Memorandum submitted by the Department
for Work and Pensions (MS 01)
1.1 The Government is pleased to report
that all the recommendations made by the Social Security Select
Committee in its report in April 2000 of its inquiry into Medical
Services have been addressed.
1.2 Since publication of the report, and
the Government's response in June 2000, Medical Services' performance
has demonstrated significant and ongoing improvement in all three
key areas of: service level delivery, customer care, and medical
quality and professional standards. The Government and Medical
Services both recognise and acknowledge that improvement is a
continuous process, and that further achievements can be made.
But the Government is impressed by the very tangible evidence
from Medical Services of renewed determination to succeed.
1.3 In particular, the new senior management
put in place by Schlumberger when they took over Sema Group in
April 2001 to form SchlumbergerSema Medical Services, has demonstrated
clear commitment to working together with the Department for Work
and Pensions to achieve continual improvement in performance.
An extensive Change Programme has been implemented to improve
service delivery. The Programme fully supports the Government's
commitment to modernising the delivery of service to customers;
and its commitment to helping and supporting people off benefit
and back into work.
2.1 All the recommendations made by the
Select Committee in its report on Medical Services have been addressed.
Specific examples of action taken include:
Development of an ongoing programme
of continuing medical education for all doctors. This incorporates
and extends beyond the training specified in the target set by
Development of a number of specific
training modules on disability awareness and customer care.
Development of a system for objective
evaluation of the effectiveness of training.
A thorough review of complaints handling
and effective remedial action.
Clear information to claimants about
the medical assessment process; the availability on request of
interpreters or same-gender doctors; and the complaints process.
Clarification of the Incapacity Benefit
scrutiny guidelines, and removal of any financial incentive to
clear cases by scrutiny rather than by examination.
Implementation of a fee increase
Active sponsorship of the Diploma
in Disability Assessment Medicine.
2.2 Details of the action taken in response
to individual recommendations are at Annex 1.
3.1 In its response to the Select Committee's
report, the Government set four targets by which tangible improvements
in service and medical quality standards would be judged:
Within six months to reduce the proportion
of "C grade" medical reports which fail to meet the
Department's standards by 10 per cent; and within one year to
reduce the proportion of "C grade" reports across all
benefits to less than 5 per cent
Within one year to demonstrate improvement
in compliance with the agreed medical scrutiny guidelines for
Incapacity Benefit claims so that the proportion of non-compliant
reports is less than 5 per cent
Within one year to deliver training
to all doctors covering: the assessment of people with mental
health problems; behaviours, attitudes and sensitivities for dealing
with people with disabilities; and distress-avoiding techniques
for the examination of people with musculo-skeletal conditions
Within two years to improve customer
satisfaction rates to at least 90 per cent
3.2 Medical Services have delivered these
targets, as monitored by the IMPACT Contract Management Team:
The target for "C grade"
reports relates to the proportion of "C grade" reports
averaged across all benefits. This figure has fallen to 3 per
cent. The most recent figure for Incapacity Benefit "C grades"
is 2.4 per cent. The most recent figure for Examining Medical
Practitioners (EMP) reports is 6.4 per cent, which is a significant
improvement. At the time the targets were set, the proportion
of "C grade" EMP reports was around 12 per cent.
Non-compliance with scrutiny guidelines
is also below 3 per cent.
All doctors employed or contracted
to work for Medical Services have received the specified training,
and also a number of other training modules, relating to customer
care and to assessment of specific disabling conditions. These
modules form part of an ongoing programme of continuing professional
education, discussed and agreed with the Department's Chief Medical
The most recent customer satisfaction
surveys showed a satisfaction level of 96 per cent.
4. MEDICAL SERVICES'
(i) Service Levels
4.1 Medical Services' performance against
service levels fell in late autumn 2000, particularly in relation
to Incapacity Benefit examinations. There were a number of underlying
Doctor attritiona number of
doctors had resigned earlier in the year when work volumes were
The effects of a catching-up exercise
in continuing medical education, with training being delivered
to a large number of doctors in the summer and early autumn of
An increase in the Incapacity Benefit
scrutiny to examination rate from around 35 per cent to around
65 per cent following clarification of the scrutiny guidelines.
