Vol. 428 No. 3
6 Mr. J. O'Keeffe asked the Minister for Social Welfare his views on whether those in receipt of disability benefit are given adequate medical examinations before being disqualified from benefit on the grounds that they are fit for work, and on whether there should be greater liaison with their GPs and consultants, whose findings are very often at variance with those of the medical referees.
Medical referees provide advice, by way of a second opinion to that of the client's own doctor, which assists deciding officers and the independent social welfare appeals officers in determining claims.
Clients who claim disability benefit are likely to be called for examination by a medical referee. Cases are selected for referral on the basis of the initial certified cause of incapacity. For example, a client certified as being incapable of work due to influenza for more than a few weeks may be called for a review relatively quickly.
When a medical referee examination is arranged, the client's doctor is notified and invited to be present. The doctor is also requested to furnish a report on the medical history and present condition of the client, including reference to any recent examinations by consultants, in order to assist the medical referee in considering the case. Any consultants' reports submitted are carefully considered.
At the examination, the medical referee establishes the client's past history of medical illnesses and of his or her current complaint. The medical referee then tries to determine whether the client is suffering from the illness as certified by their own doctor to a degree that makes the client incapable of work.
In cases where the certified cause of incapacity is not confirmed, the medical referee carries out a full clinical examination. This involves examining the client's heart, lungs, central nervous system, blood pressure and, if relevant, urine analysis. The purpose of these tests is to determine whether the client could be incapable of work by reason of some other illness.
Where a medical referee is of the opinion that the nature of the client's illness does not render him or her unfit for work, the case is reviewed by the medical adviser. A deciding officer then decides the question of entitlement to benefit. Where the deciding officer decides that the conditions for receipt of benefit are not satisfied the person concerned is informed in writing and is advised of the right to appeal.
Where an appeal is lodged, that is in about 10 per cent of all cases for which examinations are arranged, a second medical referee examination is arranged. The second examination is conducted by a different medical referee and the client's doctor is again invited to be present and to submit any additional information and reports. An appeals officer may, if he considers it necessary, request a further report from an independent consultant to assist him in determining the client's entitlement to benefit.
The medical referee system works well and specific liaison arrangements are built into the administrative procedures. As the Deputy can see, the client's own doctor is invited to be present at each examination and to submit medical opinions for consideration by the deciding officer. The arrangements are kept under review to ensure that clients' needs are met. If the Deputy has a particular situation he has come across I will be glad to have it examined.
Like most Deputies, I have received representations about the most bizarre decisions made by medical referees. In one case which arose last year the notification that a person was fit for work had to be redirected from his home to the intensive care unit of Cork Regional Hospital. In another case an appeal had to be postponed because the girl in question was undergoing an operation on the day the appeal was to be heard. I suggest to the Minister that he may be adopting a rather smug attitude to what is a serious problem and that while there is a need to weed out phoney claims genuine people are being badly treated under the system. In many cases decisions are being made, after a cursory examination, that people are fit to work, which decisions are entirely contrary to the views of their doctors.
I have to remind the Deputy that we must proceed by way of supplementary questions at this time, and avoid making statements.
The system is based on the decisions made by professional medical people and provides for two sets of appeals. There will always be cases which give rise to a difference of opinion and cases where someone may not give full information to the medical referee, particularly to the first medical referee. As the Deputy will know from his experience — I know this from my experience — people may not give their full medical history to the first medical referee. The Department of Social Welfare provides for appeal to two medical referees and a separate administrative appeal at the end of that process. That is a good system and it works well, but it will not deal with every case. Exceptions will arise from time to time but by and large the system will respond to these if they are brought to the attention of the relevant people.
May I ask the Minister to follow up on his offer to review the system and, above all, to listen to the experiences of his colleagues in this House who have had to make representations on behalf of their constituents? I am not only referring to his colleagues on this side of the House; I am sure some of his colleagues on the other side of the House have had representations made to them in regard to similar cases. I ask the Minister to conduct a review so that decent people who are being subjected to extra stress and pressure can have their cases for disability dealt with in a fairer system.
It would be difficult to have a fairer system, but I accept that some people may find it stressful to be called before a medical referee. In some cases, people do not explain their position properly to the medical referee. That is the type of case I have come across. It is very easy for Deputies and me to present individual cases, but the system has to cater for hundreds of thousands of people. The system is based on the best medical evidence available at the time. Medical referees are there for that purpose. There is also the right of appeal to a second medical referee and, apart altogether from that, an administrative appeal. When cases are brought to the attention of the Department by Deputies on behalf of their constituents we intervene again to try to ensure that no relevant points are missed. In that sense, it is a good system. I am always concerned to ensure that the system works well and that the people who are administering it are giving people the time and attention required. I will take the points made by the Deputy in this respect into consideration.
