Part 3: Determining eligibility for sickness and invalids' benefits

3.1
In this Part, we set out our findings about:

• the information recorded in medical certificates;
• health practitioner practices in issuing medical certificates;
• Work and Income's use of other information to determine eligibility; and
• the roles and practices of regional health advisors and regional disability advisors.

Our overall findings

3.2
In the sample we selected, when the revised medical certificates were completed in full they provided relevant information for case managers to use when making decisions about eligibility. However, the quality of the information provided by GPs varied. Some questions were unanswered or the information was not detailed enough to be useful. We also noted instances where information on the medical certificate or in other records suggested that case managers should have referred the application to the regional health advisors or regional disability advisors before deciding on eligibility, but had not done so.

3.3
When they were used, the computer-based Medical Disability Advisor and the regional health advisors and regional disability advisors led to better and more informed decision-making. For example, our sample of case files included applications that had been referred to the regional health and regional disability advisors. Based on their advice, some applications for sickness and invalids' benefits had been declined. Some beneficiaries who were considered for an invalid's benefit were, after discussion with the health practitioner, kept on the sickness benefit, and beneficiaries on the invalid's benefit were reassigned to the sickness benefit.

3.4
We have made eight recommendations in this Part, about:

• ensuring consistent practices for reviewing applications;
• improving the quality of information recorded in medical certificates;
• promoting a more comprehensive and systematic assessment of all available information to determine eligibility;
• making better use of regional health advisors and regional disability advisors; and
• reviewing the circumstances of longer-term sickness beneficiaries (that is, people who have received a sickness benefit for more than one year).

Information recorded in medical certificates

The revised medical certificate introduced in September 2007 has provided relevant information for determining eligibility. The usefulness of medical certificates was sometimes limited because the information recorded was not complete or sufficiently specific.

3.5
The medical certificate is the main source of information a case manager uses to determine eligibility – and then ongoing eligibility – for a benefit. To help case managers determine eligibility, it is important that health practitioners record sufficient information on the medical certificates.

3.6
For our sample of beneficiaries, we examined how health practitioners answered the questions in the medical certificate, how much detail was provided, and how useful that information was for determining eligibility.

3.7
The amount and usefulness of the information provided varied. In some cases, the medical certificates did not clearly describe the effect of the person's medical condition on their ability to work. Instead, this was sometimes expressed in general terms, for example "fatigue, insomnia, low mood", "needs supervision", or "depression". These responses provided limited or no information about the person's ability to work (in their own profession or in another line of work).

3.8
In our sample, not all the required questions in the medical certificate had been answered. Sometimes the information in the medical certificate was not provided consistently (for example, in relation to work planning and training timeframes).

3.9
In our view, the Ministry needs to work with health practitioners to improve the consistency and amount of information provided in the medical certificates.

Optional question about treatment

3.10
The medical certificate includes an optional question about any treatment the person is receiving for medical conditions listed as affecting the person's ability to work. The question is asked to help the case manager with planning, not for determining eligibility.

3.11
In our view, information about treatment is valuable when considering the prognosis and likely health outcomes for the beneficiary, and is particularly relevant when deciding eligibility for an invalid's benefit or where a person has been receiving a sickness benefit for a long time. Often, treatment is able to control a condition (for example, diabetes or epilepsy) or provide periods of wellness (for example, in some cases of mental illness), during which a person can work. Information about the treatment a person was receiving was one consideration for regional health advisors and regional disability advisors when they reviewed applications – particularly in the case of applications from longer-term sickness beneficiaries and invalids' beneficiaries.

3.12
Centrelink, Work and Income's Australian counterpart, considers whether all reasonable treatment options have been pursued before deciding whether a medical condition should be accepted as permanent.

Health practitioner practices in issuing medical certificates

Work and Income did not systematically collect or analyse data on health practitioners' practices in issuing medical certificates.

