Select Committee on Public Accounts Minutes of Evidence

Examination of Witnesses (Questions 40 - 59)



  40. What about the doctors themselves?
  (Ms Lomax) The doctors themselves?

  41. What about them? It seems to me very often the experience of doctors making decisions is not sufficient to be able do it.
  (Ms Lomax) They have got to have quite a lot of experience.

  42. They very often do not even know what some of the illnesses are about that they have to make decisions on.
  (Dr Aylward) First of all, I should point out that before a doctor can undertake examinations or give advice on behalf of the Department via SEMA they must have at least five years' experience in various specialties including general practice. The majority of these doctors are, in fact, in general practice and they are doing that work at a different time to when they work for SEMA. In addition, the doctors have to go through a series of training modules in their induction and I have to be satisfied on the information I receive from the medical director that those doctors have achieved a level that shows that they are skilled and equipped.

  43. We will come back to that. I had a case, which might sound funny, of a woman with no legs who was turned down for a mobility allowance because they said she had false legs and she could walk.
  (Dr Aylward) The decision was that the doctor had said that she could walk whereas she did not have any legs?

  44. A hell of a decision that was. You needed five years' training for that.
  (Dr Aylward) We do have and do know there are doctors in the system who should not be there and I have power to dis-approve those doctors.
  (Ms Lomax) Also look at the nature of the benefit that is being administered. The question is not whether she has got legs or not, the question is whether she is mobile and with the aid of artificial legs she might be mobile.

  45. That is a most ridiculous statement. A women with no legs is mobile because she happens to be able to walk because she has got false legs and is turned down for Disability Living Allowance.
  (Ms Lomax) The general nature of the benefit is the effect of your disability on your mobility[5]. It is not a series of clinical judgments about the objective nature of your ailment. That is one of the things which causes huge confusion. It is a very difficult benefit to administer and people do not understand this, but that is what the benefit is for.

  46. She won her appeal.
  (Ms Lomax) I do not know the details of the case.

  47. She won her appeal.
  (Ms Lomax) But I do not accept that just by describing someone's ailment you can say that is a ludicrous decision. The whole nature of this benefit is that it depends on the effect that this has on you and your ability to cope. It is not a list of clinical ailments and if you have got that then you get the benefit and if you have got something else then you do not. It is not that sort of benefit, Mr Steinberg.

  48. I find that an amazing statement. You said that you never get any complaints from doctors who have given letters to the appeals. Let me read you a letter that I got from an eminent physician who gave advice and a doctor turned down his evidence. He says: "I am writing in support of the above named appeal against the decision not to award her Disability Living Allowance. I have seen copies of the medical assessment carried out, which shows a complete lack of understanding of this lady's complex medical problems. She was first referred to me in November 1995 following a history of severe debilitating glandular fever, which failed to resolve." He goes on to give the whole of the medical terms. So here we have a doctor who frankly might see the appellant for five or ten minutes making a decision against an eminent doctor who has not only national fame but international fame on this particular subject. His advice was turned down by an agency doctor who probably did not even know what the disease was. How can that be fair or justified?
  (Ms Lomax) I cannot possibly comment on a case that I do not know the details of.

  49. You should be able to comment. You should be able to say to me "that is ridiculous" because it is ridiculous.
  (Ms Lomax) I cannot possibly comment on a case like this. I can ask Dr Aylward again to explain what the nature of this examination is in general terms but we cannot comment on individual cases.
  (Dr Aylward) May I answer that about the nature of examinations to amplify what Ms Lomax has said?

  50. Yes.
  (Dr Aylward) When you talk about diagnosis, there may be very eminent people in the world who are eminent diagnosticians and they are able to treat the disease but they may not, in fact, be very well aware and they have not been made experts in understanding the effects of the disease. The diagnosis does not matter. A particular diagnosis may have a whole range of effects upon function. But just supporting an application, and I am unable to comment on this particular case, which just relates to the diagnosis is really not going as far as we would want in looking at whether or not somebody meets the entitlement criteria for benefits.

  51. I just find this incredible. Let us move on. When complaints are actually made rarely is there ever an acceptance that errors have been made. I think your attitude today bears this out, that you are not prepared to realise that there are many, many errors taking place, frankly, by doctors who I do not think are capable of making these decisions. You do not seem to accept that. Let me give you another constituency example. This was a gentleman called Mr Dye. I wrote a letter to the Benefits Agency about his case. He was asked by the Benefits Agency to attend for a medical examination on 1 February 2000. Mr Dye was completely forgotten about in the office that he went to. They put the lights out and the cleaners came in and he was still sitting there. They then realised that he was still sitting there and the doctor came and said "we had better take him in". They took him in and he had a five minute interview with the doctor of which, Mr Dye reckons, 60 seconds was an examination. He was then told that he had failed the examination, that they were going to recommend the refusal of benefits and, in fact, he could not even read the report because it was so badly written. When I complained to the Medical Services I got exactly the same sort of answer that you have given me today. It says: "Dr Fulton stands by her medical opinion given in the report. She accepts that the actual physical examination was relatively brief", that is good of her, "it was however sufficient to enable her to complete the report to the required standard." So a 60 second medical determined this man's benefits for, I suppose, probably the rest of his life. Then it says: "I have had your letter, the report and the examining doctor's comments looked at by one of our Medical Advisers who found the report to be full, justified and the examination appropriate. Regarding the doctor's handwriting, we do not currently provide typed reports for the Benefits Agency." It is self-regulation and whitewashing everything over, not being prepared to look at the case. So I wrote to the Minister and I got the same rubbish back to be quite honest giving exactly the same information that had been given by the Medical Services. I find it quite incredible that people's lives are in many respects ruined because of bad decisions that are taken in some cases by obviously incompetent doctors. This is only one case I have given you. I can give you another case. I can go through the last 13 or 14 years where I can give you files of cases. It does not seem to me to be good enough. By the way, Mr Dye went to appeal and won his appeal, so the decision was wrong in the first place. So he went through all this trauma, all this stress, and then he won his appeal. Something is drastically wrong when this happens.
  (Ms Lomax) We do accept that medical quality is a problem and that is something that this contract was designed to address and we are working on. We have a large number of initiatives in hand to improve it. To that extent I accept what you are saying, things are not good enough and we are trying to improve them.

