Benefits Agency Medical Services/All Work Test
(BAMS/AWT)

Briefing for Labour MPs

Written by Keith Rushworth. November 1997

Introduction

Much of what is written here relates specifically to M.E. because this is an area I am aware of. However BAMS/AWT causes widespread suffering across a wide range of disabled people - it does not adequately take account of fatigue, or pain, or fluctuating conditions, or mental illness. At least one of these factors probably plays a part in the majority of disabling conditions. Far better than what I have written here, I recommend to you the National Association of Citizens Advice Bureau report "An Unfit Test" published in March of this year. For anyone with a concern for the disabled this is essential reading.

The Test Itself

The All Work Test procedure begins with a 20 page form (IB50) which BAMS send to disabled people. Most of this form is completed by ticking boxes. The questions are mostly unanswerable for people who have a fluctuating fatigue problem, which is precisely what M.E. is. Questions like: "Can you pick up a 5lb bag of potatoes?" or "Can you walk up a flight of 12 steps?". The form does give huge spaces for people to explain what effect it might have on them if they do these things, but it is often impossible for a patient to quantify the tendency to relapse caused by picking up one 5lb bag of potatoes or even by walking, once, up a flight of 12 steps. The form , in essence, is a minefield, with the sufferer put in the horrendous position of needing to write a virtual Medical Thesis on M.E. (Most Doctors could not do this).

If the patient writes explanatory comments on the form beside the boxes without ticking them, the form is promptly returned with a letter saying "Tick all the boxes or your benefit will be withdrawn"

Sometime after filling in the form, and seemingly without any regard to what has been written in it, the patient will be called up for a medical examination. Again, in the case of somebody with M.E., this is an absurdity since it has no physical signs. The tests which the doctors carry out are without meaning because there is no definitive test which will distinguish a person who has the illness from one who does not. In fact the diagnosis of M.E. is very difficult and could never meaningfully be made in a twenty minute examination. The person who must diagnose M.E. is the patient's GP, who knows the patient well, who has their whole medical history to hand and will have seen the patient on many occasions, and have observed the progress of the illness. If a GP is satisfied, with all their wide medical experience and their intimate knowledge of the patient, that the patient suffers from M.E., that is as definitive as you can get. The previous system relied on "Sick Notes" or Certificates written by GPs - No Sick Note, No benefit. That could be extremely harsh on patients whose GPs did not believe in M.E., but such Doctors are happily a decreasing minority, and it would be hard to formulate a fairer system. (Patients still had to pass additional examinations with a D.S.S. Doctor.)

The Tests are almost continuous

The BAMS procedure for the 'all-work' test tends to take many months, perhaps as many as six, from the sending of the initial form to the point when the patient knows the BAMS decision. Recall for a further test may then well take place in only another six months. This means that M.E. patients may spend something like half their lives under the BAMS microscope. There is no end to the testing unless the person is thrown off benefit.

The Points System

The reason for BAMS obsessive insistence on people placing ticks in boxes is that they assess a person's fitness for work according to a points system. Each particular difficulty will have a corresponding points score and if all the points add up to 15 then that person is considered unfit for work. When the test was introduced the Government promised that fatigue would be fully taken into account in the test. However fatigue does not get any points at all. Nor does pain. Since introduction the large numbers of patients being thrown off Incapacity Benefit proves that fatigue and other factors are not properly taken into account. Although Government estimation of overall benefits fraud tends to hover around the 2% mark, throw-offs from Incapacity Benefit have hit 27%. Most have their benefit restored on appeal, but the appeal system is clogged with tens of thousands of extra people, some forced to wait up to a year. This not only causes widespread suffering but is a ridiculous waste of money.

"Fit for work" and "Employable" are Not the Same

Under the all work test a person with good management skills and no legs scores 15 points, making them "unfit for work". But such a person might find rewarding and well-paid employment. The same person with legs but no energy (chronic fatigue) would score zero points on the test and therefore be found "fit for work", but would be quite unemployable. In a nutshell "fit for work" according to the all work test and true employability are totally different concepts, and the gap between them leaves disabled people in the wilderness between work and benefit.

Slander against Disabled People

In calling people for this test again and again, BAMS are making the assumption that anybody who may in some miraculous way get well will not go back to work. Why do they make this assumption? What evidence do they have that disabled people, if they get well, will not return to work? In fact, the evidence relating to people with Chronic Fatigue is that they are hard-working, high achieving, caring people. M.E. rarely seems to strike people who take life easy. In view of this it is fairly clear that anybody who has had M.E. and who has recovered sufficiently, to return to an active life, and to work, will do so with great joy and at high speed. For BAMS to say that patients with M.E. and other semi-invisible disabilities must be called up repeatedly, to see if they have become capable of worry but are deliberately avoiding it, is a gross slander on these people.

M.E. is incurable: patients should not be called up

M.E./C.F.S. is an illness that has no known cure. There are many people who tout one cure or another, but nothing has yet been proved, and nobody can produce quantities of people who did have Chronic Fatigue in the past, for several years, and who have now recovered and are able to work again. This means that Chronic Fatigue Syndrome is fundamentally an incurable illness. What the BAMS 'all-work' test seeks to do is to discover if people have been cured of their illness. It is completely irrational to be constantly testing people to see if they have been cured of an incurable illness.

