Examination of Witnesses (Questions 20
- 39)
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
20. One of the concerns in the report about
the way in which SEMA doctors carry out their assessment is, as
I understand it, in the original contract the delivering of assessments
on time was not linked to payment. You have talked about increasing
the fees for doctors, which presumably incentivises them to deal
with claimants more efficiently, more effectively, more quickly
or whatever, but the same does not apply to GPs who are an important
part of the process.
(Ms Lomax) I am not sure it is within our gift. Perhaps
you would like to answer that?
(Dr Aylward) I think we should understand that the
remuneration that general practitioners receive under their NHS
terms of employment includes an element which is specifically
focused on the service that they provide the Department of Social
Security in providing these reports. To say that the reports are
rendered by GPs without fee is not really correct, there is a
remunerative element in there which is acknowledged by the GP.
On the other hand, if the GP is asked for information which is
outside of the information he needs to provide in the issuing
of a certificate or a statement for Incapacity Benefit then that
GP is paid. As Ms Lomax has said, in DLA GPs are paid for all
the information that they provide and all information they provide
in Industrial Injuries Benefit. There is an element of fee that
is available for GPs to incentivise them.
21. Let me move on then to the way in which
the customers perceive the system which they have to go through.
The report says that if customers do not feel at ease in the examination
that could influence the quality of the assessment and the information
which they give for that. That is an understatement really, is
it not? I think all of the Members of Parliament around this table
see almost weekly in their postbags concerns from people about
the way that they are treated in this system. Let me ask Ms Cleveland,
the people who are called in for assessment, are they malingerers,
are they law breakers?
(Ms Cleveland) Certainly not. They are called in for
assessment because it has got to the time of their particular
claim when a review is due.
22. If that is the case, why do people who come
to me to complain about their treatment believe that they are
regarded as malingerers and potential law breakers? Why is it
that they complain that doctors are rude to them? Why is it that
the medical examination, if they are given one, is regarded as
superficial and sometimes downright insulting to the people called
for assessment?
(Ms Cleveland) In terms of the medical assessment
I do think there is some confusion about the purpose of the medical
assessment. I am talking about Disability Living Allowance in
particular here. The medical assessment is to assess how their
disability impacts their ability to care for themselves or their
mobility, it is not a diagnostic medical examination. Certainly
from the letters I get, and I cannot judge whether they are the
same representations you get, it is a confusion that quite a short
medical assessment can actually make the assessment for DLA purposes,
but it is not the same as a diagnostic element. In terms of the
way in which people are being dealt with by doctors, clearly that
is something that we take up continually with SEMA and through
the contract.
23. When it comes down to a lady constituent
of mine who was taken in for what she regarded as a medical examination
and the doctor dropped a pencil on the floor and said "pick
it up" and when she did said "well, that is it, you
have effectively passed the assessment or failed the assessment",
whatever words you want to use to describe it, I think she has
got just cause in saying "hang on a minute, why am I being
treated in this way?" Let me move on from that. Why is it
that GPs' evidence appears to have been often ignored? They are
asked to provide evidence but it does not appear to have very
much bearing on the output.
(Ms Cleveland) I do not think GPs' evidence is ignored.
I think there is an issue about the quality of the GPs' evidence
in terms—
24. How many times do you get complaints from
GPs that they believe that the assessment result is entirely at
odds with the information that they have provided, and sometimes
provided properly, and put into the system?
(Ms Cleveland) I personally have never received a
letter from a GP about that. I just do not know the figures for
the numbers that may have come through the medical assessment
side.
(Dr Aylward) I have not received any either.
25. So you never get any letters from GPs saying
"why did you ask me for the information if it then appears
to have been ignored?"
(Ms Cleveland) I am not saying that we do not get
them in the Benefits Agency, I am saying I personally have not
had any. I can go away and make enquiries to find out how many
have we had and let you know[2].
26. Mr Jones, who actually deals with complaints
about the system?
(Mr Jones) We do have a formal complaints procedure
that has been put in place and we are continually updating and
working on that. We are continually developing that system in
terms of complaints. I would agree with Alexis in the sense that
a lot of the complaints come from the fact that people misunderstand
the purpose of the examination and they think they are getting
a full medical examination when, in fact, the nature of the examination
is different. At the moment we are updating our information in
this area and there is a new pamphlet on complaints currently
being produced and it is just ready to be signed off by the Department
for issue in the immediate future.
(Mr Raja) SEMA directly have received no such letters
from doctors, GPs, stating that.
Mr Campbell: The report seems to suggest that
you must have told the NAO that the surveys that you conduct about
customer attitudes show that most of them are content with the
examination that they get and yet the number of complaints are
rising and I would say the number of complaints in my postbag
are rising too.
Mr Rendel: Hear! Hear!
Mr Campbell
27. Which is true?
(Ms Lomax) The number of complaints in total is relatively
small, it is about 4,000 or 5,000 out of 1.3 million referrals
a year. The Customer Satisfaction Surveys have shown ratings of
over 90 per cent in recent months. There still may be a number
of very seriously aggrieved constituents but it only takes a fairly
small number to make your postbag feel uncomfortable. This is
a very difficult area. This is an area where people have been
denied benefit as the result of a medical examination, and that
is something which both GPs and customers can feel very unhappy
about. Do you want to say something?
