Examination of Witnesses (Questions 1
- 19)
WEDNESDAY 21 MARCH 2001
MS RACHEL
LOMAX, MR
NORMAN HAIGHTON,
DR MANSEL
AYLWARD, MS
ALEXIS CLEVELAND,
MR FRANK
JONES, MR
ZAFAR RAJA
AND DR
CAROL HUDSON
Chairman
1. This afternoon we are considering the Comptroller
and Auditor General's Report on the Medical Assessment of Incapacity
and Disability Benefits. We welcome Rachel Lomax, Permanent Secretary
of the Department of Social Security, who has been with us several
times, Frank Jones, Executive Vice-President of the SEMA Group,
and I think we can go straight into it. Mr Jones and others from
SEMA, just to explain the procedure, I will try to give you some
guidance as to which part of the report I am referring to in each
question. I will start, Ms Lomax, with paragraph 2.12 and figure
14 which show that most Disability Benefit Centres exceed your
target time of 30 days for clearing new Disability Living Allowance
claims. The average time in one centre is 46 days. As a result
many claimants have to wait several weeks longer than they should
to get their money. Why does it take so long and what are you
doing to improve this?
(Ms Lomax) Why does it take so long?
2. Yes.
(Ms Lomax) A number of reasons. Are you talking about
Disability Living Allowance and why does it take more than 30
days?
3. Yes.
(Ms Lomax) The need to get medical evidence from a
number of sources means delays can be outside the Department's
control. There are a number of reasons why it might take a long
time to clear a DLA claim, both within the Benefits Agency and
also the reliance on evidence from outside the Agency. It is a
heavily clerical operation still. I think it is fair to say, it
is not well supported by IT. There is a certain amount of paper
chase between the centres where the claims are taken and local
offices.
4. Are you doing anything to streamline that?
(Ms Lomax) Yes, there is a modernisation programme
which has been under way since 1998. Would you like to add anything,
Alexis, you know more about it?
(Ms Cleveland) In advance of waiting for the new IT,
which is at the heart of the modernisation programme, what we
have been doing is setting up business models that actually map
out the process. Looking at where the delays in the process are
and tackling those is our matter of first urgency in terms of
trying to improve the speed which all of those processes take.
Although, as Ms Lomax said, some of those seem to be directly
outside our control, the way in which we approach doctors, the
way in which we ask claimants to fill in forms, the way in which
we liaise with SEMA, are all things that we are looking to tackle.
5. Thank you. Ms Lomax, paragraphs 2.14 to 2.15
of the report tell us that it can take between 90 and 170 days
to complete the review of Incapacity Benefit cases and that such
delays could be wasting up to £40 million a year. What are
you doing to tackle those very large variations and backlogs?
(Ms Lomax) The £40 million that you refer to
here is clearing the once-for-all backlog, is it not?
6. Yes.
(Ms Lomax) The honest answer to that—
Chairman: It is per annum.
Mr Williams
7. It is wrong appeals.
(Ms Lomax) There are two sources of delay which this
report drew attention to. There are two areas where the NAO suggested
we might make savings. One is trying to reduce the underlying
backlog, where I think the honest answer is that we do not have
any plans to break into the underlying backlog at the moment,
partly because we are having difficulty in getting down to the
levels of backlog that there were when this report was compiled,
for reasons which we will no doubt go into later on. The area
where we do have plans to make progress, and Alexis will no doubt
want to speak more about this, is trying to reduce the variations
between different centres.
(Ms Cleveland) At the moment we are doing several
things. Again, we have got another business model which is now
a computerised model and that will be ready for this April and
we will be putting that on our local intranet so that is available
to staff locally. The biggest challenge we actually face in making
significant improvements here is the lack of management information
that we have. The information that is provided here was taken
from a sample of cases where we backtracked on performance. We
do not have regular information on the length of time it takes
to do some of these processes, so our first action is to put some
management information processes in place and then we will be
able to identify where the issues are and tackle them.
Chairman
8. I see there are two sets of £40 million
and that is why there is confusion here. Some of it does relate
to backlog and I am sure others will come back on that. Enormous
effort goes into the assessment of these benefit claims by the
Benefits Agency, by SEMA Group and by GPs up and down the country.
Yet paragraph 15 shows high rates of successful appeal and the
Appeals Service has indicated that the interpretation of evidence
is a factor in a quarter of the decisions they change. Why can
you not eliminate this confusion for claimants on whether or not
they are entitled to be paid these benefits?