3.13
The Ministry carried out analysis in September 2006 that identified deficiencies and varying practices in how health practitioners issued medical certificates for sickness benefit applicants. In June 2007, the Ministry proposed to create a profile of health practitioners, to identify those whose practices in issuing medical certificates differed significantly from those of their colleagues. The reasons for the differences could then be investigated.

3.14
In our view, there are several possible explanations for variations in assessment practice. For example, health practitioners practising in lower socio-economic areas, or specialising in mental health, would be expected to assess a higher number of people eligible for a sickness benefit. In some cases, health practitioners could be more inclined to, or under pressure to, issue medical certificates.

3.15
At the time of our audit (from September to December 2008), the Ministry told us that it had not yet created a profile of health practitioners. It was not systematically collecting or analysing data to establish unusual patterns in how health practitioners were assessing people and completing the medical certificates.

3.16
The Ministry's Principal Health Advisor may, on occasion, make contact with health practitioners. This occurs infrequently, and such discussions involve advising health practitioners who might be experiencing pressure to fill out a medical certificate, or consulting with any health practitioners who express serious concerns about Work and Income's processes.

3.17
In our view, collecting and interpreting data on the assessment and certification behaviour of health practitioners would enable the Ministry to identify and investigate reasons for varying practices. This analysis would enable the Ministry to take appropriate action, which might include reviewing the design of the certificate, providing additional training and guidance, or reporting any concerns to a health practitioner's professional body.

Using other information to help determine eligibility

Case managers were not making sufficient use of other methods and information to help determine a person's eligibility for the sickness or invalid's benefit.

Using medical certificates to determine eligibility for the sickness benefit

3.18
To establish eligibility for the sickness benefit, Ministry policy requires case managers to consider the information in the medical certificate.

3.19
The medical certificate records the beneficiary's current medical status. It generally provides no information about work history and personal circumstances. It does not show the length of time the beneficiary has been receiving the benefit or the progress made towards returning to employment. To review this information, case managers have to look at the Ministry's online records or previous medical certificates.

3.20
The sickness benefit is intended to help people who are temporarily off work or working at a reduced level. It is expected that most sickness beneficiaries' ability to work will improve, allowing them to progress towards employment. However, as at December 2008, almost half of all sickness beneficiaries – 47% or 24,000 people – had been receiving a sickness benefit continuously for a year or more.

3.21
Our observations and discussions with case managers indicated that, in line with Ministry policy for assessing eligibility for a sickness benefit, case managers were generally making limited use of information other than the current medical certificate. Their approach was no different when they considered ongoing eligibility for long-term beneficiaries.

3.22
In the sample of sickness beneficiary cases that we looked at, we identified apparent inconsistencies in the information available to case managers – including case notes, journals, and past medical certificates (where available) – about a person's medical condition, benefit history, or personal circumstances. In our view, these inconsistencies warranted referring the application to the regional health advisor or regional disability advisor for clarification and advice before the benefit was granted.

3.23
Instances where we considered clarification should have been sought included:

• unusual changes to the assessment of when the person would be ready to plan to return to work;
• changes in diagnosis from one medical certificate to the next; and
• inconsistencies between the person's work history or intentions and the health practitioner's assessment of when that person would be ready to work.

Using medical certificates and other information to determine eligibility for the invalid's benefit

3.24
To establish eligibility for an invalid's benefit, Ministry policy requires case managers to consider the current medical certificate as well as other information available about a person, including case notes, journals, previous medical certificates, hard copy files, vocational assessments, and specialist medical assessments.

3.25
In all the service centres that we visited, new applications for the invalid's benefit had to be referred to the regional health advisor or regional disability advisor for a recommendation about entitlement. Some regions had adopted this policy later than others.

3.26
Where applications were referred to the regional health advisor or regional disability advisor, the requirement to consider other relevant information was, in our view, met by the case manager. We noted instances where, after the advisor reviewed additional information and talked to the health practitioner, some applications for the invalid's benefit were declined and the beneficiary remained on the sickness benefit. In our view, this shows how useful this specialist resource can be.

