Cases determined
by scrutiny and by examination
116. The Institution of Professionals, Managers
and Specialists (IPMS), which represents Medical Advisers employed
by Sema Group argues that the payment system agreed by the DSS
is distorting practice. IPMS notes that many areas of work carried
out by Medical Services attract no fee whatsoever. In contrast
"Incapacity Benefit cases referred to scrutiny...do command
a fee which is the same whether the client is accepted as unfit
for work at scrutiny or called for examination."[117]
117. A case determined by scrutiny is one where the
person passes the All-Work test and is found unfit for work. A
person claiming Incapacity Benefit can only fail the All-Work
Test and be found fit to do work if they have had a medical examination.
The memorandum from Medical Services shows a considerable fall
in the number of Incapacity Benefit examinations during the last
two quarters since SEMA took over the contract. The number has
dropped nationally from 135,718 in the quarter Feb-Apr 1999, to
104,860 in the quarter Aug-Oct 1999.[118]
118. The latest Incapacity Benefit Quarterly Statistics
(August 1999) show a steadily falling number of claims terminated
through failing the All Work Test from 40,700 in the quarter ending
August 1998 (35,500 in February 1999; 33,800 in May 1999) to 32,100
in the quarter ending August 1999. At the same time, the number
of Incapacity Benefit claimants exempted from the All-Work Test
(being automatically treated as incapable of work) is rising:
from 311,300 in August 1998 to 345,300 in August 1999.
119. The Department told us that the numbers of people
called for examination relating to an All Work Test as a proportion
of those processed has fallen in each of the three regions:[119]
All Work Test Scrutiny to Examination
| | Apr-98
| Dec-99 |
| | No.
processed
| No.
referred
for Exam
| S to E rate
(per cent)
| No.
processed |
No.
referred
for Exam
| S to E rate
(per cent)
|
| Northern | 24424
| 14899 | 61.00
| 23970 | 8102
| 33.80 |
| South East | 14578
| 9330 | 64.00
| 17490 | 5964
| 34.09 |
| South West | 18121
| 8879 | 48.99
| 9342 | 3363
| 35.99 |
120. The Benefits Agency Sessional Doctors Association
told us that "there has been a reduction in the number of
IB sessions carried out throughout the country. This is understood
to have followed a change of procedures which make it easier for
benefit to be continued without a medical assessment being carried
out."[120] The
BMA said that "we are extremely concerned at the number of
cases now being decided by Scrutiny—we understand that in
some offices this approaches 70 per cent due to shortage of money
to undertake examinations—and many GPs are simply incredulous
at the outcomes of some individual All Work Tests."[121]
121. Medical Services say that the falling number
of examinations as compared to scrutiny cases is as a result of
better targeting. We were told that Medical Services "identified
through our management information system that we could make some
improvements to better target examinations, particularly to try
and avoid examinations on those people who have significant disabilities,
people who do have clearly demonstrable problems where the evidence
corroborates the level of disability and we introduced clearer
guidelines for all doctors providing that type of advice. That
is one of the significant factors which has resulted in a decrease
in the number of examinations coupled with the decrease in the
volume of examinations."[122]
The Minister also said that "What we appear to be doing is
examining fewer and fewer people but exempting from examination
people whom we are able to determine by scrutiny do qualify for
the benefit, and that must be a good thing."[123]
122. The draft Medical Quality Surveillance Group
(MQSG)[124] Annual
Report says that both Medical Services and MQSG are investigating
the fall in examinations compared to scrutiny, "to establish
whether the new lower rate reflects best practice through better
targeting of examinations...or whether it reflects problems in
medical scrutiny."[125]
However, the Chief Medical Adviser to the DSS, who chairs the
MQSG, has since said that "it was quite clear at the time
that we began to write that report in November of last year I
felt that I was not assured at all that there was a valid reason
for the fall in scrutiny to examination numbers.... although the
work that we have done since November reassures me greatly that
probably my scepticism and cynicism is unfounded...There are various
issues which comfort me in making me believe that there is a true
reduction due to understandable reasons which are not connected
with any money making schemes and that is yes, there is much more
