Examination of Witnesses (Questions 40
- 59)
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
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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