Bad Medicine

“Men will always be mad, and those who think they can cure them are the maddest of all.”

“Doctors put drugs of which they know little into bodies of which they know less for diseases of which they know nothing at all.”
― Voltaire

The College of Policing released a report in 2015 concerning an inquiry it arranged into the Injury on Duty process. This post will discuss how that report revealed issues concerning the Occupational Health clinicians who are used by forces in the role of ‘duly qualified medical practitioners‘ as required by the Regulations which govern police injury pensions.

Each of the quotes used below are excerpts from the College’s report.

Before I begin, I need to mention the structure of the College.

It is perhaps not quite the independent seat of learning and academic rigour which one might naturally expect of anything calling itself a ‘college’. It is currently a private limited company, with but one shareholder, who is the Home Secretary. It’s own web site tells us that,

‘As the College is currently a company limited by guarantee, as well as an Arm’s Length Body of the Home Office, all members of the Board are Company Directors. ‘

In plain language, the College is the Home Office pretending to be an academic institution.

Being arm’s length is a bit like the Mafia setting up apparently legitimate shell companies to launder its money and to give the appearance of respectability. With the Home Office it is not dirty money which needs to be laundered, but dirty, disrespectful ideas which seek to undermine the law of the land.

Just as the College is not quite what it would like us to think it is, much the same sort of misdirection applies to the odd little off-shoot of the medical profession known as Occupational Health.

By some self-publicising accounts Occupation Health is a, ‘multi-disciplinary approach to developing and ensuring compliance with safe working practices, and maintaining the health and well-being of those employed in a particular occupation or workplace’.

Phew. Quite a mouthful.  One has to wonder quite what that has to do with regards to administration of the Police Injury Benefit Regulations. Yet the situation is that forces have been persuaded to accept that any SMP must hold a minimum qualification in occupational health.

Occupational Health clinicians like to get people back to work, or help prevent them getting injured or ill in the first place. That is their raison d’etre. Notwithstanding that a police officer is not an employee (they are holders of office), once medically retired a former officer injured on duty is no longer employed in any sense of the word – they are retired via incapacity – so it is hard to see quite what value an occupational health clinician can bring to the area of police injury pensions.

Injury on Duty awards are governed by Regulations, which mention not a single word about duly qualified medical practitioners needing to have a qualification in occupational health. All that the Regulations require is the selected medic is actually qualified to practice – which means they must be registered with the GMC.

So, how is it that IOD pensioners are now faced with having to be assessed by medics whose chosen ‘specialisation’ has effectively removed most of them from the actual day-to-day practice of ‘real’ doctoring? The answer is that some few years ago, the now-defunct Police Negotiating Board, whose remit was to negotiate the details of pay and conditions for serving police officers, strangely decided to issue a joint circular, with the Home Office, in which it agreed that all ‘duly qualified medical practitioners’ who were to make decisions under the Regulations should hold a minimum qualification in occupational health.

The effect of this has been to narrow the pool of duly qualified medical practitioners who might work as ‘selected medical practitioners’ (SMPs) down from the approximately 236,000 doctors who are licensed to practice medicine in the UK, to a measly handful of doctors who have bothered to qualify for what most mainstream doctors regard as the utterly irrelevant specialisation of occupational health.

The small number of potential doctors who can be selected by a police pension authority has been further diminished by the interference of the National Attendance Management Forum which has seen fit to produce a list of doctors it claims ‘have shown an interest in’ working as SMPs. This is, of course, typical new-speak meaning that these doctors are the sort who are either gullible enough or corrupt enough to see the Regulations as no more than a general guide which can be ignored.

Disabled former officers have been powerless to prevent the erosion of the role of what was intended by the Regulations to be performed by independent, experienced medical professionals. Instead, they now face the prospect of the level of their pension income being in the dubious hands of doctors who are on the very bottom tier of the medical profession, and who have shown themselves to be variously incompetent, corrupt or ignorant of what the Regulations require of them.

IODPA has seen examples of SMPs knowing full well that a former officer is a 100% band 4 but still, with perverse logic, and directly contrary to the Regulations, give the retiree a figure of 85% in order to provide some forlorn future ‘hope’ of a recovery to the disabled person. Similarly, SMPs have looked to the future and speculated about what jobs a retiree may be able to do – thus completely missing the point that an assessment of degree of disablement is supposed to be based the extent the disabling effects of duty injury have – past tense – had on the individual’s capacity to work. In other perversions, SMPs ‘decide’ that an individual is, say, 50% disabled, only for some HR pen-pusher with no medical qualifications take a short list of wages which might be earned, compare them to either the former police salary earned, or some nominal figure plucked from the data on national earnings produced by the Office of National Statistics, and then – wait for it – take one from the other to determine a ‘degree of disablement’ then take the 50% off the resultant figure.

This sort of manipulation is without a doubt completely unlawful. IODPA gives fair warning to HR managers, SMPs and Chief Constables that this issue will be dealt with in the High Court in due course.