4.2 A recovery programme has been successfully
implemented and has resulted in a 17 per cent increase in the
number of examinations performed in 2001 compared to 2000, with
a further 10 per cent increase expected in 2002.
4.3 In autumn 2000, the number of deferred
Incapacity Benefit examinations was around 250,000. All the deferred
cases involve claimants in receipt of Incapacity Benefit who are
due to have their entitlement reviewed. This rose to a peak of
around 350,000 in spring 2001, on account of the factors outlined
above. Since then the number of deferred cases has steadily reduced.
It now stands at around 220,000, and is predicted to fall below
100,000 by spring 2003.
4.4 The improvements which have been implemented
Better workflow planning and management,
with closer working between the Department and Medical Services.
More flexible use of doctor capacity,
including options to work more flexible hours, including evening
and Saturday sessions.
Offering additional payment to doctors
agreeing to cover areas of doctor shortage.
An improved pay package for doctors.
Sessional doctor fees were increased by 3 per cent in September
2000, and by a further 15 per cent from April 2001.
Recruitment of additional doctors,
both directly employed and sessional.
4.5 Changes have also taken place within
the Benefits Agency and Jobcentre Plus. The priority of this work
has been raised, and a clear steer has been given on working in
partnership with Medical Services to agree the volume of referrals.
Details of deferred cases by Area Directorate are shown in Annex
4.6 Previously the price for an Incapacity
Benefit scrutiny report or an examination was the same. The contract
has been re-priced to remove a potential perverse incentive to
clear cases by scrutiny rather than by examination and to simplify
commercial negotiations. The current scrutiny to examination rate,
following clarification of the scrutiny guidelines in November
2000, and a series of joint seminars for scrutiny doctors by the
Department and Medical Services in April 2001, is around 50 per
cent. Details by contract package area are shown in Table 1.
SCRUTINY TO EXAMINATION RATES
||December 00||December 01
||January 02||February 02
(ii) Customer care
4.7 A number of new, contractually binding, customer
care targets have been agreed, relating to:
Provision of same-gender doctors on request.
Provision of interpreters on request.
Customer waiting time at examination centres.
Customers being sent home unseen.
Timeliness and quality of response to complaints.
4.8 All customers receive clear written information about
the assessment process; about the availability of interpreters
or same-gender doctors on request; and about Medical Services'
complaints process. The information also explains clearly the
difference between a complaint and a request for reconsideration
of an adverse benefit entitlement decision.
4.9 The appointment system for examinations has been
made more flexible, and now offers customers the option of evening
or weekend appointments.
4.10 The timeliness and quality of response to complaints
is monitored regularly by the IMPACT Contract Management Team;
and management action by Medical Services is automatically triggered
if a doctor receives multiple complaints.
(iii) Medical quality and professional standards
4.11 Medical Services have developed a comprehensive
induction training programme for all newly-recruited doctors.
They have also developed a robust and comprehensive programme
of continuing medical education, which is delivered to all doctors
on the basis of individual personal development plans and training
needs analysis. Both training programmes have been agreed with
the Department's Chief Medical Adviser.
4.12 The Medical Skills Database which is now in place
captures full details of each doctor's skills, training, and quality
performance, both in terms of quality audit of the doctor's work,
and any complaints received about the doctor.
4.13 Medical Services have demonstrated their strong
support for the Diploma in Disability Assessment Medicine (DDAM)
by sponsoring doctors to train for and sit the examination; and
by offering financial recognition to employed doctors who achieve
the Diploma. Over 50 doctors currently hold the DDAM, the majority
of them Medical Services doctors, and a further 25 doctors so
far have expressed an interest in sitting the examination in 2002.
5. THE GOVERNMENT'S
5.1 The contract for Medical Services was awarded for
five years from September 1998, with the option of a two year
extension. In November 2001 the Government announced its decision
to extend the contract by two years, to August 2005. The extension
is subject to confirmation, and subject to Medical Services satisfactorily
delivering detailed conditions for improvement.