3.27
We reviewed applications in two service centres that adopted the practice of making referrals to the regional health advisor or regional disability advisor in the last quarter of 2008. In this subgroup of our sample, of the 47 applications that had not been referred to the regional health advisor or regional disability advisor for a recommendation on eligibility, nine applications had information on the file that suggested that such a referral was warranted. For example:

• The beneficiary was carrying out a full-time course of study and the GP did not know whether the condition would last longer than two years.
• The beneficiary was completing a full-time university course as well as working part-time. The file also contained a medical certificate that said the beneficiary was not permanently and severely disabled and did not medically qualify for an invalid's benefit.

3.28
There were 26 applications where ongoing eligibility for the invalid's benefit was assessed. Nine were referred to the regional health advisor or regional disability advisor. Five of the remaining 17 had information on the file that suggested that the application warranted referral. This information included:

• the GP signing the certificate for a 13-week duration;
• the beneficiary applying for a training incentive allowance for a pilot's licence two months before a renewal was granted, even though the beneficiary's condition was musculoskeletal; and
• an assessment on file where the beneficiary had said that they were ready and able to work in less than six months.

3.29
In our view, where applications for long-term sickness benefits and invalids' benefits are not referred to the regional health advisor or regional disability advisor, there is value in case managers reviewing past online records. If necessary, case managers should refer to previous medical certificates. Any inconsistencies can be referred to the regional health advisor or regional disability advisor for their recommendation before a decision about eligibility is made.

Verifying the circumstances of long-term beneficiaries

3.30
Work and Income had a number of designated doctors⁵ who were used to provide second opinions on a person's medical incapacity, to help case managers to determine both benefit entitlement and appropriate interventions.

3.31
Case managers were able to refer a beneficiary directly to a designated doctor when:

• the beneficiary's health practitioner advised that they were not best placed to provide the medical information and a second opinion was appropriate; or
• the beneficiary was not able to, or did not, provide a report or medical certificate and Work and Income records did not hold enough information to determine whether the person was entitled to an invalid's benefit; or
• the beneficiary chose to see a designated doctor.

3.32
Case managers are also required to refer other cases to the regional health advisor or regional disability advisor for advice before deciding if the beneficiary should be assessed by a designated doctor. These situations include when:

• diagnosis is unclear;
• there is not enough information in the certificate and existing reports, assessments, or Work and Income records to decide entitlement;
• the medical information is ambiguous or conflicting;
• a previous medical certificate contains a substantially different diagnosis or recommendation;
• the beneficiary is involved in activities that appear to be inconsistent with recorded incapacities; or
• the duration for the particular condition exceeds the duration recommended by the Medical Disability Advisor by 50% or more.

3.33
Work and Income's information technology system, SWIFTT, records the "recommended incapacity duration". This is intended to alert case managers to the need to refer sickness beneficiaries to the regional health advisors or regional disability advisors because the duration recommended by the health practitioner exceeds that recommended in the Medical Disability Advisor. In addition, the standard case management reports available to case managers include a report that identifies the sickness beneficiaries in each case manager's portfolio who have exceeded the expected recovery period.

3.34
One of the regions that we visited was encouraging its case managers to actively manage this group of sickness beneficiaries. Case managers were asked to identify sickness beneficiaries who had been on the sickness benefit for 50% longer than the average time that it takes to recover from the condition. They would then refer these beneficiaries to the regional health advisor or regional disability advisor to confirm ongoing eligibility for the sickness benefit.

3.35
In this region, for the information provided to us for the period from October 2007 to November 2008, the regional health advisors and disability advisors were referring sickness beneficiaries to a designated doctor to confirm their ongoing eligibility for the sickness benefit where the duration exceeded the Medical Disability Advisor guidelines.

3.36
In another region we visited, during the same period case managers had referred 114 beneficiaries to the regional health advisors and regional disability advisors because the beneficiaries had exceeded the expected recovery time. Of this group, the advisors recommended that 66 sickness beneficiaries be referred to a designated doctor for a second opinion.

