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6.6 pm
Dr. Peter Brand (Isle of Wight): I welcome the report. I have practised as a general practitioner for 25 years and have had to go through the agony of some of my patients' contact with the Benefits Agency in its medical manifestations. Not much has changed to date. In fact, matters got a lot worse during the dreadful benefit integrity project, when there seemed to be a witch hunt.
The thing that concerns me most is that we are asking doctors who work for the Benefits Agency--they did so in the past directly, but now do so through Sema--to do their job wearing a blindfold, or blinkers at best. As the hon. Member for Clwyd, West (Mr. Thomas) pointed out, history is important when making an assessment, but so is examination and having access to the result of investigations. We do not have an integrated system where relevant knowledge is made available.
We are not just talking about disbursing £25 billion of public money, although it is right that we should take that seriously and target it at the right people. Decisions by the Benefits Agency can have a dramatic impact on people's clinical outcomes. For the Benefits Agency to say, "Go back to your doctor and get another certificate," adding in brackets--it is never stated--"Make sure that it is for a
different condition, so that we can restart your claim," is nonsense. A doctor can write a further certificate, but that does not reinstate the benefit for that patient, unless we are being particularly clever about something.One sometimes sees the real effect. We get these amazing decisions by the examining doctors who will not accept the history given by the patient and who will not take steps to ensure that investigation results are available to them. That means that the appeal mechanism gets triggered, if the patient is well advised. However, many patients do not have that level of advice.
The internal system that BAMS used to have, and which still exists, involves having an assessor. Those decision makers are not competent either. I do not think that they are empowered to ask for more information so that a reasonable decision can be made.
I urge the Minister really to examine the contractual relationship between the Department of Social Security and the Department of Health, so that the Benefits Agency can buy more relevant information from the national health service. I realise that that information is not a free good and takes time to produce. Although I take the point made by my hon. Friend the Member for St. Ives (Mr. George), doctors are busy people and are expensive. Their time will be paid for either by the national health service, as part of their contract, or by a fee of some sort. I think that it would be helpful if the fee were a bit more up-front than it is now. The routine bits of paper that doctors are asked to fill out are of so little value that they really are not designed to give the Benefits Agency the information that it should have.
As I said, we are debating not only the disbursal of £25 billion, but a clinical matter. In the past few years, I have had a couple of cases that are perhaps relevant to this debate, one of which involved a relatively young man with unstable angina. He was trained to be a builder's labourer. He was not a very bright chap. He was assessed under the all-work test and was told that he was fit to go to work. However, he was not competent to do anything except heavy physical work--no other job was available to him.
The man was driven back into work, until I stopped him by telling him that he would drop dead. I am very glad to say that, soon after, he had his heart surgery. Now, he is much more stable and is even back at doing some good physical work. However, he is doing that within his own limitations.
In the letter that I wrote for the man--incidentally, I did not charge for it--I asked the Benefits Agency who would represent it at the coroner's court should he drop dead after returning to work. I did not receive an answer from the agency, but it reinstated his benefit. It really is appalling that one has to go to such lengths to achieve the right result.
Another case involved a man who was a gas fitter--which involves lots of crawling around little holes and turning one's head upside down--and had an unstable spine. He had very clear neurological signs, down his legs and his arms, of an unstable cervical spine and was awaiting surgery for it. Again, a clever person said that he was fit to go to work. If that man had continued in his job, he could have become a tetraplegic. Again, it was necessary for one to make that point so clearly, although any clinician worth his salt would have worked it out.
The Government acknowledge that there is an extraordinarily high rate of success in appeals. I must congratulate my constituent, Dr. Ralph Gasson, who is a doctor of divinity and devotes his life to representing people at appeals. He does lots of them, and has a better than 90 per cent. success rate. There really is something wrong with a system that allows that to happen.
In response to the Select Committee, the Government said:
- A successful appeal does not necessarily indicate that the medical report was substandard.
People should not have to have an appeal before receiving what they need. Let us face it, benefits are just as much part of the health package as any direct medication, physiotherapy or occupational therapy.