5.2 Sema Group, who were awarded the contract in 1998,
were taken over by Schlumberger in April 2001, to form SchlumbergerSema
Medical Services. The new company installed new managers at senior
level. The new management has demonstrated its commitment to close
working with the Department to improve both current performance
and future service delivery.
5.3 The new senior management structure of Medical Services
has from the start demonstrated a determination to succeed in
delivering the contract. There has been tangible change in attitude,
and in implementation of improvements. This has been demonstrated
in the achievement to date of a number of new targets for performance
improvement. Changes within the Department at senior management
level have resulted in much closer working between the Department
and Medical Services, with regular performance review at strategic,
as well as at day to day, level.
5.4 Confirmation of extension of the contract is subject
to Medical Services meeting the targets set out in the IMPACT
amendment document. These include achieving new performance targets
The number of Incapacity Benefit examinations
Medical quality standards.
Contractual changes to secure continuity of service
at contract end.
Delivery of a number of milestones in the Medical
Services Change Programme which SchlumbergerSema have introduced
to improve service delivery. Details of the Change Programme are
5.5 Performance in key areas has improved, particularly
in relation to Incapacity Benefit examinations and medical quality
5.6 The Government believes that an extension to the
contract offers the best opportunity to make the service improvements
it wishes to see, and Medical Services are on target to deliver
the required improvements, and to participate fully in the Department's
future programme of work in support of the Government's objective
to modernise delivery to customers, and to help people into work.
6. MEDICAL SERVICES
6.1 Medical Services have embarked on a Change Programme
to improve service delivery. They are working in close co-operation
with the Department on a series of projects:
Evidence based medicine.
Governance and key performance indicators.
6.2 This project aims to ensure that doctors advising
on Incapacity Benefit claims have access to all relevant medical
information from the claimant's own GP case notes. A pilot is
under way in Rotherham and Sheffield, with GPs and claimants who
have given their consent, for Medical Services to access GP case
notes and extract the relevant information, instead of asking
the GP to provide a written report. The pilot has been well received
by the BMA, and also supports the Cabinet Office initiative to
reduce the burden of paperwork for GPs.
Evidence based medicine
6.3 This project aims to secure consistency in conducting
medical examinations and selection of appropriate functional descriptors
in the Incapacity Benefit Personal Capability Assessment (PCA).
It is based on use of fully researched medical protocols for examination,
associated with an IT application. Four protocols are being developed,
covering musculo-skeletal, cardiovascular, respiratory, and mental
health conditions. The outcome will be high quality, consistent
reports, based on best medical practice, which will contribute
significantly towards consistent and robust decision making. Computer-generated
printouts will ensure legibility.
6.4 A pilot will start in June 2002, with phased roll
out to all examination centres over the next two years. Doctors
will be in a position to implement training in the best medical
practice approach from an early stage of roll out, but time is
needed to install the necessary IT in all 200+ examination centres.
Viable doctor pool
6.5 This is a project to ensure recruitment and retention
of the right number of doctors, with the right medical and interpersonal
skills, in the right places to deliver the required service levels
at a satisfactory quality standard. The selection process looks
at the doctor's interpersonal skills, aptitude for the work of
disability assessment, and willingness to adapt to the new skills
required, as well as their previous clinical experience. More
than 40 new offers of employment have been accepted since December
2001, with more than 20 new doctors having already joined the
6.6 It is more than a recruitment project: it also develops
a career path in disability assessment medicine for employed doctors.
It ensures appropriate personal professional development; and
that all doctors working for Medical Services will meet the professional
standards required for revalidation by the General Medical Council
(GMC). The outcome will be a skilled and motivated workforce,
which sees a future in disability assessment medicine, thereby
enhancing retention of doctors as well as recruitment.
6.7 Medical Services and the Department have embarked
on improved joint forecasting of resource requirement, to enable
better planning of the medical workforce required to meet service
6.8 Sponsorship of the DDAM is part of this project.
Medical Services are committed to sponsor a minimum of 20 employed
doctors to sit the Diploma this year, and up to 35 doctors in
each of the next two years. A comprehensive training plan is being
developed for aspiring candidates. The Department is sponsoring
sessional doctors who carry out work on its behalf; up to 20 bursaries
per year will be available to cover examination fees.