Given that considerable doubt has been cast on the professional competence of SMPs, on their independence, and on the unwarranted and illegal interference with their decisions by HR personnel, any reasonable police pension authority would cease the practice of wage comparison at once. Of course, we at IODPA know full well that police pension authorities will do what they always do and deny there is anything wrong.

Just as occupational health qualifications have no part to play in the role of SMP so is reason, common sense and decency absent from the small number of Chief Constables who continue to allow their wayward HR managers to abuse disabled former officers and stick two fingers up to the Regulations.

We need now to return to the inquiry which the College of Policing completed, to get a glimpse of the full, disturbing picture of the shambles that is the administration of police injury pensions.

Shockingly, the College admits that that some forces take delight in the subversion of the Regulatory process by influencing the SMP. Moreover some SMPs take delight in being influenced to do the subversion – what better way to keep the paymaster happy!

In the event of incidents of force subversion of the regulatory process, considering SMPs are on the whole employees of occupational health providers working under contract with the force, there is a clear conflict of interest for the companies in question in the event that a SMP raised concerns. – paragraph 19.10

That is no surprise to us. Add together a force willing to subvert a lawful process with a SMP whose occupational health mindset is such that they only sees their role as being to get someone back to work and you have a rather a monstrous double-sided conflict of interest.

The College reveals there is little attraction in working as a SMP.

In addition to this there is a general perception articulated by a number of clinicians who engage with this review that the police service is not a desirable employer. At the heart of this issue appears to be concerns over vulnerability to baseless complaints, or threats of complaints, by officers or former officers, to the GMC in order to obtain more favourable pension settlements. Other SMPs report perceived pressure from management to obstruct the process and influence decisions – paragraph 19.7

It is the involvement of and bastardisation of ‘guidance’ by the National Attendance Management Forum, and the fact that it has produced a list of doctors, and companies providing doctors who are willing to act as SMPs that has meant a small pool of lowly occupational health clinicians now have a monopoly. The NAMF has its set list of preferred SMPs – a list that, we repeat, has had the consequence of further stifling the available pool of competent clinicians. SMPs are now given work just because they have been working as SMPs and not because their judgements are sound.

Otherwise excellent doctors are either barred from becoming SMPs or see the role as beneath them, and dangerous to their professional reputation to boot.

Many forces are experiencing increasing difficulty in identifying suitable doctors to perform this role. The role of the SMP is a specialist one and at the time of writing the available resource is limited. Historically, when the relevant regulations were written, many SMPs worked as Force Medical Advisors (FMA) in other forces. However ongoing changes to occupational health delivery has resulted in the vast majority of forces now obtaining clinicians from private companies with no prior background of the police service.- paragraph 19.3

 

One of the problems relating to the difficulties in obtaining suitable doctors as SMPs is cost. Whilst SMPs can represent a significant cost resource to Forces, SMP work is relatively poorly paid compared to other roles clinicians can obtain both in the field of occupational medicine and in the private sector. In addition to this, the General Medical Council (GMC), in their 2014 edition of our annual ‘state of medical education and practice’ report, recognises the decline in the number of doctors choosing to go into occupational medicine and reports that occupational health has more doctors aged over 50 than any other speciality. – paragraph 19.5

On one hand the College is saying there is a shortage of SMPs and on another they say they are underpaid. Market forces do not work this way. A rare resource can charge an inflated amount; what the College fails to report is that a cabal of SMPs have a monopoly and all the available work is taken by a small number of well-paid ‘guns for hire’.  We know, for example, of one SMP who was paid over £45,000 for conducting fewer than a dozen reviews. These ‘established’ names suffocate competition and prevent new blood from entering the profession.

We have to also comment that it seems the College is saying that becoming a SMP is really the last chance saloon for occupational health clinicians who have failed to make a living elsewhere.

The situation, according to the College, is that these rather pathetic failures are thrown in the deep end when they take on the role of SMP.

There is at present no recognised training or qualification for Force Medical Advisors (FMA) attempting to manage these complex issues, or for SMPs, who must make statutory, quasi-judicial decisions.- paragraph 15.3

It is not the Regulations which are complex. In fact, as statutory instruments go, they are concise and clear. The esoteric fog only exists because the police pension authorities have, in the words of the College, repeatedly attempted to subvert the process. It has fallen to the judiciary to undo the damage the Home Office and individual forces inflict on the Regulation’s interpretation.

Perhaps the raw truth is more like the College has heard forces moan to them that they are finding it difficult to undermine the Regulations. That, having dreamed up a cunning plan to control the supply of doctors who can act in the role of SMP, some forces now find they have contracted people who are so useless as to not even be capable of perverting the Regulations convincingly.

The PNB guidance states that in order to perform the role of a SMP a doctor must be competently trained to effectively assess a police officer’s medical condition and disability. However the role of the SMP also requires them to understanding the complex regulations and case law and make arbitrations on evidence. These requirements lie outside the normal skill set of a professional clinician and are more associated with the role of a legal professional. – paragraph 15.4

Again the College is seeking to excuse the poor administration of Injury Awards by repeatedly proclaiming that the Regulations are complex – conveniently forgetting that it is those who administer the Regulations who have forced the wealth of case law into existence as a result of their inability to do things right.