(Mr Haighton) Indeed. It is a fraction of one per
cent, the number of people who complain, and in practice over
the last two quarters the number has declined quite significantly.
Although we recognise that there are some very serious complaints,
the volume is not as perceived, it is actually really quite small.
The Customer Satisfaction Survey, which we have now had running
for several months, and it was one which we redesigned with the
help of the National Audit Office, has actually given us consistent
rates of 92-93 per cent in the last few months. So I do not think
the anecdotal evidence quite matches the actual figures.
28. I think that is exactly my question. That
is what I cannot understand; why the impression that was created
in the Report does not seem to match up with what we as Members
of the Parliament might see. I want to move on, if I may, to look
at some figures. As I understand it, SEMA have got the contract
for five years at a cost of some £305 million over that period
and the savings are in the range of 10 to 14 per cent. Are those
figures right?
(Mr Haighton) That is correct.
29. If that is the case, 10 to 14 per cent over
that five-year period would mean savings of somewhere between
£30 million and £50 million. Is that right?
(Mr Haighton) Yes.
30. We have just been told that the fees are
increasing by 15 per cent and according to the Report the Government
are funding half of that. Is that right?
(Ms Lomax) Fees per session for doctors.
31. So that is £2 million a year?
(Ms Lomax) That is right, yes.
32. So if the savings are at the lower end,
which is £6 million a year, am I right to conclude that a
third of that is now taken up by this extra cost to the Department,
so the savings will not be as great?
(Ms Lomax) They will not be as great, no.
33. Paragraph 2.10, the Department is entitled
to £16 million worth of service credit for SEMA's failure
to meet performance targets[3].
Has that money been collected?
(Ms Lomax) Some money has been collected
in the form of a service credit.
34. How much of it?
(Ms Lomax) About £600,000. There was another
£1.6 million due to us which was basically put in suspense
against improvements in service that we wanted to see. The purpose
of that was to incentivise SEMA to put those improvements into
place.
35. So that is money the Department could have
claimed because of failure to meet targets in the past but you
have not collected it to incentivise them to meet their targets
in the future?
(Ms Lomax) Yes, as something for SEMA to go for, especially
at this stage in the contract.
36. Presumably the same incentives exist into
the future as existed in the past. They are incentivised from
day one but you have not collected on their failure to meet those
targets?
(Ms Lomax) There may be a range of reasons why we
do not collect service credits, including sometimes problems which
led to new service credits which may not have been entirely within
SEMA's control. Sometimes the judgment is that it is better that
SEMA hangs on to the money and uses it to improve service than
we take it off them with a risk of giving it back to them in the
form of putting money on top of the contract. We are having to
put extra money into this contract in order to deliver the quality
that we as a Department feel is absolutely necessary. We do not
feel that taking money off SEMA and then giving it back is a sensible
thing to do.
(Mr Haighton) If I could describe more fully what
the service credit regime is for[4].
It is there to act as an incentive, it is there to provide remedies
where the supplier has not met the targets that we imposed, but
it is also there to recognise there is not always a clear responsibility
for failure to meet these targets. For instance, there is a whole
range of things that have happened in the last year like fuel
strikes which have had a direct effect on some of this. Each month
we look at what the service levels are, we work through the reasons
and then decide whether it is proper to apply service credits
or withhold them or just abandon them, depending on the circumstances.
Chairman: Can I ask the witnesses to try and
keep the answers a little briefer or we will be here for a very
long time. Mr Gerry Steinberg?
Mr Steinberg
37. I want to pursue what Mr Campbell was originally
questioning you on. I get very cross because I see some of the
most appalling decisions, frankly, made by this Department in
terms of some of the constituents that I come to meet. I was interested
in Part 3 of the Report which is entitled "Improvements in
the quality of assessment have yet to be fully delivered."
I thought that was a bit of an under-statement really, particularly
in Paragraph 3.2 where it says: "And reporting by the President
of the Appeals Tribunals has indicated that insufficient or poor
quality medical evidence is one of several key factors affecting
the quality of decisions." Does that refer to the GPs and
the medical appeals doctors?
(Ms Lomax) It is all sources of medical evidence.
It is hospital doctors as well as SEMA doctors and GPs.
38. So insufficient or poor quality medical
evidence is affecting the quality of decisions, can we assume?
(Ms Lomax) The appeals success rate suggests that
the quality of decision-taking is not as good as it could be.
39. If there is poor quality medical evidence
which affects the quality of decisions, what can be done about
it?
(Ms Lomax) We need to improve in two areas. First
of all, we need to improve the quality of medical evidence and
there is a range of things that Mansel can expand on what we are
doing towards that, including introducing a new Diploma in Disability
Assessment. This is a particular area of medicine which needs
upgrading. We also need to improve the ability of decision-takers
in the BA to interpret the medical evidence they receive.
2 Note by Witness: The Department acknowledges
that it will have received letters in support of customers from
their GP but cannot provide any figures as these letters are recorded
under the benefit customer's name and not the doctor's name. Back
3
Note by Witness: The Department is, in fact, entitled to
£1.6 million, not £16 million, worth of service credit
for SEMA's failure to meet performance targets. Back
4
Note by Witness: Service credits can only be held over
for a maximum of three months after which they either have to
be applied or extinguished. Back
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