6.9 Recruitment of sessional doctors also continues,
and a number of these have received induction training over the
past few months.
"Did Not Attend"
6.10 This project, having successfully completed its
pilot stage, is being rolled out nationally. Its aim is to better
manage the appointment scheduling system for examinations, to
reduce the number of claimants who are given an appointment but
fail to attend. Through a combination of offering claimants greater
flexibility and choice of appointment times and dates, and a telephone
booking system, the "Did Not Attend" (DNA) rate has
been very significantly reduced in the pilot areas.
6.11 In some areas, the DNA rate was as high as 30 per
cent. This meant that, to avoid wasting scarce resources, Medical
Services operated a policy of overbooking examination sessions.
However, if all claimants called turned up, a proportion would
have to be sent home unseen. The project has reduced the DNA rate
from around 30 per cent to around 4 per cent in the pilot areas
of Derby and Stoke; and there has been similar success since the
recent roll out to Bootle. This reduction in DNA rate allows for
more accurate scheduling of examination sessions, and in turn,
a reduction in the number of claimants sent away unseen on account
6.12 This initiative has also introduced a mechanism
to provide Decision Makers with more comprehensive information
in the event of a claimant failing to attend. If a claimant is
unable to show "good cause" for failing to attend an
examination, the Decision Maker can disallow Incapacity Benefit.
The initiative will allow Decision Makers to make more robust
disallowance decisions in this circumstance, with the aim of minimising
the number of cases which go around the loop.
Governance and key performance indicators
6.13 This project has looked at management information
available to monitor performance against contractual obligations,
to reduce gathering and scrutiny of excessive amounts of information
while at the same time ensuring that key information regarding
performance measures is collected, analysed, and used by both
Medical Services and the Department to ensure continual improvement.
6.14 Governance arrangements have also been reviewed,
and a new structure for interface meetings, with more focused
terms of reference, has been developed. This will facilitate closer
working at all levels within Medical Services and the Department,
and joint ownership of performance within the end-to-end Medical
27 March 2002
Committee Recommendations: Progress Update March 2002
Sixth Report: Medical Services (HC 183) Published:
20 April 2000
Government Reply: (Cm 4780) Published: June 2000
(a) Time Spent With Claimants
We recommend that no reduction in average times spent examining
claimants should be allowed to occur, unless hard proof can be
deployed to show that there has been a genuine increase in claimant
satisfaction. We are sceptical that the two can occur simultaneously.
We also recommend the present duration of examinations be monitored
by the Medical Quality Surveillance Group to ensure that they
are sufficient to enable the doctors to produce accurate reports
without being under pressure of time.
The Government insists that sufficient time is given to claimants
at examinations so that in providing a "fit for purpose"
report for decision makers Medical Services does not compromise
the achievement of claimant satisfaction.
The Government believes it is essential for doctors to provide
sufficient time during an examination to enable the claimant to
describe the effects of their condition in their own words. The
doctor may or may not agree with the claimant's own assessment,
but the Government recognises that failure to listen to the claimant
increases the risk that the doctor's report will fail to advise
the Benefit Agency's decision maker of relevant matters, which
could affect the decision on benefit entitlement, and lead to
a decision being overturned at appeal.
All examination forms now show the time of starting and completing
Examination sessions are booked more flexibly, to allow doctors
to decide how many claimants to see in a session. If a doctor
sees more than his or her average in a session, the reports for
that session are automatically monitored.
(b) Inaccurate or Distorted Recording of Information
We recommend that Medical Services design and implement a
system of recruitment, training and monitoring that ensures that
its doctors can perform the fundamental task of information recording
to an accurate standard. Action should be taken to dismiss those
doctors who consistently fail to attain the necessary standard.