information available now at scrutiny than there ever was. We
are into the fourth or fifth year of Incapacity Benefit. Many
people are turning up who have had earlier reports done by the
examining doctors and earlier reports from general practitioners
and psychiatrists particularly in mental health cases which will
better inform the doctor of scrutiny as to whether or not this
person's functional level is above or below that threshold. In
addition, there is evidence that there has been a reduction in
the number of cases that have been referred to Medical Services
during the period of the contract. I see that there has been a
reduction of 11 per cent in referrals."[126]
He also said, however, that "we will be looking at this in
much greater detail and we will have answers in a couple of months'
time."[127]
123. It is significant to note that the Parliamentary
Under-Secretary for Social Security has now reported to Parliament
that a recent survey by the Department's Medical Policy Group
has shown that "some Medical Services doctors are not following
the scrutiny guidelines which means that some Incapacity Benefit
awards may have been made incorrectly."[128]
As a result, the Benefits Agency has instructed Sema Group's Director
of Medical Services to take corrective action immediately to ensure
compliance with the medical quality standards specified in the
contract. The Chief Medical Adviser to DSS will also be carrying
out further audits of the scrutiny process. Furthermore, the Chief
Medical Adviser's Medical Quality Surveillance Group is making
arrangements for a joint audit, with Medical Services, of the
standard of each individual doctor undertaking scrutiny, which
is due to start in May.[129]
124. We welcome the fact that the Department has
now acknowledged that the Committee's concerns regarding the falling
number of medical examinations being carried out were justified.
However, we remain concerned that there may be structural reasons,
relating to the nature of the contract with Sema Group, why this
problem is occurring.
125. The Minister told us that "Sema get paid
the same fee whether advice is given on the basis of scrutiny
or examination, but the mechanism for ensuring that the Government
is not shortchanged is the annual review mechanism. The data on
the number of people examined is absolutely transparent. If the
numbers are going down then there is a strong basis for a claim
for an adjustment in the Government's favour in the pricing of
the contract, which is considered in the context of a number of
bids from Sema for adjustments in their favour to enable them
to do things that they would wish to do with the contract".[130]
We believe this interpretation of the role of the annual review
mechanism is open to question.
126. Mr Robin Crowder-Naylor, the Director of Medical
Services, told the Committee that "Sema does not use the
Scrutiny to Examination ratio as a mechanism to increase its profitability
of the contract..... I accept that the ratio of people examined
against cases scrutinised does have a bearing on our cost base,
but as such it is only one of many factors."[131]
Mr Crowden-Naylor also stated that "the contract allows the
S to E ratio to fall to 20 per cent. Even prior to contractorisation....
the ratio was steadily dropping and was last benchmarked at 48
per cent pre-contract."
127. We note the reasons put forward by the Chief
Medical Adviser as to why a fall in the number of examinations
might be occurring for entirely legitimate reasons. If there is
better targeting of examinations to those cases which are marginal,
then that is to be welcomed. However, there is a suspicion in
the minds of some—including the BMA and some Members of
this Committee—that the reduction is happening for financial
reasons. The mere fact that this suspicion can be entertained
is extremely worrying, as the effects of an increased use of scrutiny
rather than examination—if it is done for the wrong motives—could
result in claimants getting benefits they do not deserve. If this
is happening, it is not only unfair, but it is also an inexcusable
waste of taxpayers' money.
128. The inference could be drawn that Sema is profiteering,
although we note their insistence that they do not use this method
to increase profits. But what is entirely unacceptable and of
particular concern is that the contractual system allows such
a suspicion to be possible. We recommend that the contract
be renegotiated in such a way as to ensure that there can be no
question of profits being increased as a result of a policy which
could cost the taxpayer millions of pounds through the payment
of benefits which should not be made. We further recommend that
the Committee of Public Accounts considers inquiring into this
matter.