Any competent holder of a medical degree will take huge offence at the College’s assertion that making decisions based on arbitrations of evidence is beyond their skill-set. Given the regulatory demands of any aspect of the medical profession such understanding is surely a core skill.

To date there are limited training opportunities available and no centrally accredited SMP qualification. Individual SMPs are therefore reliant on their experience of the work, personal endeavour and any ad hoc training they have been given by their employers. – paragraph 15.5

The Regulations in their current form have been in existence since 1987. Almost 30 years have passed and the College brazenly declares that there is still no gold-standard to measure the competency of a SMP.

Again the College conveniently forgets that the current chaos of poor and shady SMPs had its birth in Home Office circular 46/2004 which contained guidance from the Home Office which was an unlawful carte blanche attack on the Regulations. It took a courageous IOD pensioner to drag the Home Office to the very door of the High Court before the Home Office caved in and accepted the guidance was unlawful and agreed to withdraw it.

The guidance has been erased but the perversions of the Regulations continue, with some forces inventing ever more complex ways of manipulation so as to produce decisions which reduce the amount of pension paid.

It is no wonder that even decent SMPs are hopelessly confused or find their genuine efforts to apply the Regulations properly are frustrated.

The review has found little to no evidence of the private companies who are contracted by forces to provide both occupational health provisions and SMPs providing formal training for SMPs. Furthermore it is questionable whether consideration of training was included in tendering when obtaining SMPs through occupational health companies. – paragraph 15.9

Even the business school mantra of, ‘If in doubt outsource it’ is called into question by the College. By hiring a company to provide a SMP a police pension authority will lose any in-house experience but at least they can blame a private company when it all goes wrong. Or not. The private companies become bigger and bigger and as they do so they become less fit for purpose. The College fails to address why all this public money is given to occupational health companies who fail to evidence competency in the tendering process.

So, where is all this going? What actually lays behind the Home Office encouraging the College to make its enquiry? Why is the Home Office apparently content so see exposed so many failures by forces, their HR departments and SMPs?

Bear in mind when pondering this apparent own goal that the College is an arm’s length body of the Home Office. The College is the Home Office.

The report contains a blatant clue as to what the Home Office hopes to achieve. It raises the spectre of complaints against SMPs and it puts forward the suggestion that, when performing their roles under the Regulations, SMPs should have immunity from GMC standards.

It is noted that in separate correspondence to the Home Office representations have been made to suggest judicial exclusion for the role of the SMP. Furthermore legal opinion obtained as part of this review suggests that a medical authority appointed under the Regulations may be covered by the doctrine of
judicial privilege.- paragraph 19.2

Who made these ‘representations’ and what motivated them being made? It is an astounding suggestion – that doctors which the Regulations require do nothing more complicated or demanding than make independent medical assessments and decisions should need to be elevated to the status of a Crown Court Judge.

This immunity is contrary to the guidance of the GMC who state …

.

The first duty of a doctor registered with the GMC is to
make the care of their patient their first concern. The
term ‘patient’ in this guidance also refers to employees,
clients, athletes and anyone else whose personal
information you hold or have access to, whether or not
you care for them in a traditional therapeutic
relationship. – Section 2

A SMP is always a medical doctor first and therefore is answerable to the GMC. Under the Regulations their role is primarily medical in nature and purpose. A SMP must comply with the Regulations. Yes, decisions a SMP makes form part of a quasi-judicial process, but the College is in error when it suggests the SMP should become a judicial figure, for that element and responsibility is already present and rests with the office of police pension authority.

The report is nothing more that a sham. It is not the independent, impartial, academically rigorous enquiry it purports to be. As a dissertation it would be torn apart, for its entire purpose is to provide support for an idea. It is an exercise in propaganda.

Appendix D of the report contains the ugly truth of the Home Office’s purpose. The Home Office likes appendices. It was appendix C to Home Office circular 46/2004 which tried to encourage forces to act unlawfully. Here we have yet another appendix intent on much the same objective.

Appendix D offers a vision of a future arrangement when Regional Centres manage all aspects of the administration of injury awards. Forces, and SMPs, will completely lose the independence of thought and action which the Regulations are intended to ensure. The Home Office will have recreated the infamous Volksgerichtshof, the ‘people’s courts’ of the Third Reich, which were intended to provide that regime with an apparently lawful way of side-stepping the inconvenience of an independent judiciary.

Various benefits to such an arrangement are touted, but the plain truth is that if regional centres are created then they will be controlled entirely by the Home Office, no doubt through another shell company – sorry, an arm’s length body – which will ensure that all doctors hired as SMPs are compliant, corrupt and whose purpose will be to subvert the Regulations to the very great detriment of the brave men and women who were disabled in the line of duty.