X PERFORMANCE SINCE CONTRACTORISATION
149. We are concerned that evidence provided by claimants
and others (such as that noted at Section III above) and the very
high rate of successful appeals indicate that the quality of examinations
and reports produced by Medical Services is not of a consistently
high standard.
150. We received evidence which suggested that performance
has not improved since Sema took over the contract, and that this
was in part because their bid was, to use the BMA's phrase, "too
lean."[151]
NACAB told us that "At the time of appointment, the CAB Service
expressed reservations that Sema Groups would, in practice, be
able to improve on the performance of the Benefits Agency Medical
Service.... The CAB Service expressed its concern publicly that
it would be difficult for Sema Group to provide a better service
and satisfy its shareholders given that they would receive substantially
lower funding than had been necessary to provide medical services.
The CAB Service's anxiety has not been lessened by the many reports
made... of poor medical examinations and the high level of successful
appeals. The volume of complaints, taken with the restrictions
of fees for examining doctors, the pressure being put upon doctors
to carry out more medical examinations in the same period of time
and the absence of liaison arrangements suggest that Sema Group
might be having difficulty in providing a satisfactory service
within the financial terms of the contract."[152]
151. We were also told that problems with the service
did not start with Sema's delivery of it, but had been present
previously. RADAR told us that "we have not noticed any particular
change over the past year. What we have noticed over the past
few years is a deterioration in the quality of the service provided
to disabled claimants.... we have always had complaints but over
the past few years these have very much increased."[153]
Advice Centres for Avon told us that "the proportion of complaints
and the lack of liaison have remained the same."[154]
152. Medical Services explained their system for
auditing quality as follows: "Medical Services have defined
a series of "Quality Statements" to cover the different
medical actions and reports that are produced in the various benefits
included within the... contract..... A comprehensive system of
random and targeted audit has been set in place to monitor the
reports produced against the relevant quality standard. The auditing
process is carried out in each of the Medical Services Centres
throughout the country.... A three point grading system has been
adopted. The "A" and "B" grades indicate a
satisfactory report. "A" grades are entirely satisfactory,
whilst "B" grades indicate the presence of a minor error
which does not affect the validity of the report, it remaining
fit for its purpose. The "C" grade is allotted to reports
which Medical Services deem to be unsatisfactory.... The overall
results from the random audit are reported to the Contract Management
Team on a monthly basis."[155]
153. The DSS told us the number of DLA/AA and IB
cases audited each month for the period January 1999-January 2000,
in each Medical Services centre, the percentage of overall workload
this represented, and the percentage of reports being categorised
as As, Bs and Cs.[156]
Unsatisfactory reports classed as Cs were the smallest proportion.
We have calculated that 8.8 per cent of DLA/AA reports and 7 per
cent of IB reports were classed as Cs. There were 23 instances
(out of a total of 299 items of audited data[157])
where twenty per cent or more of reports audited were classed
as Cs.[158]
Moreover, we are not satisfied that the numbers of cases audited
is large enough: typically, between two and three per cent of
DLA/AA cases are audited; for IB, this figure is often less than
one per cent. It should also be noted that the auditing is carried
out by "experienced and additionally trained Medical Advisers"[159]
who are employed by Medical Services. Without questioning the
integrity or professionalism of the individuals involved, we believe
that the audit would command greater confidence if it was conducted
by people from outside the organisation.
154. The Medical Quality Surveillance Group (MQSG,
see paragraph 122 above) stated that "a revised audit system
has been developed and... is due for national implementation on
1 December... One of the key changes will be the introduction
of formal training and approval processes for a limited number
of auditors, drawn from within the ranks of experienced medical
advisers at each unit."[160]
The Group concluded that "qualitative performance has been
maintained or improved in comparison with that prior to cutover."[161]
It also stated that "quantitative service level performance
has demonstrated significant progressive improvement."[162]
155. Where Benefits Agency decision makers consider
reports to be unsatisfactory, they can demand a reworked report.
The MQSG stated that "the Agreement requires that rework
does not exceed 1 per cent of output. The current overall level
in each contract package area has been consistently less than
1 per cent since September 1998. The MQSG is monitoring any trends
in overall rework levels, and in levels by benefit."[163]
It is extremely surprising that the level of reworked reports
requested is so low, especially given that 8.8 per cent of DLA/AA
reports and 7 per cent of IB reports were found to be unsatisfactory
by Medical Services themselves. We recommend that the Benefits
Agency explores the reasons why decision makers appear to demand
reworked cases so infrequently and makes systemic reforms to ensure
that unsatisfactory reports are never accepted.
156. We fear that, in view of complaints, the concerns
expressed by advice agencies and others, and the level of successful
appeals, the quality audit system is not effective in presenting
an accurate picture of the standards of reports. We recommend
that the sample of reports audited be larger, especially for IB
cases, and that the audit be carried out by an outside body, so
as to increase confidence that it is an independent and objective
exercise.
Performance since contractorisation:
overall conclusions
157. The Committee has not been convinced that
there has been an improvement in the quality of examinations and
reports since contractorisation. Some efficiency improvements
have been made: the challenge now must be to improve the quality
of reports and the treatment of claimants. Given that there is
pressure on doctors to see more patients more quickly it is difficult
to see how this can be achieved. Ministers should ask themselves
whether one of the goals of contractorisation—improved service
to the public—has really been achieved. If they conclude,
as we do, that it has not, they should take steps to renegotiate
the contract, or otherwise influence performance to ensure that
this goal is met.
151 Q 72. Back
152
Ev. p. 19. Back
153
Q 2. Back
154
Q 148. Back
155
Ev. p. 103, para 8.2. Back
156
Further evidence provided by the DSS, BAMS 28A, Annex 3, not
printed. Back
157
Overall, data was collected over 13 months for DLA/AA examinations
from 11 centres, and from 12 centres for IB examinations, making
299 items of audited data. Back
158
For example, for DLA/AA reports, Edinburgh: February and March
1999; Manchester: February, April, May, June, July, October and
November 1999; Bristol: May 1999. For IB reports, Bootle: January
1999; Edinburgh: June 1999; Glasgow: April 1999; Leeds: October
1999; Newcastle: June 1999 and September 1999; Birmingham: May
1999; Cardiff: May 1999; Nottingham: May 1999, September 1999
and January 2000; Sutton: January 1999 and August 1999. Back
159
Ev. p. 103, para 8.2. Back
160
BAMS 41, para 4.2, draft report from the Medical Quality Services
Group, not printed. Back
161
BAMS 41, executive summary, draft report from the Medical Quality
Services Group, not printed. Back
162
BAMS 41, executive summary, draft report from the Medical Quality
Services Group, not printed. Back
163
BAMS 41, para 8.2, draft report from the Medical Quality Services
Group, not printed. Back
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