THE
ADJUDICATION
PROCESS
23. With the launch of DLA in 1992 the policy intention
was that it should be less bureaucratic and that claimants would
complete self-assessment forms which would give them a greater
opportunity to have an input to the decision-making process. We
asked the Agency about the length and complexity of the form.
It told us that a new form was introduced in October 1997 which
was considerably shorter but it agreed that it is still a long
form and people find it difficult to complete.[19]
24. The Adjudication process is the means by which
the Agency makes decisions on claims submitted. The decisions
on claims are made by lay Adjudication Officers who must have
regard to the evidence submitted and judge whether the claim complies
with the criteria for the scheme. If necessary Adjudication Officers
can seek the claimant's permission to approach General Practitioners
and/or hospitals for further information. In addition, three specialist
units are available to provide support and guidance to Adjudication
Officers. They are the DLA Advisory Board, the Medical Referee
Service and the Central Adjudication Service.[20]
The Advisory Board
25. The DLA Advisory Board for Northern Ireland is
an independent body whose primary role is to provide advice to
the Department on medical matters that the Department has referred
to it; and to the Department's medical practitioners on cases
that they refer to it. The main work of the body, in conjunction
with its GB counterpart, has been in assessing and advising on
the content of a Disability Handbook which is seen by the Agency
as a reference manual for Adjudication Officers. However, since
the Board was established in 1991 the Department referred only
one condition to it for advice and during 1995-96 its medical
practitioners referred only five cases to it. The Department intended
to review the use it makes of the Board within the context of
parity with Great Britain on social security matters.[21]
26. We probed the Agency about the limited use it
made of the expertise in the Advisory Board and were told that
the Disability Handbook is used extensively by Adjudication Officers
and is regarded by the Agency as essential to the work of its
staff. We also asked about the annual cost of the Advisory Board
and were told that it was less than £30,000 per annum.[22]
The Medical Referee Service
27. The Medical Referee Service, which is a specialist
unit within the Department, provides a daily advisory service
to Adjudication Officers, which ranges from a general explanation
of how various illnesses impact on a disability to discussion
of a particular case. The medical officers' function is to ensure
that Adjudication Officers are presented with up to date advice
upon which they can make decisions. The highest percentage of
cases referred to it for advice was around 12 per cent in 1993-94
and 1994-95 and this fell to two per cent in 1996-97. There was
a large imbalance in the level of usage of the service by different
Adjudication Officers.[23]
28. The Committee asked the Agency why it had not
made more use of the Medical Referee Service and was told that
it was instead making greater use of the claimants' general practitioners.
The Agency said it believed that a claimant's general practitioner
knows the individual better and will be able to form a more rounded
view of the claimant's condition. In addition, the Agency said
that it has good links with the Medical Referee Service, holding
seminars with them and seeking medical advice on a day to day
basis.[24]
29. The Medical Referee Service also provides an
audit role in that it examines one per cent of new claims to verify
the concept of self-assessment against the clinical findings of
a medical examination of the claimant. NIAO found that for several
years the Agency had not been forwarding the correct number of
cases for such testing and only 22 per cent of cases which should
have been submitted were forwarded in 1996-97. During a six month
period in 1995 the Agency failed to send any cases for examination.[25]
30. The audit of cases by the Medical Referee Service
showed that there is a definite inclination on the part of the
claimants to exaggerate the degree of their disability with more
than 20 per cent of claims exaggerated by more than 25 per cent
in 1996-97. We found this to be a worrying position and were alarmed
to learn that the Agency was unaware of the information held by
the Medical Referee Service on exaggerated claims.[26]
When we questioned the Agency on this matter it confirmed that
it was not aware of the formal findings of the Medical Referee
Service and could offer no explanation as to why such information
was not being relayed to it. It was aware, however, of the possibility
of the exaggeration of claims and said that arrangements had now
been put in place to ensure that it would receive the data in
future.[27]
31. A second audit role that the Medical Referee
Service completes is to report on the quality of Examining Medical
Practitioners' reports. The NIAO report shows that the Medical
Referee Service's audit indicates a high level of dissatisfaction
in a number of areas including the quality of examinations undertaken.