Stress and M.E.

One of the horrors of the BAMS examinations is the stress that they cause in M.E. sufferers. Few people understand that the impact of stress on an M.E. sufferer is far greater than it is on a healthy person. A significant stress, without any physical exertion whatever, can easily promote a major relapse. Living with the threat of BAMS is therefore much worse for an M.E. patient than for a healthy person living even with the threat of redundancy.

How easy is it to change this system

Some people have claimed that the system cannot be changed without a new Act of Parliament. However it appears that there are many ways that the system could be ameliorated short of that. Firstly there are guidelines given by the D.S.S. to Benefits Agency Medical Services on how patients are dealt with. So the precise way in which any individual is dealt with is not always a matter of Statute law. To take one example, people may be re-called for a BAMS medical anything from 3 months to 18 months after having had one. If people were re-called after 18 months rather than 3 or 6, this would save a considerable amount of stress on sufferers and relatives.

Secondly, and more significantly, the guidelines for call-ups vary from one medical condition to another. It would not be difficult to change the guidelines for M.E. patients, even to the extent that they are not called at all. This would be humane and sensible, especially where a patient has already been through the test one or more times.

Further Information

More addresses and phone numbers

The following suggestions to improve matters have been made to Harriet Harman in a letter sent on 4th November 1997

1. An immediate announcement of a latest date for the scrapping of BAMS and the All Work Test. A commitment to return to the former system of checks, or another which is not less fair than that system.
2. As a matter of urgency, halt and abandon the BAMS privatisation procedure, which is now almost complete.
3. Make a commitment to retain the existing Independent Appeals Body, which is currently under serious threat.
4. A short (and urgent) piece of legislation, as was used last year to toughen the IB50 question on altered states of consciousness, to give points for fatigue and other factors. This will need to follow a comprehensive but brief consultation exercise with recognised disability groups.
5. Renegotiate terms of employment with Adjudication Officers (A.O.s) to remove Performance Related Pay. Provide A.O.s with the same advice given under the former system (D.S.S. Disability Handbook, 1992, Section Two, entitled "Presentation of Disability").
6. Remove all targets, quotas, predictions and expectations for benefit cut-offs from BAMS. The only target must be for 100% fair and just decisions.
7. An immediate amnesty - that is, the effective granting of appeals - to all people who have been in the appeals system for (say) two months or longer.
8. Through advice to BAMS Doctors, stop frequent recalls for the Test for people who have long-term illnesses.
9. M.E. to be added to the list of Potentially Exempt Diagnoses.
10. Stop recalling people who have won appeals.
11. Stop recalling people whose Hospital Consultants confirm their lack of fitness to work.
12. Begin immediately to reduce the size of BAMS, at least by natural wastage, spending the money saved on Doctors and other staff for the Health Service.
13. Increase time allotment which BAMS doctors have to complete a patient review, medical examination and report, from the present 50 minutes to 90 minutes, in line with BMA stated requirement.

Note on point 12.
In order to introduce BAMS and the AWT, the Benefits Agency employed an additional 800 Doctors. Additional operating costs compared to the former system of checks on disabled people were £150 million in the first year.

Further Problems for M.E./C.F.S patients - Treatments and Research.

The mistreatment of people with M.E. by BAMS/AWT does not occur in a vacuum, but within a culture of denigration of the illness and those affected by it. At the root of this lies a suppression of the facts relating to the physical nature of the illness, and attempts to promote psychological explanations instead. Sufferers are incensed by this, not because of the stigma which still attaches itself to mental illness, but because wrong understandings lead to :

1. Inappropriate, useless, or even damaging treatments.
2. Inappropriate, useless and wasted Research Funding.

The evidence for M.E. being primarily a problem of persistent viral infection is very strong. (Secondarily, as with Gulf War Syndrome and Sheep-dip Syndrome, organo-phosphates are, from current knowledge, the most likely agents). The viruses most likely to be responsible are closely related to Polio, and are called Coxsackie viruses, following an epidemic in a U.S. town of that name. Epstein-Barr virus is also likely to be implicated.

The best viral research in this country is probably carried out by, or in association with, the Persistent Virus Disease Research Foundation. The Research Committee of this organisation consists of eminent men, six Professors and five Doctors, but so far as I am aware it has attracted no Government Research funding at all. What has attracted funding is psychiatric research, which has no more relevance to M.E. than to Polio.

The treatments promoted by psychiatrists include "Cognitive Behaviour Therapy" and "Graded Exercise". Such treatments are being used on M.E. patients with only the merest fraction of the testing which a new drug would have to pass. These techniques may involve forced exercise or activity, which classically brings about relapse.

In view of the impact on both treatment and research of the 'psychological model', a major concern of M.E. patients is the Royal Colleges Report on M.E. The Report was produced by a panel packed with psychiatrists, and hence endorses the psychological model. Many M.E. patients are currently campaigning for the withdrawal of this Report, and would appreciate MPs' support. They would also like to see some real research money going into M.E. Half a million pounds has just been awarded for teenage acne research; it cannot be right for M.E. to receive only a few thousands, and that going mainly to psychiatrists.

There is much scope for beneficial Government action here with little or no Parliamentary time and at very little cost in terms of overall health budgets.