More rigorous recruitment criteria and procedures have been
introduced as part of the contract with Medical Services. These
require that doctors recruited by Medical Services must:
be fully registered with the General Medical Council;
have at least three years' post registration experience
including one year in general practice and at least six months
in psychiatry, rheumatology, rehabilitation, or occupational medicine;
have at least five years' experience in general
Doctors have to be approved by the Department's Chief Medical
Adviser on behalf of the Secretary of State before they are permitted
to undertake examinations on claimants or render medical advice
in regard to benefit claims. Medical Services must demonstrate
that doctors have attended the appropriate training and have passed
a formal multiple choice question paper on completion. Doctors
must also have achieved a satisfactory standard on 100 per cent
audit of the first examinations or reports undertaken.
In order to address the deficiencies in the quality of EMP
reports Medical Services set about the revision of guidance for
EMPs. Following approval of the revised guidance by the Department's
Chief Medical Adviser, it has been issued to all EMPs. In addition
Medical Services has commenced an in-depth programme of EMP training,
with a series of initiatives designed to improve performance.
Particular emphasis will be given to assessment of mental health
conditions, and to the appropriate use of personal descriptions
in reports. Evaluation of the training will include robust analysis
of the competencies of EMPs in gathering and recording accurate
and relevant information obtained in the examination and assessment
of claimants. The recent introduction by Medical Services of a
comprehensive Medical Skills Database for doctors will substantially
improve their ability to deal with matters of individual quality
and performance. This database records details of the doctor's
medical background, training received, and outcomes of quality
audit of the doctor's work. The database will be further developed
to also record details of complaints against the doctor.
The Government shares the Committee's views that poor performance
in these competencies should not be tolerated. Action is already
taken by the Department's Chief Medical Adviser to withdraw approval
from those doctors who consistently fail to attain the required
standards. To date 14 doctors have had their approval withdrawn
for this reason.
(c) Legibility of Reports
We agree [with those who raised the matter in their evidence]
that illegible reports are unacceptable.
The Government also shares the Committee's view that reports
which are illegible should not be tolerated. If a decision maker
is unable to read a report it will be returned to Medical Services
for rework. Doctors are no longer used if they fail to demonstrate
fundamental skills in recording information to an accurate standard.
Work is in progress to investigate an IT based, electronically
completed form, to reduce the need for doctors to produce lengthy
Electronic completion of IB report forms is being piloted
as part of the Evidence Based Medicine project, with full roll
out to all examination centres expected to have taken place by
March 2004. Doctors whose hand-written reports remain illegible
are asked to provide typed transcripts.
(d) Training in Customer Care
We recommend that Medical Services has a dedicated training
course in customer care for all new doctors, and that customer
care issues also run as a 'golden thread' through all other training.
There should be regular refresher training in customer care issues,
delivered on an annual basis as a minimum, and such training should
be assessed to ensure its effectiveness. All doctors who work
for Medical Services will have several years' experience of customer
care in a clinical setting, and the majority conscientiously provide
a high standard of service. However the Government recognises
that doctors often require additional training to provide an appropriate
level of service to customers undergoing medical assessments for
Medical Services already provides training on customer care
issues, using training modules developed in consultation with
the Department and external organisations such as The Equality
Foundation and NACAB. As well as forming part of the initial training
of newly recruited doctors, update training about appropriate
customer care forms part of all benefit-specific training materials.
For example the revised guidance for EMPs contains expanded sections
on customer care and appropriate assessment techniques, comprising
one third of the material.
The Government expects the effectiveness of update training
to be rigorously assessed by post-training evaluation and ongoing
monitoring of doctors' performance. The Department will analyse
Medical Services' data on complaints and claimant satisfaction
to ensure that training is appropriately targeted and assiduously
The Department is working with Medical Services to ensure
that all aspects of the treatment of claimants are reviewed. In
particular, a task force has been set up to review all communications
to claimants, to identify ways in which they might be improved.
The Department will, through the Medical Quality Surveillance
Group (MQSG), chaired by its Chief Medical Adviser, continue to
work closely with Medical Services to develop and monitor the
effectiveness of these initiatives. The Department will give particular
attention to monitoring the outcome of the regular claimant satisfaction
surveys undertaken by Medical Services.
As well as providing training in customer care as part of
all benefit-specific training, Medical Services have developed
a specific module addressing customer care.
