I think that I’m a man of integrity … and if I think that the Work Capability Assessment … test or whatever … is not proper … I will speak out against it.”

In the light of what happened while he was at the DWP, I leave it to readers to judge whether he will.

When big business dabbles with welfare; a cautionary tale

unum“Jack Gilligan, who was the Democratic governor of Ohio… said ‘You know there will never be democracy in America when big business can buy both parties and expect a pay-off, whichever one wins. And you know, a touch of that may possibly have spread in this direction.” Tony Benn.

I have been researching the relationship between US insurance giant (and lawbreaker) Unum and successive UK governments – Conservative, New Labour and Coalition – and the minimal research I have managed so far tells me that, if there’s one thing the Labour Party needs to do to ensure its electability in 2015, that thing is the expulsion of Unum and all private insurance firms, their subsidiaries, partner companies, and people who have worked with or for them, from any position of influence. Kick them right out!

Any government that fraternises with these vampires puts corporate profits above the well-being of its citizens. That is clear from what I have read. I want to go into certain aspects in detail, but before that, you deserve to know the details, so I’ve written a little story for you:

Once upon a time, a big insurance company had a little problem. It had been making money hand-over-fist by investing people’s premiums in high-interest portfolios, but interest rates were falling and new kinds of ‘subjective illness’ had arisen, for which medical science was not prepared – ‘chronic pain’, ‘chronic fatigue syndrome’, fibromyalgia, multiple sclerosis, Lyme disease.

The solution devised by the bosses was to reduce the number of successful claims it paid out, by aggressively disputing whether the claimant was ill. So the company skewed its medical examinations to its own favour by questioning illnesses that were “self-reported”, labelling some disabling conditions as “psychological”, and playing up the “subjective” nature of “mental” and “nervous” claims.

“Sickness is temporary,” they said. “Illness is a behaviour – all the things that people say and do that express and communicate their feelings of being unwell. The degree of this behaviour is dependent on the attitudes and beliefs of the individual, as well as the social context and culture. Illness is a personal choice.” In other words: “It’s all in the mind; these people are fit to work”.

Around the same time, a small country had a big problem with people claiming out-of-work benefit because they were ill. This was not a problem because they were lying about being ill – fraud amounted to less than one per cent of claims. Nor was it a problem because too many people were claiming – benefit levels were among the lowest of any countries nearby, and claims were on a par with those other countries.

No, the problem was that the man running the system, whose name was Peter**, wanted to make money out of it.

So he hired the boss of the big insurance company, whose name was John***, and asked him to help out. John said, “We have a great test that you can use! Instead of asking whether someone can do their job, you assess their general capacity to work, with a series of – we call them – descriptors. One could say the person ‘Is unable to cope with changes in the daily routine’, ‘Is frightened to go out alone’. Then the results get passed on to different people – adjudication officers – who judge whether they deserve your benefit. But the clever bit is that these officers aren’t doctors – the customer might be saying they’re sick but medical evidence has nothing to do with what the test is about! We’ll train your adjudicators – for a price. We’ve even got a sexy name for the test: It’s bollocks!”*

Off went Peter to try it and, lo and behold! The rise in claimants came to a halt, as if by magic. But it wasn’t magic. It was bollocks.

Meanwhile, the insurance company was making out like a bandit. Not only was it now at the heart of the small country’s government, it was able to make money from the claimants as well. Before the new rules came into effect, it advertised for customers, saying the new system meant “if you fall ill and have to rely on state incapacity benefit, you could be in serious trouble!”

Before long, the big insurance company found it was even bigger, with a quarter of all its post-tax income being paid by people in the small country.

Meanwhile, back at home, people had started to complain about the big company. It was a big, NASTY company, they said, because it had forced them to accept less when they claimed than their policies offered. The government there found that the big company had relied too much on in-house professionals; had constructed doctors’ or examination reports unfairly, for its own benefit; had failed to evaluate claimants’ conditions in their totality; and had placed an inordinate burden on claimants to justify why they should receive the benefits for which they had paid. Many claims were found to need re-examination.

That did not make a scrap of difference to the people running the sickness benefit system in the small country that had asked for the big nasty insurance company’s help. An election had happened and Peter had been asked to leave, but the new people in charge, Frank**** and Tony*****, were keen to capitalise on what had gone before and transform their welfare system into a new marketplace – a source of revenue, profitability and economic growth.

With help from the big nasty insurance company, they decided that the solution was not to cure the sick – or even to prevent their sickness in the first place – but to convince them that work is therapeutic, aids recovery and is the best form of rehabilitation. In other words, bollocks*. This way, with the help of the big nasty company’s bollocks* tests and adjudicators who based their decisions on bollocks*, they could say the problem was with the person who had the illness. Their behaviour and beliefs became the focus of the government’s moral judgement and action. If they did not change their ways, then sanctions would be used as a “motivational tool” – and people would be starved back into work.

And that, dear child, has continued to this very day! People claiming sickness or disability benefits in the small country, which is called the United Kingdom, have to take a test in which medical evidence plays a tiny role, run by people who are not doctors and judged by people who are not doctors. Many of these decisions have been found to be unfair, and have often been found to have failed to evaluate claimants’ conditions in their totality – which is why people with terminal cancer have been found fit for work. Many claims have been found to need re-examination.

You can see the hand of the big nasty insurance company at work, can’t you!

That is because the big nasty insurance company, which is called Unum, has been at the heart of the small country’s government ever since it was first invited in. And they intend to live happily ever after, at the public’s expense.

“A lot of people think that disabled people don’t have sex, but this is not true, because the government are screwing us hard.” Francesca Martinez, The News Quiz, BBC Radio 4, January 11, 2013.

*I should apologise for the fault in my computer. Every time I try to type – I’ll just cut and paste it in here – “the biopsychosocial model” or any combination of those words, it comes out “bollocks”. Sorry!

**Peter Lilley

***John LoCascio

****Frank Field

*****Tony Blair