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Confidentiality and disclosure: ATOS, GP extractor scheme and benefits claims



The Government has outsourced duties for awarding benefits claims to ATOS. It has also outsourced the handling of “big data” from NHS GPs to ATOS. Medicine and law maintain that safeguarding against conflicts of interests is essential for preserving integrity of the professions (for a comparative approach, see here). The Solicitors Regulation Authority (SRA) for example have produced full guidance in chapter 3 on this matter in their Code of Conduct. However, chapter 4 on confidentiality and disclosure also provide important information, particularly in relation to the mandatory requirement O 4.4 for “information barriers” to safeguard against breach of confidentiality (click on the picture to see an enlarged view).

These are currently the details of contracts awarded for the GP Extraction Service (“GPES”). ATOS are very open about their “GP Extraction Service” (details here).

Peter Oborne from the Telegraph, and many others, have warned against the portrayal of “benefit cheats” being misleading (see for example his article here, Nonetheless, professional monitoring and surveillance services, for example “George Osborne must correct his claims about benefit fraud. And his portrayal of the poor as mean-minded and cheating”  Specialist private investigator firms such as Boothroyds do exist, which have some focus on benefits claimants. This has been a war waged in the popular media, for example on the BBC website and one from ITN news about a “crippled man winning a motorcycle race”:

The issue here is whether the patient has given “implied consent” for the “lawful transfer” of data from NHS to outside agencies. I have previously written about this issue under the present legislation. ATOS have previously denied that they operate any targets regarding benefits.  Quoted in an article by Amelia Gentleman in the Guardian, an ATOS Healthcare spokesperson said: “It is simply and absolutely untrue that there are targets for the number of people to be assessed as fit-to-work; neither set by the Department for Work and Pensions nor Atos Healthcare. Every person we see is assessed individually with a focus on the facts of their own case.” The GMC will be mindful that their code of conduct, “Good medical practice”, cites conflicts of interest specifically in paras. 74-76:

Margaret McCartney has previously elicited from the GMC, the regulatory body for doctors, that “The first duty of all doctors is ‘to make the care of your patient your first concern’. But that is not the only duty doctors must observe. Being open and honest and acting with integrity is also an essential part of medical professionalism.” The full response is here. Indeed, the GMC make it further clear that dishonesty in writing reports cannot be justified by reference to the first duty of doctors. Further advice on disclosing information for employment, insurance and similar purposes can be found in this document.

The legal issue which is most crucial to this is whether there is a legal argument that the importance of disclosure outweighs the importance of confidentiality, and this is an issue for the professional regulatory bodies concerned governing the behaviour of all agents in the situation above. There is a good arguable case that ATOS should have effective information barriers in place. It is unlikely that patients when they have consented for their data to be held by GPs are aware that data can be so easily transferred to outside organisations.  This is further complicated by the finding from Nature and Science within the last fortnight that it may be possible to identify the identity of individuals from “anonymised” data.

The response should not be one of “moral panic“, arguably.  However, this is the sort of the letter that could produce a legal, regulatory and ethical nightmare:

 

Imbalance of information has been a problem endemic in much of life recently



 

 

 

 

 

 

Had certain people at the BBC known about, and acted upon, the information which is alleged about Jimmy Savile, might things have turned out differently? George Entwhistle tried to explain yesterday in the DCMS Select Committee his local audit trail of what exactly had happened with the non-report by Newsnight over these allegations.

‘Information asymmetry’ deals with the study of decisions in transactions where one party has more or better information than the other. This creates an imbalance of power in transactions which can sometimes cause the transactions to go awry, a kind of market failure in the worst case.  Information asymmetry causes misinforming and is essential in every communication process. In 2001, the Nobel Prize in Economics was awarded to George Akerlof, Michael Spence, and Joseph E. Stiglitz for their “analyses of markets with asymmetric information.” Information asymmetry models assume that at least one party to a transaction has relevant information whereas the other(s) do not. Some asymmetric information models can also be used in situations where at least one party can enforce, or effectively retaliate for breaches of, certain parts of an agreement whereas the other(s) cannot.

In adverse selection models, the ignorant party lacks information while negotiating an agreed understanding of or contract to the transaction, whereas in moral hazard the ignorant party lacks information about performance of the agreed-upon transaction or lacks the ability to retaliate for a breach of the agreement. An example of adverse selection is when people who are high risk are more likely to buy insurance, because the insurance company cannot effectively discriminate against them, usually due to lack of information about the particular individual’s risk but also sometimes by force of law or other constraints. An example of moral hazard is when people are more likely to behave recklessly after becoming insured, either because the insurer cannot observe this behavior or cannot effectively retaliate against it, for example by failing to renew the insurance.

Joseph E. Stiglitz pioneered the theory of screening, and screening is a pivotal theme in both economics and medicine. In this way the underinformed party can induce the other party to reveal their information. They can provide a menu of choices in such a way that the choice depends on the private information of the other party.
Examples of situations where the seller usually has better information than the buyer are numerous but include used-car salespeople, mortgage brokers and loan originators, stockbrokers and real estate agents. Examples of situations where the buyer usually has better information than the seller include estate sales as specified in a last will and testament, life insurance, or sales of old art pieces without prior professional assessment of their value.