NIAO considered that the absence of training until March 1996
for Examining Medical Practitioners on how to complete reports
may have contributed to this situation.[28]
We asked the Agency why no one in the Department or in the Agency
had recognised the importance of training for the role of Examining
Medical Practitioners in the self-assessment process. The Agency
said that some training had been provided and that when the problems
became clear regarding the reports that general practitioners
were submitting, extra training and seminars were provided.[29]
The Central Adjudication Service
32. The Chief Adjudication Officer, who is independent
of both the Agency and the Department, provides advice to Adjudication
Officers on the interpretation of the law; keeps the operation
of the adjudication system under review; and reports annually
to the Department on adjudication standards. In relation to the
advisory role, the Agency had no record of the number of requests
made annually by its staff for advice and many requests were oral
rather than in writing as recommended by the Central Adjudication
Service.[30]
33. Each year the Chief Adjudication Officer reports
on monitoring standards and does this in the form of comment sheets
on the cases he examines. A comment sheet does not necessarily
mean that the claimant has been incorrectly paid but may indicate,
for example, that the wrong part of the law has been applied by
the Adjudication Officer. The standard of adjudication, as reported
by the Chief Adjudication Officer, started off as very poor in
1992-93 with 72 per cent of decisions giving rise to comment but
has improved over time to a suspected error rate of 33 per cent
in 1996-97. Of the 33 per cent of errors found by the Central
Adjudication Service, payment was found to be incorrect in seven
per cent of cases and in doubt in a further 17 per cent. The conclusions
drawn by the Chief Adjudication Officer in 1996-97 were consistent
with his reports in earlier years and recorded "insufficient
evidence on which to make a decision"; "incorrect law
applied or applied incorrectly" and "record of decision
incomplete or inaccurate" as the main reasons for questioning
decisions.[31]
34. The Agency pointed out to the NIAO that in many
cases insufficient evidence is a difficult and controversial area
in adjudication matters and there are very often differences of
opinion among its officers and between them and the Chief Adjudication
Officer's staff. It added that in the absence of a measurement
or law to specify how much evidence should be sought before deciding
on a claim, interpretation of insufficient evidence will continue
to be a matter of contention.[32]
35. When we suggested to the Agency that it had not
been taking the findings of the Chief Adjudication Officer seriously
enough, we were told that the steadily improving picture provided
encouragement and this showed that the Agency had taken the comments
seriously.[33] However,
the Agency agreed that the standard of adjudication was totally
unsatisfactory to begin with and even now with improvements was
still at an unacceptable level. It had found the NIAO report to
be catalytic in allowing the Agency to start a programme of improvements
to what was a very difficult benefit.[34]
It was beginning to see an improved position in its 1997-98 monitoring
and hoped that this position would continue.[35]
36. The Committee also noted that the Agency's own
monitoring of the work of its Adjudication Officers did not compare
the performance or the decision success rate of Adjudication Officers.
The Agency said that it was aware of such shortcomings and had
taken steps both in the past and currently to ensure that improvement
took place.[36]
Conclusions
37. We note that the claim form was reduced in length
in October 1997. However, it is still a long form and difficult
for claimants to complete. We suggest that the Agency keeps this
aspect under review.
38. The Committee is concerned that so little use
was made of the Advisory Board, particularly when the evidence
in the NIAO report indicates that the Agency was making so many
incorrect adjudication decisions. While we commend the valuable
work that the Advisory Board carried out producing a handbook
for Adjudication Officers we will be interested to hear from the
Department the outcome of its deliberations about the future of
the Board.
39. We consider that the Agency has not made best
use of the services available to it from the Medical Referee Service.
We are concerned that the level of referral has fallen to only
two per cent in 1996-97 and recommend the Agency should ensure
that all its Adjudication Officers make fuller use of the
service in the future.
40. We regard the audit of new claims by the Medical
Referee Service as an important contribution to checking on and
maintaining standards. We recommend that the Agency complies with
the obligations regarding the number of cases to be submitted
for audit.
41. We note that the Agency now has arrangements
in place to obtain data from the Medical Referee Service on exaggerated
claims.
42. The Committee agrees that the absence of formal
training for Examining Medical Practitioners may have contributed
to the unsatisfactory medical reports received by the Agency.
The Committee is concerned that no one in the Department or the
Agency recognised the importance of training for the role of Examining
Medical Practitioners and that training was not provided much
sooner. In future where changes take place to benefits training
of all staff relevant to the operation needs to be considered
early in the implementation process.
43. We recommend that the Agency should encourage
the use of written casework consultation when using the Central
Adjudication Service as it provides evidence of the extent and
nature of advice sought and whether all Adjudication Officers
are making use of the service.
44. The Committee view the Chief Adjudication Officer's
findings on the standard of adjudication with the utmost concern
and we are not fully convinced that the Agency has grasped the
significance of the problem that it faces. It is essential that
the Agency sets in place a programme of sustained improvement
in its adjudication standards that will lead to a marked change
in the Chief Adjudication Officer's findings when he reports annually
to the Department.
45. We recommend that the Agency should look again
at its own monitoring of adjudication quality and introduce steps
to compare the performance and decision success rate of Adjudication
Officers. We regard this as an important component in the management
process to identify weaknesses and to draw lessons for improving
the quality of adjudication.
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