(Ms Lomax) I think there are a number of reasons why
the success rate at appeal is so high. Sometimes it is because
claimants appear in person at the interview and further evidence
comes out at that stage. I think the area where we could make
more progress is in the interpretation of medical evidence by
decision takers in the BA. That is where I think we need to have
feedback from the Appeals Service and the tribunals to the people
in the BA who are taking decisions. When we introduced the "decision
making and appeals" legislation, we probably reduced attendance
at appeals and lost some information there. We need to close that
loop. You have got various plans in hand.
(Ms Cleveland) We have already set up a working group
with the Appeals Service to actually get feedback on this advice.
The other issue we are looking at is the use of presenting officers
at appeals, whether someone from the Agency goes along to the
tribunal as well, and we are looking to run a pilot linked to
one of our Disability Centres to see whether that makes a difference
in terms of the decision making at the appeal. The customer can
always offer new medical evidence at the appeal which may change
the decision. That does not mean to say that the original decision
was wrong.
9. I am sure that somebody will come back on
this because it comes up in constituency matters all the time.
Let me move to Mr Jones. This refers to figure 17 on page 28 of
the report and also paragraphs 3.23 to 3.24. Figure 17 on page
28 shows that between five and 12 per cent of reports were unacceptable
by your own quality monitoring standards, and paragraphs 3.23
to 3.24 show that 20 to 30 per cent of scrutinies did not comply
with the guidelines set. How can you justify this level of assessments
that are below standard?
(Mr Jones) We take the issue of medical quality very
seriously. Clearly we have introduced, since we started the contract,
an internal quality audit system in order to improve the quality
of medical examinations. We have developed this jointly with the
Department and they validate it and are satisfied that we have
improved the quality of the medical examinations, although there
is still quite a way to go as the figures show.
10. Do you have any later figures than this?
(Mr Jones) We do have some later figures. Since the
Select Committee we have been working to the new Government medical
quality targets that were set from the Select Committee and we
are approaching achieving those targets already. I think we do
have some updated information.
(Dr Hudson) Yes, we do have some updated figures for
figure 17. They are internal figures so may not necessarily have
been validated by the DSS which is why we have not presented them.
It does show that we have still got some way to improve in the
way of examining medical practitioners in the customer home area.
That is still an unsatisfactory rate of ten per cent, however
that is lower than the 12 per cent that is shown in that particular
area. Of the others, on Incapacity Benefit the unsatisfactory
is three per cent. However, the totally satisfactory A grade reports
on Incapacity Benefits have gone up to 88 per cent. In SDA the
figures are very much the same. Clearly we know where we need
to turn our attention next in those areas.
11. At least it is in the right direction but,
as you say, there is still some way to go. Part 4 of the report
reveals a disturbing picture of the quality of service to benefit
customers, with people being turned away from pre-booked appointments,
higher levels of complaints and concerns about poor customer service
to people from ethnic minority groups. How can you be satisfied
with the quality of your customer care and what are you doing
to improve that?
(Mr Jones) First let me deal with the overbooking
problem and turning people away. Obviously we share the concerns
that the report raises in that area. It is important to understand
that the problem is caused by the large number of people who do
not attend the appointments that have been made for them. Up to
30 per cent of the people do not attend. Therefore, if we did
not do something in terms of overbooking there would be a significant
lack of use of the scarce doctor resource, which no doubt we will
come back to, if only two-thirds of the time was spent investigating
people. We acknowledge that one of the other areas that we are
looking at is paying the doctors on a fee per case basis rather
than on a session basis to give more flexibility because forecasting
what is going to happen at a particular session is very, very
difficult. We are introducing at this point in time a new system
where we pay doctors on a fee per case which will encourage them
to stay and clear backlogs if people turn up and there are overbooked
attendances. I think it is fair to say that on the figures there
are ten times more people who do not turn up than we actually
turn away.
12. Even so, it does not help the ones who are
being turned away. Let me move on because others will come back
to that one I suspect. Back to you, Ms Lomax. Paragraphs 3.13
to 3.17 and your memorandum show the severe effects that doctor
shortages are having on SEMA Group's ability to meet service delivery
targets and it is not unreasonable to believe that this could
get worse. SEMA Group proposed three years ago that you should
make greater use of other healthcare practitioners in this work
and yet nothing has happened. What are you doing to ensure that
there is a viable workforce which can deliver the medical assessments
you need to time and quality standards?
