Distrusting doctors’ evidence: a qualitative study of disability income support policy makers in Australia and Ontario, CanadaAshley McAllister A B C and Stephen R. Leeder B
A Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, 171 77, Stockholm, Sweden.
B Menzies Centre for Health Policy, Faculty of Medicine, University of Sydney, Sydney, NSW 2006, Australia. Email: email@example.com
C Corresponding author. Email: firstname.lastname@example.org
Australian Health Review - https://doi.org/10.1071/AH16092
Submitted: 22 April 2016 Accepted: 28 March 2017 Published online: 15 May 2017
Objective The aim of the present study was to describe how policy makers (bureaucrats and politicians) in Australia and Ontario (Canada) perceive evidence provided by doctors to substantiate applications for disability income support (DIS) by their patients with mental illnesses. Because many mental illnesses (e.g. depression) lack diagnostic tests, their existence and effects are more difficult to demonstrate than most somatic illnesses.
Methods Semi-structured interviews were conducted with 45 informants, all influential in the design of the assessment of DIS programs. The informants were subcategorised into advocates, legal representatives, doctors (general practitioners (GPs) and specialists (e.g. psychiatrists)), policy insiders and researchers. Informants were found through snowball sampling. Following the principles of grounded theory, data collection and analysis occurred in tandem.
Results Informants expressed some scepticism about doctors’ evidence. Informants perceived that doctors could, due to lack of diagnostic certainty, ‘write these things [evidence] however [they] want to’. Psychiatrists, perceived as having more time and skills, were considered as providing more trustworthy evidence than GPs.
Conclusion Doctors, providing evidence to support applications, play an important role in determining disability. However, policy makers perceive doctors’ evidence about mental illnesses as less trustworthy than evidence about somatic illnesses. This affects decisions by government adjudicators.
What is known about the topic? Doctors (GPs and psychiatrists) are often asked to provide evidence to substantiate a DIS application for those with mental illnesses. We know little about the perception of this evidence by the policy makers who consider these applications.
What does this paper add? Policy makers distrust doctors’ evidence in relation to mental illnesses. This is partly because many mental illnesses lack diagnostic proof, in contrast with evidence for somatic conditions, where the disability is often visible and proven through diagnostic tests. Furthermore, GPs’ evidence is considered less trustworthy than that of psychiatrists.
What are the implications for practitioners? Although doctors’ evidence is often required, the utility of their evidence is limited by policy makers’ perceptions.
Additional keywords: disability welfare, grounded theory, mental illness, policy design.
References Stone DA. Doctors as gatekeepers: illness certification as a rationing device. Public Policy 1978; 27 227–54.
 Swartling M, Alexanderson K, Wahlstrom R. Barriers to good sickness certification – an interview study with Swedish general practitioners. Scand J Public Health 2008; 36 408–14.
| Barriers to good sickness certification – an interview study with Swedish general practitioners.CrossRef |
 Engblom M, Alexanderson K, Englund L, Norrem G, Rudebeck CE. When doctors get stuck in sick-listing consultations: a qualitative study of categories of sick-listing dilemmas. Work 2010; 35 137–42.
 McAllister A
 Hyland T. A critical analysis of the Ontario Disability Support Program Act and social citizenship rights in Ontario. Research paper, Institute of Political Economy, Carleton University, Ottawa; 2001.
 Lankin F, Sheikh MA. Brighter prospects: transforming social assistance in Ontario. Toronto: Ontario Commission for the Review of Social Assistance; 2012.
 Department of Social Services (DSS). Characteristics of disability support pension recipients: June 2013. Canberra: DSS; 2013.
 Social Benefits Tribunal. Statistical tables 2010–2011. Toronto: Government of Ontario; 2011.
 Charmaz K. Constructing grounded theory: a practical guide through qualitative analysis. 1st edn. Thousand Oaks, CA: Sage Publications; 2006.