My final plea--I do not think that this issue was addressed by the Committee--is that we should have not only a better and smoother way into work, with better therapeutic earnings allowances and tax credits, but a way of dipping into work and coming out of it again if it does not work out. Many people are reluctant to take that step because they know that their mortgage interest payments, for example, will not be reinstated until quite a long time after they have discovered that they cannot cope. That is particularly important in respect of mental health, but it also applies to other areas.
Generally, people are keen to make a contribution, but the present system seems either to goad them with very crude pushes or to put up barriers. I hope that the excellent report by the Select Committee will goad the Government into taking positive action.
6.15 pm
Mr. Eric Pickles (Brentwood and Ongar): It is a great pleasure to follow the hon. Member for Isle of Wight (Dr. Brand). He was looking rather ashen-faced when we were discussing doctors' remuneration, but we are grateful that he stayed. I found his final point about people coming off benefit most interesting. Last year, the Minister and I served on the Standing Committee considering the Welfare Reform Bill, which made certain changes to protect the benefit claimed by disabled people. That was a welcome step and it might also be appropriate in respect of incapacity benefit.
I, too, would like to congratulate the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) on an outstanding report. I know that we always thank the chairmen of Select Committees and say that they have produced thorough reports that we are pleased to debate, but this is an excellent report. Since I have been a Front-Bench spokesman on these issues--and it has been two years now--I have been fortunate enough to consider a series of really good reports at a time of quite rapid change in social security. I am most grateful to the hon. Gentleman and the Select Committee.
I do not want to cause the Minister any embarrassment or discomfort by saying that the Government's response to the report is well rounded and most welcome. It is sensible in its general approach, with one exception, to which I shall turn in a few moments.
The report deals with a service that is undergoing an enormous transformation. After all, it is only a relatively short time since the Government took the sensible decision to privatise the service, and it is fair to say that it is a good idea to monitor the great changes that are under way.
At times during the debate, we rather lost sight of what the Government were seeking to achieve, which is set out on page 1 of their response:
- The Government chose the option of contracting-out because it believes that the public is entitled to good quality public services. What matters is what works.
There have been considerable changes during the inquiry and since the report. We know that, generally, better accommodation has been available in which to carry out examinations; there has been a shorter waiting list; waiting times have been reduced and there have been some improvements to the audit system. However, the Select Committee was quite right to identify problems with regard to quality, timing and, most crucially, training.
The hon. Member for Roxburgh and Berwickshire talked about benchmarks and said that it would have been better to have had some idea of how bad the system was before the process started. The hon. Member for Belfast, South (Rev. Martin Smyth) gave us an idea as to what the system was like before the changeover, and how it operates in his constituency. There was also a problem in respect of the specifications of the contract that was sent out. That is a common difficulty in central and local government.
It is a common problem that people become anxious about matters that are not in the contract. The Committee's report mentions structural problems, and there is always some tension about omissions from contracts. When I was on a Select Committee, we had discussions about specifications for railways and we had an interesting witness appear before us. I asked him why problems were experienced in meeting the specifications and he said, "As a general rule, meeting specifications within a contract is a bit like walking on water. It is easy to do if both are frozen." In this case, items missing from the contracts have created much of the problem.
It is indicative that the contracts contained no medical quality targets, only medical standards. My hon. Friend the Member for New Forest, West (Mr. Swayne) mentioned the problem of lack of pay for training, but much of the training requirement was additional to the contract. Of course, Sema bid on a tight basis for the contract and has ended up funding things that were not part of the contract price. In the process of re-examination of the contracts, we should perhaps ensure that quality targets are included in matters that are put out to tender.
My experience of such matters goes back eight or nine years and I believe that things are getting better. Hon. Members have described the current problems, and dreadful cases still arise to which hon. Members will wish
to alert the Minister, but there is a general feeling of improvement. Much of the frustration that revolved around the old all-work test was really about assessment, because, before the changes were made, there was no real way to judge matters.I have some points to make that may be unfashionable and go against the general tenor of the debate with regard to desk-top scrutiny. I accept what the hon. Member for Hendon (Mr. Dismore) said about the risks, but there is a risk the other way. It would be worse if, in order to prove that everything was above board, we forced people to go through medical examinations when it was obvious from the medical documentation and case history that there was no need for them to do so. I cannot see the point of putting people through the anxiety of a medical examination when it is obvious that they will not pass it. The hon. Gentleman is right about the need for proper scrutiny, but it would be wrong to force people into medical examinations, thereby increasing the waiting list, for reasons of financial control, when their illness is evident.
