Chapter 3

Issues with individual impairment tables

3.1        During the inquiry, some submitters expressed concerns regarding certain impairment tables and their application to some disabilities and conditions.

3.2        The National Council on Intellectual Disability (NCID) raised specific concerns regarding the draft revised impairment table for intellectual function.[1] NCID was 'appalled at the lack of professional care in the development of the revised DSP impairment tables' and stated:

With due respect to the advisory committee and associated consultants who assisted the Commonwealth to develop the revised Tables, the Table on Intellectual Function,

• lacks coherence with international definitions and assessments of intellectual function,
• lacks consistency with the World Health Organisations’ International Classification of Functioning, Disability and Health (ICF),
• lacks coherence with the Commonwealth’s Guide to Social Security Law for manifest (DSP) qualification,
• lacks any valid testing with people with intellectual disability and the general population to determine the validity and impact of the Table, and
• lacks standardisation and clarity within the Table itself.[2]

3.3        Using the draft revised impairment tables, NCID conducted their own testing 'on people with an intellectual disability, who have an IQ score of 70 to 79, and currently receive the DSP'.[3] People with an IQ in this have 'cognitive impairment...not significant enough to meet the criteria for intellectual disability in terms of the international definitions, but some of them may have poor community functioning'.[4]

3.4        NCID was also concerned about the application of the draft revised impairment tables on people with a manifest intellectual disability. NCID felt the draft revised impairment tables did not make clear whether they would apply to people manifestly qualified for DSP.[5]

3.5        At the public hearing on 6 September 2011, Mr Mark Pattison, Executive Director, NCID advised the committee that the issue with respect to people with a manifest intellectual disability had been resolved:

We have since undertaken a process with FaHCSIA to address our concerns and, as a result, they have agreed to some changes or amendments to the introduction of the table.

We have clarified that people with an IQ score of less than 70 will continue to be manifestly qualified for the DSP and will not be subject to the tables.[6]

3.6        NCID was, however, still in negotiation with FaHCSIA about the table for intellectual function and its application to people with an IQ between 70 and 79. Mr Pattison praised FaHCSIA for its 'leadership and cooperation...in addressing our concerns' and stated:

FaHCSIA have asked NCID to prepare a proposal to establish a technical group to consider the option of using available adaptive behaviour assessments that have strong evidence of standardisation normed against the general population and have tests for validity and reliability. This option would be an alternative and, if accepted, would replace the revised table No. 9 on intellectual function. We are currently in the process of putting this proposal together and NCID is confident that this will provide a valid and reliable assessment that will assess conceptual, social and practical skills and, importantly, identify individuals with cognitive impairment who require assistance from others for basic adaptive functioning.[7]

3.7        Notwithstanding FaHCSIA's cooperation, Mr Pattison was careful to point out that NCID's support for the draft revised impairment tables was conditional:

Senator BOYCE: Provided that you agreed the changes you wanted with the department, would you support the tables?

Mr Pattison: We would support the intellectual function table, yes.

Senator SIEWERT: Thank you for clarifying that.

Mr Pattison: That is where our expertise lies.

...

Senator SIEWERT: So that is the only table you are commenting on?

Mr Pattison: Yes. We are not commenting on the whole thing because, as I said, I think it turned out to be a more complex task than envisaged in the beginning.[8]

3.8        The committee supports NCID's recommendation to align the impairment table for intellectual function (revised table 9) with the latest definition and research of intellectual disability, including the World Health Organisations’ International Classification of Functioning, Disability and Health (ICF). The committee urges FaHCSIA to work with NCID to address outstanding concerns regarding the application of revised table 9 to people with an IQ between 70 and 79 prior to implementation of the draft revised impairment tables.

Chronic pain

3.9        During the course of the inquiry, the committee heard from both painaustralia and the Australian Pain Management Association (APMA).

3.10      painaustralia was supportive of the review of the DSP impairment tables:

...because people with a disability should be assessed on their ability to function and therefore to work. That applies to some but not necessarily all people whose condition is characterised by chronic pain. So the transition to tables based on functional ability is certainly welcome.[9]

3.11      painaustralia was concerned, however:

...that some people with chronic pain conditions which do not attract an underlying diagnosis, let alone a treatable one, may be disadvantaged by that exclusion...It is of some concern that pain is considered under the new proposals to be a symptom only and not a condition in its own right. We have two points to make there.

Firstly, this does not in fact acknowledge the change in medical knowledge, neurobiological knowledge, about the nature of chronic pain, which is really now considered to be an incurable condition and, in many cases, only partly reversible. It does not readily reduce to an antidiagnosis.