(Ms Lomax) The measures that SEMA have just announced
to raise pay for sessional doctors by 15 per cent on 1 April addresses
probably what is at the heart of the matter. The research that
was done last year showed that poor pay was a major reason why
the doctor shortage had arisen. There are a number of other measures
that SEMA are introducing to recruit doctors. They have a very
vigorous doctor recruitment campaign starting and I hope that
the position will get better. We are putting something like £2
million into the contract to help fund the higher pay for doctors.
We hope that that will bring results. We are putting in an audit
trail to make sure the money does indeed go towards paying for
doctors.
Chairman: There are some other questions that
I will come back to at the end if they are not met.
Mr Campbell
13. Ms Lomax, if I can start with a point that
the Chairman picked up on when he talked about the backlog and
he was also referring to the delay in processing assessments for
Incapacity Benefit. I note, for example, that in the office serving
my region, which is Tyne Tees, it takes more than 20 days to process
assessments. You seemed to be suggesting to the Chairman that,
in fact, the position is now worse than when the report was produced,
is that right?
(Ms Lomax) It is, yes. If you look at the memorandum
that we put to the Committee last week it explains how, during
the course of last year, we became aware that the doctor shortage
was a lot worse than we had realised. Then the clarified guidelines
were introduced in November, which are referred to in the NAO
report, and that led to a very sharp rise in the number of IB
cases going to examination and put great pressure on the dwindling
pool of doctors that SEMA had. As a result of that backlogs have
built up quite sharply. We have decided to hold them back in the
BA in order to give SEMA a bit of breathing time to recover. We
are hoping that the recovery will be complete in most areas in
May or June but in some areas it will be the end of this year
before we get back to the position that we had last year.
14. About half the time the delays are in the
bit that SEMA deals with, are they?
(Ms Lomax) Yes. This is a delay that has grown as
a result of doctor shortage. It is not the underlying delay as
a result of the complicated and unduly paper based process of
BA.
15. So how do you bear down on what is a problem
both for yourselves and for SEMA?
(Ms Lomax) The only answer has got to be more doctors.
That is why we have agreed to put extra money into the contract
to fund a very sharp increase in pay for sessional doctors who
are the ones conducting the IB examinations.
16. Let me turn to that then. As the Chairman
has suggested, on Incapacity Benefit, and as I understand it from
time to time people receiving Incapacity Benefit are called for
assessment, some will remain on benefit and some will not but
of those who, in a sense, lose their case 50 per cent of the rejections
appeal and 40 per cent of that 50 per cent have the decision overturned.
That is not a very accurate system, is it?
(Ms Lomax) That quite a lot of the appeals succeed?
17. It seems very odd that of the thousands
of people who are called half of them win their case the first
time around and then of the other half who are rejected for 40
per cent of them the decision is overturned.
(Ms Lomax) I think this is the issue that the Chairman
drew attention to which is that there is some room for the decision
takers in the BA to learn from what happens at the appeals stage,
to make sure that we do get better quality of decisions, and that
decision takers are interpreting medical evidence correctly. What
disturbs me most is those appeals which succeed because people
in the BA misinterpreted the medical evidence that they had the
first time around. There will always be some appeals that succeed
because people's circumstances are found to have changed or because
they bring fresh evidence when they get to appeal. There were
25 per cent of cases, which the NAO refers to, where the BA decision
taker misinterpreted or did not interpret the medical evidence
correctly. That is something we could and should do something
about.
18. Am I right that GPs are not usually paid
for providing the information?
(Ms Lomax) It is part of their terms and conditions
of NHS service that they do IB exams[1].
That is not true for DLA. For DLA we pay them extra money. For
IB it is part of their NHS terms and conditions.
19. It is not excusable if they do not provide
the information in the form that you want but it is not altogether
surprising, is it, that forms sometimes are not returned or insufficient
detail is provided because they do not have the extra incentive
that payment would perhaps provide?
(Ms Lomax) It is part of their terms and conditions.
It is not a choice available. But I do take the point you are
making. Yesterday the Prime Minister was talking about the burden
of paperwork on GPs which is something that the Government is
concerned about. As part of that, we have taken part in a Cabinet
Office study looking at how we might be able to contribute to
lightening the load of paperwork for GPs. That is one area where
we thought we might be able to make more use of nurse practitioners,
in lightening the load on GPs.
1 Note by Witness: Part of the terms and conditions
of NHS Service is that employees undertake IB work, not IB exams. Back
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