(Carlow-Kilkenny): Would the Minister not accept that the present system is an anachronism in this day and age in that a person who may have to undergo treatment by a leading specialist, who has at his disposal the best equipment the Department of Health can afford to make available, can be examined visually across a table by a medical expert with a little travel bag of tricks? It is time we faced up to the reality that such a system cannot give fair play to anyone. Regardless of the points made by the Minister about how good it is, the system should be abolished immediately because it cannot give fair play to anyone. For example, a decision could be made against somebody who has back trouble if there is no backup specialist expertise available. A medical referee——
Brief questions, please.
(Carlow-Kilkenny): It is ridiculous that a person who has been told by a specialist that there is no hope for him, so to speak, can be told by someone sitting across the table from him that he is fit for work.
Is leor sin, a Theachta.
People are advised to bring with them to the appeal any specialist or consultant advice they have received.
(Carlow-Kilkenny): It will be ignored.
It is not ignored; that is not a fair comment.
(Carlow-Kilkenny): It is a fair comment.
In the case of people who suffer from back trouble, great arguments can arise, and they will probably always arise. For example, some people who are working in this House full time have very serious back problems, and the Deputy is looking at one of them now.
Join the club.
(Carlow-Kilkenny): I should not have given back trouble as an example.
I have no problem showing the pain I am in at any time. This is one of the difficult areas which have to be dealt with; it is a contentious area. The question of whether one is suffering from stress is also contentious — even specialists will have different opinions on whether one is suffering from stress. The system as a whole is reasonable and it is up to us to ensure that it works properly. As I said to Deputy O'Keeffe, I will look again at the operation of the system.
Would the Minister not agree that in many cases people feel intimidated and degraded when they come before a medical referee? Does the Minister carry out any analysis or monitor the performance of medical referees? Does he accept that disability benefit recipients are at a serious disadvantage at this stage in that they find it almost impossible to get consultants' reports on their condition due to the three and four year waiting lists?
By and large disability benefit is paid to people who cannot attend work for a certain period. I know that in Ireland some people have been on disability benefit for six, eight, ten or 18 years. One will not find similar cases in any other country in Europe. Such people should be on invalidity pension but, as the House knows, this benefit is taxable. In view of the fact that disability benefit will shortly be taxable I am sure some people will move from disability benefit to invalidity benefit. We know that this anomaly has existed for a long time — many people who at regular intervals qualify for disability benefit should properly be receiving invalidity benefit. As the Deputy will know from the Social Welfare Bill, 1993, I am introducing a provision which will enable invalidity pension to be granted to people earlier, for example, in cases where a person has a serious life threatening or obvious illness. It will be possible in future to draw up regulations covering these people. Such regulations will not be ready tomorrow, but they will be drawn up. This is a slightly complicated area and, as Members have often said, it should be possible to decide in less than a year that people in a certain category should go straight on to invalidity pension. Regulations in this regard will be drawn up, and these will cover some of the people to whom the Deputy has referred.
What are the qualifications of these medical referees? It seems ludicrous that a person who is deemed unfit for work by a senior consultant is, after a cursory examination, deemed fit for work by a medical referee. Are these men medical diviners? What sort of superior qualifications do they have?
Since the Deputy is a legal person, I am sure he knows that doctors differ from time to time, just as legal people do. Medical referees must have at least six year's satisfactory experience in the practice of medicine since registration or provisional registration, as the case may be. In addition, they are supposed to have requisite knowledge. The appointments are made by the Civil Service Commission, who are totally independent.
Are they Civil Service doctors?
Sometimes they are not very civil.
Among the medical referees there is a consultant physician.
I know him and I exempt him from my remarks. He is the exception that breaks the rule.
Because he is a friend of Deputy O'Keeffe, he would never make one of those decisions. He is probably a Corkman.
He is.
There is a consultant occupational physician and a doctor with a master's degree in psychotherapy. There are also 11 referees who are members of the Society of Occupational Medicine. Two medical referees hold diplomas in occupational health and another is currently studying for that diploma. One medical referee is a member of the Royal Academy of Medicine. Most of the medical referees have been senior house officers and registrars and some have worked at junior consultant level. They are well qualified.