The second point is that the implication of note 35, which accompanies the new tables, is that pain is treatable. The note says: 'It is important that the cause of pain is properly diagnosed and treated.' With the best will in the world and the best knowledge in the world, that is not always possible. There are some people who do have an ongoing chronic pain problem and treatment is certainly limited.[10]

3.12      The APMA had 'some relatively minor concerns that the revised impairment tables are not completely aligned with medical understanding of persistent pain'.[11] In contrast to painaustralia, the APMA stated:

We believe that the draft tables correctly differentiate between pain as a symptom and persistent pain as a condition. This is where we have taken a different view from painaustralia. We believe, however, as the professor pointed out, that the current wording of paragraph 35 of the revised tables can be a little bit misleading. We have suggested in our submission the change of one word, which would clarify that distinction. We support the revised tables' requirement that proper investigation, diagnosis and management to the maximum extent possible be undertaken. In relation to people living with persistent pain, we do believe that this is in their interests even where they are seeking disability support pension payments and may face some delays as a result of this medical investigation.[12]

3.13      Mr Paul Murdoch, Vice President of the APMA sought to clarify the difference in opinion between the two organisations:

I agree with what [painaustralia] says but I think his assessment of the tables is incorrect. I do not think the tables exclude chronic pain, or persistent pain as we prefer to call it, or any of the various types of conditions, such as regional pain syndrome et cetera, from being accepted as diagnosable conditions. I think what the advisory committee that set up the tables is seeking to do is stop general practitioners in particular from merely reporting that a patient is suffering from pain, which of course is associated with a wide range of medical conditions, and, therefore, sending them off to Centrelink to apply for DSP on the basis of that reporting of the symptom.

Pain can be a symptom, but persistent pain is not a symptom; it is a disease in its own right. If the tables accept that, as we believe they do, the diagnosis of persistent pain constitutes a diagnosis of a condition rather than merely a description of one or more symptoms suffered by someone with an unknown disease, I do not think we have a problem. If the professor and painaustralia are right and the tables do not accept a diagnosis from, for example, a pain medicine specialist that a person suffers from persistent pain, whatever the cause might be, there is a problem. We differ in our interpretation of what the tables are intending to say.[13]

3.14      In response, FaHCSIA informed the committee the department was 'in ongoing discussions with...a number of pain-management groups'[14] and 'obviously are still taking on board issues that they have raised'.[15]

3.15      The committee encourages the department to continue to engage in ongoing discussions with pain management groups, such as painaustralia and the APMA, as well as other stakeholders. This will help to ensure there is satisfactory engagement with and outcomes for disability groups, including an understanding of the revised impairment tables.

Episodic mental illness

3.16      During the inquiry into the Family Assistance and Other Legislation Amendment Bill 2011, the Mental Health Council of Australia (MHCA) raised concerns regarding the application of the impairment tables to co-occurring and episodic mental health conditions, in particular the inability to accumulate 20 points for a 'severe impairment' across multiple tables.[16]

3.17      During the current inquiry, Mr Frank Quinlan, Chief Executive Officer of the MHCA was asked about episodic mental illness. The MHCA observed:

The concern with this matter is that a person could be assessed as ineligible for DSP when they are functioning quite well, but could lapse into an episode shortly thereafter.  There doesn’t appear to be a specific system for managing the episodic nature of many mental illnesses.[17]

3.18      The committee agrees that it is important that the impairment tables, the the assessments made by assessors, should appropriately reflect the potentially significant impairment that can be caused by episodic mental illness. It notes that draft revised impairment table 5, titled 'Mental Health Function', states in the introduction:

• Impairment Table 5 should only be used where the person has a diagnosed psychiatric disorder resulting in functional impairment (this includes recurring episodes of psychiatric impairment).

...

• The person may not have good self‐awareness of their psychiatric impairment and/or may not be able to accurately describe its effects. Assessors need to keep this in mind when discussing issues with the person and reading supporting evidence.
• The signs and symptoms of psychiatric impairment may vary over time. Assessors should not rely on a ‘snapshot’ or once‐off assessment.
• For psychiatric conditions that are episodic or fluctuate, the assessor should apply the rating that best describes the person’s functional abilities on most days/most months.[18]

3.19      The impairment tables do therefore recognise the episodic nature of some mental illness. The new tables provide guidance for the assessor which is designed to promote consistency and fairness. The care with which the points in the tables are implemented will be critical in determining whether the recognition of episodic mental illness translates into accurate assessment of whether someone is able to obtain and stay in regular work.

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