Evaluation of training has been developed and refined to
incorporate objective and measurable outcomes.
(e) Dealing with Poor Performance
We recommend that Medical Services review their procedures
for identifying and dealing with underperforming doctors and report
back to the Chief Medical Adviser on these procedures.
The Department's Chief Medical Adviser will ensure that the
Medical Skills Database which has been developed by Medical Services
records, for each individual doctor:
medical training undertaken before joining Medical
training received from Medical Services, and its
outcome, including any need for retraining;
feedback from medical quality audit and complaints;
remedial action taken and its outcome.
The Department's Chief Medical Adviser will evaluate this
new database as a tool for identifying underperforming doctors.
Specifically the Chief Medical Adviser will monitor the following
the results of investigation of complaints against
individual doctors which reveal poor performance and/or professional
the results of Medical Services' internal audit
which will have been undertaken to assess the quality of the work
of individual doctors; and
rework data for individual doctors.
Medical Services have provided training for all staff responsible
for handling complaints. The Medical Skills Database has been
enhanced to incorporate information relating to complaints about
individual doctors. Remedial action is now automatically triggered
whenever a pre-determined level of complaint activity is reached.
(f) Treatment of Claimants: Overall Conclusion
We recommend that Medical Services and the Benefits Agency
take urgent steps to achieve better treatment of claimants: present
performance is not acceptable.
In drawing up rigorous and robust standards the Government
insists that the following quality principles must underpin all
of Medical Services' work:
professional advice is correct, complete, evidence-based
benefit claimants are dealt with fairly and courteously;
systems are in place to continually reduce error;
errors are dealt with promptly and efficiently
and lessons are learned.
To assess compliance with these principles the Government
has decided to set the following targets by which tangible improvements
in service, to achieve contracted medical quality standards, will
within six months to reduce the proportion of
"C grade" medical reports which fail to meet the Department's
standards by 10 per cent; and within one year to reduce the proportion
of "C grade" reports across all benefits to less than
5 per cent;
within one year to demonstrate improvement in
compliance with the agreed medical scrutiny guidelines for Incapacity
Benefit claims so that the proportion of non-compliant reports
is less than 5 per cent;
within one year to deliver training to all doctors
covering: the assessment of people with mental health problems;
behaviours, attitudes and sensitivities for dealing with people
with disabilities; and distress-avoiding techniques for the examination
of people with musculo-skeletal conditions;
within two years to improve customer satisfaction
rates to at least 90 per cent.
We expect Medical Services to deliver these targets. If not,
further action will be taken.
Medical Services have taken action where necessary to ensure
the standard of treatment of claimants meets that specified in
the Benefits Agency's Customer Care Charter.
Several improvements to forms and leaflets issued to claimants
have been implemented to provide clear information to claimants
at all stages of the claim process.
All the Government targets have been met.
We support the recommendation of Mind, that there be better
training on [mental health] issues for all Examining Medical Practitioners
[EMPs] and that there should be some specialist resource within
Medical Services, which could help provide such training, and
also see claimants in cases which were particularly complex.
Medical Services accept the need to enhance the knowledge,
skills and expertise of all doctors who assess and examine people
with mental health problems. The majority of doctors working for
Medical Services have experience, through their clinical work,
of treating people with mental health problems. They receive additional
training as part of Medical Services' overall training programme.
This training emphasises the need for an empathetic approach,
using open-ended questions and active listening techniques. The
Government welcomes several initiatives, which Medical Services
have embarked on to produce a robust and comprehensive package
of update training, based on current best practice, in assessment
of mental health problems. Ongoing dialogue between Medical Services
and a specialist provider of training materials using a multimedia
approach offers the potential for very considerable improvements
to the delivery of training on mental health issues.
We recommend that the Chief Medical Adviser instigates a
review of Medical Services' treatment of claimants with mental
health problems, covering time spent with claimants, doctors'
expertise, the ability of the system to assess accurately the
nature of mental health problems, to assess how the system could
be improved and, in particular, what scope there is for reducing
distress caused to claimants. We would expect to see the outcome
of such a review in due course.