This situation was first described by Kenneth J. Arrow in an article on health care in 1963. The asymmetry of information makes the relationship between patients and doctors rather different from the usual relationship between buyers and sellers. We rely upon our doctor to act in our best interests, to act as our agent. This means we are expecting our doctor to divide herself in half – on the one hand to act in our interests as the buyer of health care for us but on the other to act in her own interests as the seller of health care. In a free market situation where the doctor is primarily motivated by the profit motive, the possibility exists for doctors to exploit patients by advising more treatment to be purchased than is necessary – supplier induced demand. Traditionally, doctors’ behaviour has been controlled by a professional code and a system of licensure. In other words people can only work as doctors provided they are licensed and this in turn depends upon their acceptance of a code which makes the obligations of being an agent explicit or as Kenneth Arrow put it “The control that is exercised ordinarily by informed buyers is replaced by internalised values”

In standard civil litigation, disclosure of information takes place between the two parties in standard proceedings,  a party must disclose every document of which it has control and which falls within the scope of the court’s order for disclosure. Even if a party discloses a document, the other party is not entitled to inspect the document. Of course, this disclosure procedure might have effects in producing information imbalances, where it is important to see ‘the big picture’. Such a situation is the Leveson Inquiry, ultimately looking at how activities might be better regulated if appropriate (and by whom). The communications with the former News International chief executive and the News of the World editor-turned spin doctor, Andy Coulson, were reportedly kept from the hearings into press standards after the Prime Minister sought legal advice. Labour said that David Cameron, the UK Prime Minister, must make sure that “every single communication” that passed between him and the pair be made available to the inquiry and the public.  The cache runs to dozens of emails including messages sent to Mr Coulson while he was still an employee of Rupert Murdoch, according to reports. It was described by sources as containing “embarrassing” exchanges with the potential to cast further light on Mr Cameron’s relationship with two of Mr Murdoch’s most senior executives. However, Downing Street was said to have been advised that it was not “relevant” to the Leveson inquiry as the documents they contained fell outside its remit, according to The Independent.

Information imbalances, for us on a more daily basis, have a direct effect on the consumer-supplier relationship of the econy, We have been told to absurdity on how much of our problems as consumers would be solved if we could simply ‘switch easily’ between energy suppliers. In a sense, either there should be far less competition (i.e. the whole thing merges into one state supplier, reducing absurdities in a few suppliers all providing the same product at a high price,  similar to exam boards currently), or there should be far more competition (there is currently an oligopolistic situation in many markets, which would be greatly ameliorated by having many more active participants in the competition market.) In 2009, the four largest banks supplied 67% of the market of mortgages, and, in 2006, the ‘big four’ banks accounted for 47% of the market. According to the “Cruickshank review”, the ‘big four’ banks accounted for 17% of the market. Demutualised building societies held 48%: these are, (a) Lloyds TSB, Halifax and Bank of Scotland; (b) Royal Bank of Scotland, Natwest; (c) HSBC, First Direct; (d) Abbey, Alliance and Leicester, Bradford and Bingley.

The Competition Commission believes that helping customers to easily switch products is paramount to the effective operation of competitive markets: markets do not function without customers who vote with their feet. As Dr Adam Marshall of the British Chambers of Commerce told the Commission: ‘There’s lots of products and services on the market, but the theoretical competition between those products and services is limited by the real world barriers of form filling, hassle, bureaucracy, decisions not being taken, etc…’ The regulator responsible for consumer protection regulation should have both: (a) an explicit mandate to promote effective competition in markets in the financial sector; and (b) the necessary powers to regulate the sector to achieve this, including the ability to apply specific licence conditions to banks and exercise competition and consumer protection legislation. These powers will be concurrent with the competition powers of the OFT, and will enable the regulator to both enforce competition law and make market investigation references to the Competition Commission.

The aim of consumer protection regulation is to promote the conditions under which effective competition can flourish as far as possible, and where not, the regulator will be able to take direct action. In order best to promote the interests of the consumer, the regulator will encourage financial firms to compete: on the merit of the quality and price of their products and services; and to gain a competitive advantage by investment in innovation, technology, operational efficiency, superior products, superior service, due diligence, human capital, and offering better information to customers. Ideally, the regulator would then step in whenever there is a sign of market failure. Market failures include: (a) poor quality information being disclosed to consumers when they are deciding whether to purchase products; (b) information asymmetry between the provider and the consumer; or (c) providers taking advantage of typical consumer behaviour such as the tendency evident in retail customers to select the default option offered, and reluctance to switch products because of inertia. Any sign of market failure indicates that competition is probably not effective, and the regulator should then take action to counteract the failure.

Therefore, it is hard to see how information imbalances are not at the heart of many ‘decisions’ affecting modern life, and can lead to imperfect decisions being made. Ideally, it is up to parties to make a full disclosure about things, whether this includes personal health or corporate misfeasance; if they are not so willing to give up their secrets, they possibly can be ‘nudged’ into doing so. Of course, some parties, particularly those intending to generate a healthy shareholder dividend, may not be very keen at all at spilling the beans, and that is where law and regulation come in. However, even then there can be significant imbalances in the legal process which can be obstructive in the correct solutions being arrived at. Certainly the field has progressed substantially since this Nobel Prize for Economics was first awarded over 30 years ago.

 

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