I said that the report was excellent. However, the response on mental illness was rather smug. There was something of the Mr. Nicely-nicely about it that I found unacceptable. The Committee's recommendation (h) is that
- the Chief Medical Adviser instigates a review of Medical Services' treatment of claimants with mental health problems.
- Recently as part of the Personal Capability Assessment (PCA), development and thorough evaluation of methods assessing effects of mental health problems on ability to work, have gone some way to meeting that challenge.
- There are 200 advisers in the field who have gone through an average of 200 hours of training--and in some cases 300 or 400 hours--working towards established qualifications such as NVQ3.--[Official Report, House of Lords, 13 July 1999; Vol. 304, c. 214.]
The briefing that all hon. Members have received states that Sema is putting doctors through a three-day induction course, which will deal with cultural awareness, mental illness, post-traumatic stress, disability discrimination and chronic fatigue syndrome. That is all very sensible, but the nature of people receiving incapacity benefit is changing. Twenty-odd years ago, 9 per cent. of people had a mental illness; 10 years later, in 1988, the proportion was 16 per cent., and last year the figure was nearly 30 per cent.
We cannot say that significant changes have been made in the process of benefit payments when forms such as the one displayed a little while ago by the hon. Member for Hendon place so much emphasis on physical condition. The forms for incapacity benefit and disability living allowance are difficult for people with a mental illness or disability to complete and thereby make a claim.
Hazel Ruane of the National Schizophrenia Fellowship wrote a letter on 14 June to my hon. Friend the Member for West Chelmsford (Mr. Burns). It was passed to me by
my constituent Mrs. Murphy, on whom I rely for up-to-date information on the care of schizophrenia. The letter states:
- In fact, the plight of persons who are currently unemployed for reasons of mental ill-health is being made far worse by the present, growing trend of summarily stopping the payment of disability allowance for sufferers of schizophrenia, manic depression and other serious disorders. This may be an attempt to improve the statistics leading to the next election when, no doubt, there will be some self congratulation from the government regarding supposed achievement of manifesto targets . . . So, far from improving the implementation of care in the community, this haphazard termination of disability allowances is bound to damage it entirely.
There needs to be a balance to ensure that people with a mental illness or disability are not excluded from employment. We do not suggest that such people should be excluded from getting work, but the balance must be considered very carefully, and with sensitivity.
I have a couple of illustrations. I recall seeing the Minister and some Labour Members a couple of days ago at an Alzheimer's Disease Society reception. I talked to a lady there who had been through the assessment process. She had been asked whether her husband could walk a particular distance. Of course he could--her worry was whether he could find his way back home if he wandered off while he was walking that distance. That was not taken into account during the scrutiny of the case. She had to fight very hard to get that idea across.
As for schizophrenia, there was a difficult case at my advice surgery involving a constituent who had gone through the process. Her son was asked how high he could raise his arm above his head, but my constituent was more concerned about his ability to organise his affairs.
Someone who suffers from manic depression may give a false impression of their state of health. If manic depressives are asked how they feel, they say, "Life is wonderful, I feel great. I can do anything; I'll apply for anything. I really want to go out to work." Then, with just a click of the fingers, everything changes. That is not catered for in the forms and the way in which the assessment is made.
We have come a long way in the way that people with a mental disability are treated. However, we are a long way from achieving the sensitivity that is necessary for the various medical assessments. Life is pretty much stacked against people who are mentally ill or suffer from a mental disability. We must deal with them sensibly, and the tests that we apply should reflect that.
We all received briefing documents today from MIND, which supports the report of the Select Committee on Social Security. Given the narrow nature of our objection to this report, which by and large we endorse, I ask the Minister to look again at that recommendation and see whether he can change the Government's mind with regard to reassessing the process, from the form onwards. If he succeeds in doing so, that would be the icing on the cake for this excellent report.
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