Existing procedures for determining claims for disability
and incapacity benefits from people with mental health problems
ensure that those with a severe problem are exempt from undergoing
a medical examination. In all other cases, decision makers can
and do obtain evidence from practitioners in primary and secondary
care, and from other sources of specialist expertise and knowledge.
In particularly complex cases, and in all claims for IB by people
who have mental health problems, seeking such additional evidence
is an integral part of the decision making process, which ensures
that people with the more severe forms of mental illness are not
subjected to medical examination.
The Government recognises the particular difficulties which
may arise when assessing claimants with mental health problems,
and the need for sensitive handling of these claimants. Recently
as part of the Personal Capability Assessment (PCA), development
and thorough evaluation of methods assessing effects of mental
health problems on ability to work, have gone some way to meeting
A programme of joint discussions with welfare rights groups,
involving the Department and Medical Services, began in January
2000 and continues around the country. Although not restricted
to mental health issues, this provides an opportunity to hear
at first hand the views of representatives of people with mental
health problems on the service which is being provided; these
views are then acted upon in drawing up plans for improvements
to the service.
A considerable amount of work is thus already under way or
planned to address the issues raised by the Committee; a further
review would inevitably cause delay to this extensive programme.
In the light of this the Government believes that a separate review
of Medical Services' treatment of claimants with mental health
problems is not required at the present time.
Training has been delivered to doctors who examine claimants
with mental health problems, on the sensitive handling of people
with such problems, on the role of stress in precipitating or
perpetuating mental health problems, and in the management and
assessment of people with illnesses which have principally subjective
complaints. Input to this training has been obtained from specialist
resources. The Chief Medical Adviser has also set for training
throughout the coming year a number of items which relate particularly
to the more accurate assessment of the effects of mental health
problems. Indices have been developed with Medical Services for
the thorough evaluation of the training demand in this regard.
The Department is also evaluating mechanisms for assessing
IB review claims involving mental health problems in a way which
minimises the need for further medical examination.
(i) Claimants from Ethnic Minority Groups: Interpretation
It is of the utmost importance that claimants whose first
language is not English are able to communicate effectively with
EMPs. All claimants must be told clearly in their first correspondence
from Medical Services that they have the right to request the
presence of an interpreter if they so wish. Such correspondence
should include a multi-lingual notice inviting claimants to contact
the centre if they cannot read the letter. We look forward to
speedy action in this area.
The Government is committed to providing services which meet
the cultural and linguistic needs of all claimants, and it shares
the Committee's concern that claimants from ethnic minority groups
should not be at a disadvantage through lack of ability to communicate
effectively with examining doctors.
Current communications sent to claimants invite them to make
known to Medical Services any special needs they have. The Department
and Medical Services have set up a joint review of the standard
of communication with claimants; the participants are senior managers
within Medical Services, the IMPACT Contract Management Team,
and key Benefits Agency business units. All sides are committed
to ensuring effective communication on all issues. The review
will investigate helping claimants with their needs for interpreters,
and with special needs in other areas arising out of disabilitysuch
as preferences for alternative means of communication in place
of spoken language.
The Department and Medical Services will investigate the
costs, benefits, and policy implications of issuing multilingual
The wording "An interpreter will be provided if requiredor
you may wish to arrange for a friend or a family member to interpret
for you" has been incorporated into documents accompanying
appointment letters; and will be included in all relevant claim
forms at the earliest opportunity.
Medical Services have subscribed to a national interpretation
A multilingual notice advising claimants of the availability
of an interpreter is sent with all appointment letters.
(j) Claimants from Ethnic Minority Groups: Cultural
We recommend that doctors who demonstrate cultural insensitivity
should receive immediate remedial training and have their subsequent
performance monitored. Those doctors failing to improve their
performance after such action has been taken should be dismissed.
The Government does not tolerate racist or culturally insensitive
behaviour. The Committee's evidence about cultural insensitivity
is based on five anecdotal examples. The Department sought fuller
details from the Committee Clerk to enable these cases to be investigated
but he said that the cases had been presented to the Committee
anonymously and it did not know the identities of the people involved.
