THE ASSESSMENT OF RESIDUAL CAPACITY FOR WORK: EASIER SAID THAN DONE.

• Author: Duncan, Grant

BACKGROUND

As part of a programme to reduce the numbers of people receiving invalids' and sickness benefits and ACC weekly compensation, government has begun to introduce the concept of work-capacity assessment. A 1995 review of sickness and invalids' benefits led to a tightening of medical assessment criteria and procedures, including the use of "designated doctors". The public discussion of systems which would move beneficiaries from welfare and into work began in earnest in 1997 with the "Beyond Dependency" Conference. Later that year, ACC introduced its work-capacity assessment process, and then the May 1998 Budget proposed such assessments for income support beneficiaries. Under the new income support rules, the obligations to seek and participate in work may be "deferred" if the beneficiary's capacity for work is limited by sickness, injury or disability; and eligibility to the invalids' benefit is to be based on assessment of a permanent restriction in capacity for work (i.e., the applicant must be unable to work for 15 hours or more per week in open employment). This implies a system of work-capacity assessment to be applied to beneficiaries with disabilities. The main objective is to assess cost-effectively how many hours a beneficiary can reasonably be expected to work, within categories of less than 15 hours, 15 to 29 hours, and 30 or more hours per week.

The objective of this article is to examine the technical and practical issues surrounding work-capacity assessment. At the time of writing, the Departments of Labour and Social Welfare had begun development of a work-capacity assessment procedure for those on invalids' and sickness benefits. The ACC has already implemented a work-capacity assessment, however, and it is this latter model which will be used to raise some relevant technical issues. Cabinet minutes (30 March 1998) note that "the assessment processes for sickness and invalids beneficiaries will be consistent with those used by ARCIC [ACC], but will be more complex because of the more diverse range of physical and mental impairments involved." Hence, anything that may be learned from observing ACC's work-capacity assessment procedure may begin to have a wider relevance.

WHAT IS WORK-CAPACITY ASSESSMENT?

Work-capacity assessment occurs in a number of forms. Fitness for a specific job is frequently tested to ensure that a prospective employee, or an employee who has been absent due to illness or injury, can satisfactorily perform employment tasks without danger to their own or others' safety and health. Or, work-capacity assessment may consist of a physician certifying that a person is ill and is thus incapacitated for work, at least temporarily. Strictly speaking, the latter is a medical prescription to rest: that is, not to work. At the most common and informal level, a physician may write out a medical certificate for a sick employee to establish a right to leave from paid employment. Normally, the illness is self-limiting, and the employee returns to work within a fairly predictable period of time. These are decisions about patient care that, although inherently uncertain, are a part of a role for which physicians are well equipped.

In cases of more serious illness or injury, the patient may become eligible for a wage-replacement benefit (be it funded by the State or by private insurance). Once again, the physician is appealed to not only to testify to the existence of an anatomical, physiological or psychological impairment, but also to certify that this impairment and its treatment will necessitate further time off work. Suitable medical evidence will normally suffice for the payment of benefits, and in some cases a second medical opinion is sought.

So far, these examples relate to the question of an individual's fitness for prospective or existing employment. The match between the person, the job tasks, the physical and psychological demands of those tasks, and the nature of the work environment can be considered in detail if necessary. But what if the incapacitated person has no immediate employment to return to, and thus there may exist only the possibility of employment in some class of occupations or in a "notional" and unspecified job?

If the sick or injured person remains reliant on wage-replacement benefits for a prolonged period, it is likely that the State or the insurer will want to revisit the question of whether the beneficiary remains incapacitated for work. If there is no job to return to, an "open-ended" assessment may be required. Once again, this is often taken care of by appeal to medical judgement. The personal physician may be asked to renew medical certificates at regular intervals; or a specialist second opinion may be sought to ascertain whether the injury or illness has resolved itself successfully, and whether there remain any clinical reasons for continued disability support. Such clinical, impairment-driven assessments of work-capacity are, as will be discussed below, quite problematic. The competing interests of patients, advocates, insurers and government can compromise the independence of clinicians, and difficulties can be created "when the clinician is called on to pronounce on medical certainty in situations which medically are inherently uncertain" (Menard and Hoens 1994:251).

But the medical model is not the only approach. An alternative is to assess the person's actual or potential functioning, in terms of physical capacities (measured by, say, cardiovascular fitness, clinical dynamometry or computerised work simulation), or actual engagement in, say, activities of daily living, social relationships, employment, etc. Hence, we must distinguish between clinical and functional assessments.

The main subject of this article is the implementation of formalised procedures that seek to obtain "objective" assessments of a disabled beneficiary's residual capacity or fitness to perform past, or any other, work. Where an individual is judged to have a capacity for work, his or her entitlement to welfare benefits may be redefined, even in the absence of a job against which to match the person's functional capacity. For example, a person on invalids' benefit may be found fit for work. If unsuccessful in seeking paid work, the beneficiary -- being now expected at least to be training for or seeking work -- may be reclassified as "unemployed" and hence transferred to the unemployment benefit, now termed the "community wage".

In summary, then, this article is concerned with the work-capacity assessment of those who are receiving income support from the State by reason of sickness, injury or disability. The terms "disability" and "person with a disability" will be used inclusively to cover this.

IMPAIRMENT AND DISABILITY

In general, in order to legitimate the sick-role and time off work, society relies on members of the medical profession to certify the existence of an impairment. According to the WHO, an impairment is "any loss or abnormality of psychological, physiological, or anatomical structure or function" (WHO 1980, cited in Fraser 1992:6). For many practical purposes, it is assumed that the medical certification of the existence of an impairment suffices for a judgement of disability (that is, "any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being") and also of handicap ("a disadvantage for a given individual, resulting from an impairment or a disability, that limits or prevents the fulfilment of a role that is normal ... for that individual" (ibid.:6)). Such a reliance on clinical assessment to determine either disability or capacity for an occupation, however, has significant limitations. Disability and handicap (and hence work-capacity) are relative to norms for the individual in his or her social-environmental context. They are therefore a factor of relationships between the person and the physical and social environment. The perception and definition of disability is socially constructed, depending on current norms and values, and cannot be reduced solely to technical, medical diagnoses of impairment. Moreover, some of the behaviours characteristic of the "sick-role" are learned behaviours, and may be reinforced in response to environmental contingencies.

CLINICAL ASSESSMENT

In the context of judgements about capacity for work, the medical observation of impairments is often relied upon to make inferences about disabilities. And frequently such inferences are uncontroversial. A bout of influenza or cancer chemotherapy may render one incapable of a range of normal activities -- a range wide enough to excuse people from work with little question.

With regard to the clinical assessment of residual work-capacity for those already on welfare, the picture is more complex. The concern is with the degree of improvement and stabilisation of the illness or injury over the longer term and with the extent of recovery of functional capacity -- or, alternatively, with the person's success in adapting to and mastering the effects of a permanent disability. Medical opinions of work-capacity may have to be made in the absence of any actual job to which the beneficiary can be matched. Nonetheless, it is most likely that the fitness-for-work decision is to be based on whether the medical practitioner can certify that impairment A does not prevent the claimant from safely performing the tasks considered necessary for occupation B. The medical assessor, however, will be limited to a more open-ended assessment with little opportunity to recommend workplace-specific modifications or restrictions -- unless there is some form of assessment taking into account actual functioning. Moreover, "functional assessment of the individual's capacities will be of most use when as much is known about the job as about the individual assessed" (Cox and Edwards...