 McAllister A Hackett ML Leeder SR
 Tansey O. Process tracing and elite interviewing: a case for non-probability sampling. PS Polit Sci Polit 2007; 40 765–72.
| Process tracing and elite interviewing: a case for non-probability sampling.CrossRef |
 Sbaraini A, Carter S, Evans R, Blinkhorn A. How to do a grounded theory study: a worked example of a study of dental practices. BMC Med Res Methodol 2011; 11 128
| How to do a grounded theory study: a worked example of a study of dental practices.CrossRef |
 Australian Government Department of Health. Medicare Benefits Schedule book. Operating from 01 November 2014. 2014. Available at: www.health.gov.au/internet/mbsonline/publishing.nsf/Content/432EE55FAB58E5C4CA257D6B001AFB8A/$File/201411-MBS.pdf [verified 10 March 2017].
 Stone DA. Diagnosis and the dole: the function of illness in American distributive politics. J Health Polit Policy Law 1979; 4 507–21.
| Diagnosis and the dole: the function of illness in American distributive politics.CrossRef | 1:STN:280:DyaL3c%2FpsFWmtw%3D%3D&md5=660d7cb7f2a8aa5a18873cd142b5390eCAS |
 Whiteford HA, Buckingham WJ, Harris MG, Burgess PM, Pirkis JE, Barendregt JJ, Hall WD. Estimating treatment rates for mental disorders in Australia. Aust Health Rev 2014; 38 80–5.
| Estimating treatment rates for mental disorders in Australia.CrossRef |
 Kohn R, Saxena S, Levav I, Saraceno B. The treatment gap in mental health care. Bull World Health Organ 2004; 82 858–66.
 Henderson S, Andrews G, Hall W. Australia’s mental health: an overview of the general population survey. Aust N Z J Psychiatry 2000; 34 197–205.
| 1:STN:280:DC%2BD3c3kvVertA%3D%3D&md5=e300b064a9c586cbcfde3d0a057628f4CAS |
 Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, Rahman A. No health without mental health. Lancet 2007; 370 859–77.
| No health without mental health.CrossRef |
 Organization For Economic Cooperation and Development (OECD). Sick on the job? Myths and realities about mental health and work. Mental Health and Work. Paris: OECD Publication Services; 2012.
 Åsbring P, Närvänen A-L. Ideal versus reality: doctors perspectives on patients with chronic fatigue syndrome (CFS) and fibromyalgia. Soc Sci Med 2003; 57 711–20.
| Ideal versus reality: doctors perspectives on patients with chronic fatigue syndrome (CFS) and fibromyalgia.CrossRef |
 Arrelöv B, Alexanderson K, Hagberg J, Löfgren A, Nilsson G, Ponzer S. Dealing with sickness certification – a survey of problems and strategies among general practitioners and orthopaedic surgeons. BMC Public Health 2007; 7 273
| Dealing with sickness certification – a survey of problems and strategies among general practitioners and orthopaedic surgeons.CrossRef |
 Andrews K. Commonwealth doctors to assess new DSP claims. 2014. Available at: kevinandrews.com.au/latest-news/2014/12/12/commonwealth-doctors-assess-new-dsp-claims/ [verified 8 January 2015].
 Australian Government. 188.8.131.52 Medical & other evidence for DSP. 2015. Available at: http://guides.dss.gov.au/guide-social-security-law/3/6/2/10 [verified 1 September 2016].
 Medhora S. Family doctors to be banned from assessing DSP welfare claims. The Guardian. 12 December 2014. Available at: www.theguardian.com/australia-news/2014/dec/12/family-doctors-to-be-banned-from-assessing-dsp-welfare-claims [verified 8 January 2015].
 Wroe D. AMA gives cautious support to disability support crackdown. Sydney Morning Herald. 20 April 2014. Available at: www.smh.com.au/federal-politics/political-news/ama-gives-cautious-support-to-disability-support-crackdown-20140420-zqwz5.html [verified 29 January 2015].
 Karolinska Institutet. Läkarprogrammet – Hälsa I samhälle och miljö. Stockholm: Karolinska Institutet; 2017.
 Department of Social Services. Social security (tables for the assessment of work-related impairment for disability support pension) determination 2011. 2012. Available at: https://www.legislation.gov.au/Details/F2011L02716 [verified 12 January 2017].