3.37
We did not see evidence of this type of systematic review in the other regions that we visited. Instead, referrals relied on the initiative of the individual case manager. In the sample of beneficiary records that we examined, we identified longer-term sickness beneficiaries who could usefully have been referred to a regional health advisor or regional disability advisor for review.

3.38
Some case managers referred applications to the regional health advisors and regional disability advisors based on information in the Medical Disability Advisor, but other case managers and other staff told us that this database was not widely used. They said that they did not have time to use it, or that it was not helpful. We understand that caution needs to be exercised in applying the recommended durations to the circumstances of individual beneficiaries. However, the tool did have some practical application. Regional health advisors and regional disability advisors sometimes used the Medical Disability Advisor when reviewing applications referred to them by case managers, and encouraged case managers to refer to it when assessing applications.

3.39
For beneficiaries with complex and longer-term conditions, we noted that vocational assessments provided information that helped to identify work opportunities that recognised the effect of the person's medical condition. In our view, more widespread use of vocational assessments would be useful. This view was supported by comments from the GPs who answered our questionnaire.

Referrals to regional health advisors and regional disability advisors

Regional health advisors and regional disability advisors were providing case managers with valuable support for complex applications, although their practices could be more consistent from region to region. In our view, the criteria for referrals should be broader so more sickness and invalids' beneficiaries can be referred.

3.40
The main groups of sickness and invalids' beneficiaries referred to the regional health advisors and regional disability advisors were:

• people applying for the invalid's benefit;
• people receiving the sickness benefit who, in the view of the health practitioner or case manager, might be eligible for the invalid's benefit; or
• invalids' beneficiaries who were due for their scheduled medical reassessment.

3.41
Policies for referring beneficiaries to regional health advisors and regional disability advisors were determined regionally rather than nationally.

3.42
Some regions encouraged case managers to refer any new application for an invalid's benefit or reassessments of an invalid's benefit to the regional health advisor or regional disability advisor before an invalid's benefit was granted. Two of the regions that we visited had been monitoring their case managers and randomly auditing applications to see that this was done.

3.43
As invalids' beneficiaries become due for their periodic medical reassessments, there will be an opportunity to review a growing proportion of this group. At the time of our audit, most of this group had not yet been reviewed. This was partly due to the different reassessment periods for invalids' beneficiaries (two years, five years, or never), and partly due to the short length of time that regional health advisors and regional disability advisors had been in place.

3.44
In our view, the limited scope of reviews to date also reflects the need for regions to consolidate and broaden their referral and review practices. The Ministry told us that an estimated 35% of all invalid's benefit applications or reassessments in the 12 months to April 2009 were referred to regional health advisors or regional disability advisors.

3.45
We noted initiatives to broaden the criteria for referring benefit applications to advisors for review, such as by the nature of their incapacity. In our view, the Ministry should consider further extending the criteria for review to take account of factors such as the person's benefit and work history, their personal circumstances, the nature of their incapacity, the length of time they have been on the benefit, and their age.

3.46
We encourage case managers to make better and more frequent use of regional health advisors and regional disability advisors.

3.47
In our view, the support that regional health advisors and regional disability advisors provided to case managers was valuable. The advisors were able to speak with the person's health practitioner to get more detailed information about the person's medical condition, work capacity, and prognosis. It also provided an opportunity for the advisor and health practitioner to discuss other services that could help the person.

3.48
The extent of the reviews carried out by the regional health advisors and regional disability advisors varied. Some advisors provided more advice than others. The contribution of these specialist advisors could be improved by promoting more consistent practice. Reviews carried out by regional health advisors and regional disability advisors would be most useful if they:

• included a discussion with the health practitioner to confirm eligibility by clarifying the nature of the medical condition, the prognosis, and the effect of the condition on the person's ability to work;
• identified work opportunities for which the person might be suited, given their circumstances and incapacity;
• assessed the person's health and other needs, and services that might meet their needs; and
• recommended to the case manager a plan for actively working with the person to help them in the community or help them move into work, as appropriate.