Pressure
to see more claimants
129. A frequently repeated concern from those who
help claimants deal with Medical Services is that examinations
are too rushed to be effective, as we noted at paragraph 29 above.
However, the average length of time spent per claimant is falling,
as the number of claimants seen in each three and a half hour
session is increasing. In September 1998 the average number of
claimants examined per session for IB was 3.8; by November 1999
there had been a steady increase to 4.4 per session.[132]
The Committee has also seen evidence suggesting that Medical Services
would like this figure to increase to an average of 5 claimants
per session.[133]
130. Medical Services responded to this claim by
stating that "we are seeing more patients on average per
session because we are managing the time, managing the scheduling,
managing the way in which people are invited to the centre. We
do take into account some local knowledge about travelling problems,
on timing scheduling. We do try to call people in who have longer
distances to travel at a later time. If they have a problem with
getting up for the early sessions we can reschedule them. There
is a client help desk which certainly is able to adjust appointments
if they are not convenient. Having said that, by....managing that
time the output per session has been raised because we are using
the doctor time more efficiently, but the pressure on each individual
doctor and each individual client has not increased."[134]
131. BASDA , however, are clearly of the belief that
the increase in the number of claimants seen per session is not
simply due to increased efficiency, and stated that they "do
not feel that a rushed approach to this work is appropriate. Clients
are entitled to feel that adequate time has been given to consideration
of their situation. A recent circular to doctors in the Bristol
region asked the doctors to work more smartly and not to provide
a better report than needed. Such a limitation of quality goes
against the doctors professional ethos."[135]
The letter referred to above, from Sema to EMPs in the Bristol
region, states that "targets will generally be achieved by
working 'smarter' rather than harder, however, in some cases it
may simply mean adopting working methods to achieve a good and
acceptable report rather than one which far exceeds the expectation
of our customer."[136]
We criticise the approach taken by Medical Services which encourages
doctors to produce reports which might be of a lower quality than
that which the doctors might want to produce. Interfering with
the judgment of medical professionals in this way is not acceptable.
132. We welcome any changes in Medical Services'
procedures which allows them to see more clients per session without
adversely affecting those claimants. However, BASDA's evidence,
combined with that which we noted above at Section III, leads
us to believe that Medical Services' increased throughput of sessions
is having an adverse effect. We believe that both claimants
and doctors can feel rushed, and that the outcome will be lower
quality reports. We recommend that the Benefits Agency and
the Department should monitor closely Medical Services' performance
in order to ensure that, by increasing claimant numbers per session,
profitability is not put before performance.
Financial
Pressures: Conclusions
133. As we have noted, the falling number of examinations
as compared to cases dealt with by scrutiny, and the increasing
numbers of claimants seen per session, lead to the suspicion that
standards are coming second to profitability. It would be naive
to blame Sema for trying to make a profit—that is their
business. The onus must be on the Benefits Agency and the Department
to monitor Medical Services and, if necessary, make contractual
renegotiations, in order to ensure that financial pressures do
not lead to a lower quality service.
116 Q 72. Back
117
Appendix 17, para 10. Back
118
Ev. p. 102, para 6.4. Back
119
Further evidence provided by the DSS, BAMS 28A, Annex 1, not
printed. Back
120
Ev. p. 39, para 4.33. Back
121
Ev. p. 35. Back
122
Ev. p. 259. Back
123
Q 523. Back
124
The group established to monitor contract compliance with medical
quality and related issues. Back
125
BAMS 41, para 7.4, draft report from the Medical Quality Surveillance
Group, not printed. Back
126
Q 528. Back
127
Q 527. Back
128
HC Deb, 10 April 2000, col 23W. Back
129
HC Deb, 10 April 2000, col 23W. Back
130
Q 523. Back
131
Letter to the Chairman, 3 March 2000, not printed. Back
132
Ev. p. 100, para 6.1. Back
133
Ev. p. 42. Back
134
QQ 235-238. Back
135
Ev. p. 39, para 4.3.2. Back
136
Ev. p. 42 Back