  52. I think what really needs to be done is that the complaints need to be investigated properly and independently by somebody, not by the Medical Services who are actually carrying out the examination in the first place. Like any self-regulation they are hardly likely to come out and say "you were useless", are they? Are you prepared to look at this and see if there could be a different system for investigating complaints because complaints are really going up, are they not?
  (Ms Lomax) May I ask Norman to explain what we are doing about this?
  (Mr Haighton) After the Select Committee hearing of a year ago we had a complete review of the whole complaints process with SEMA. We put in place a whole new set of processes. There are complaints managers who handle these. The original doctor is asked for an explanation of what happened. There is an independent tier in place for people to go to if they do not think that the process has been properly followed. We are monitoring, or beginning to monitor, the quality of some of those responses. This is a fairly recent development. We have actually done a lot of work to tighten up and improve that process very significantly. I think it might be helpful if SEMA were invited to describe their work on the process.
  (Mr Raja) I can add to that in terms of better quality of responses. We now have trained 86 staff, who are admin[6] who deal with the nature of the complaints and how we respond. The training finished in mid-March so it is a bit early to evaluate what the future outcome of that is but we will be keeping a close eye on it. We have also trained doctors in customer care and how they deal with the claimants in those situations. We are producing better information and a new leaflet, as Mr Jones mentioned earlier, will be ready shortly for distribution. The overall process on complaints and how we handle them is continually being reviewed and takes into consideration all complaints that we receive.

  53. I just want to ask you one more question. What it boils down to at the end of the day is they do not get the decisions wrong in the first place. Having read this report and from my own personal experience of constituents who come to me, I am not very impressed by the examination system at all. I was horrified to read in paragraph 3.11 that many of the doctors who SEMA employ actually refuse to go on training courses. They will not even go on training courses.
  (Mr Jones) That was true but that has now been rectified.

  54. Explain how it has been rectified.
  (Mr Jones) Because we have introduced a training procedure now and we have managed to train large numbers of doctors now.

  55. In the report we have it says that in November 2000 only 26 doctors had actually gone on a training course for the diploma. Out of how many?
  (Mr Jones) For the diploma? That is a different thing.
  (Dr Hudson) Can I just make one point, Mr Steinberg. You have been talking about very distressing cases, and I do accept that, but I would like to make the point, however, that SEMA doctors do not make decisions about benefit entitlement, that is the role of the decision maker. The doctors provide part of the medical evidence.

  56. Obviously, yes, I am aware of that.
  (Dr Hudson) The doctors do not make decisions on benefit entitlement.

  57. They make a recommendation though.
  (Dr Hudson) They do not make a recommendation; they give an opinion upon which the decision-maker makes his or her decision.

Mr Williams

  58. But the quality of the evidence surely makes a difference to the decision? That is a ludicrous defence.
  (Dr Hudson) I believe it is not. Clearly others would want to talk about the role of the decision maker. I would like to take up the point about the training which we do regard as a very important issue for all of the doctors that work for SEMA, whether they are employed or whether they work on a sessional basis. You were talking about a diploma and this is a new initiative that has been put together externally by the Faculty of Occupational Medicine and the Department, and SEMA were very pleased to be part of that and to start sponsoring doctors to take this, which is an academic qualification over and beyond the sort of training that doctors have in order to do this work. We are pleased that a number of doctors have been able to take that. The normal training courses that doctors undertake are partly induction into the various benefit streams and partly a five-day continuing medical education programme which all doctors who are in SEMA will have taken part in by the end of this year.

  Mr Williams: Thank you. Mr Rendel?

Mr Rendel

  59. Mr Jones, can I start with you. How often do you recruit doctors to SEMA?
  (Mr Jones) I think we should clarify first that SEMA itself employs directly 180 doctors. The vast majority of the doctors that carry out examinations are contracted doctors or panel doctors that are recruited and fit in this work around other commitments.[7] They have been accepted as qualified, as Dr Aylward said earlier.

5   Note by Witness: The general position is that the effects of the disablement must be assessed. If, for example, a one legged person can make effective use of a prosthesis, he/she is not "virtually unable to walk". However, legislation provides for certain disabilities to result in entitlement to benefit. Back

6   Note by Witness: Of the 86 trained members of staff 70 work in administration and deal with the nature of the complaints and how SEMA Medical Services respond. Back

7   Note by Witness: The term "contracted" refers to doctors who work for SEMA on a sessional basis and who, frequently, are also engaged in clinical practice. Back

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