The Department was able to identify one case from the details
reported to the Committee. In this case the doctor involved had
already been suspended and required to follow remedial training.
She has since returned to work and no further complaints have
been received. The Department takes all complaints of racism or
cultural insensitivity extremely seriously, and where it has occurred
it takes prompt remedial action. Every single case of cultural
insensitivity is unacceptable, but the Department does not believe
that the evidence presented to the Committee reflects the general
behaviour of Medical Services' doctors.
Complaints alleging cultural insensitivity are being identified
and monitored as a distinct category.
We believe that Medical Services could be laying itself open
to the charge of institutional racism in two ways: in failing
to train adequately doctors in issues of cultural awareness; and
in failing to make claimants aware that they may request the service
of an interpreter. We expect it to address both issues as a matter
of priority. We recommend two further steps: that Medical Services
monitor the service received by claimants from ethnic minority
groups through targeted surveys and other means; and that the
Commission for Racial Equality be invited to review the work of
Medical Services in relation to its treatment of claimants from
ethnic minority groups.
Medical Services have also developed a new training module
on multicultural awareness, which will be delivered to all doctors.
Training on this issue began in May 2000.
Medical Services are keen to forge constructive links with
the CRE. A meeting has been arranged between a senior manager
from Medical Services and the incoming Chairman of the CRE, and
the CRE will be invited to participate in quality assurance of
future training or communication products.
Any complaint brought to the attention of Medical Services
will be fully investigated and appropriate action will be taken.
Complaints against Medical Services' doctors alleging culturally
insensitive behaviour, will also be closely monitored by the Department.
An additional category of complaint will be introduced to record
Meetings with the Chairman of the CRE have been fruitful
in developing a collaborative approach to cultural awareness issues
It was agreed that the CME would review and monitor the work
of Medical Services in regard to the treatment of claimants from
ethnic minority groups. CRE also agreed to assist Medical Services
in evaluating training delivered in this area.
It is unfortunate that doctors have made inappropriate references
to claimants' ethnic origins in reports, and it is clear why this
has given offence. What is perhaps more worrying, is the suggestion
that, despite undertakings having been made, effective guidelines
and training on this issue had not been given. We appreciate that
the undertakings were given at the time that the Benefits Agency
had responsibility for the service. Now that Medical Services
is Sema-run, we expect robust guidelines to be followed by all
doctors, and the necessary training to be provided to help them
Medical Services have developed guidance to doctors on the
use of personal descriptions in medical reports. The guidance,
which has been approved by the Department and NACAB, has been
issued to all doctors as a distance-learning package. Medical
Services also invited the Commission for Racial Equality (CRE)
to comment on the guidance, but received no reply.
Medical Services have also developed a new training module
on multicultural awareness, which will be delivered to all doctors.
Training on this issue began in May 2000.
All doctors receive training in multicultural awareness as
part of their induction training.
(m) Female Claimants
We recommend that the availability of an examination by a
female doctor should be spelt out clearly in the initial letters
sent by Medical Services to claimants.
The contract requires Medical Services to use reasonable
endeavours to provide a female doctor when asked to do so. Medical
Services have indicated that every effort is made to respond to
claimants' requests for assessment by a female doctor. The aim
will be to achieve a workforce which includes sufficient female
doctors to meet claimants' requests for such. Medical Services'
recruitment strategy will reflect this aim. All doctors must of
course act in a professional manner, regardless of gender.
The wording "You may prefer that your assessment be
undertaken by a doctor of the same sex and whenever possible we
will try to accommodate your request. Where you feel that your
assessment can only proceed with a doctor of the same sex, for
example on cultural or religious grounds, you must make this clear
and appropriate arrangements will be made" has been incorporated
into documents accompanying appointment letters; and will be included
in all relevant claim forms at the earliest opportunity.
We are concerned that, because of the perceived failure of
the complaints system, many claimants are choosing to appeal,
rather than to complain. We note that Sema have recognised a problem
with their complaints procedures and are conducting a review,
which we welcome. We would expect to see the results of the review
and we expect the Department to monitor performance in this area
and push very hard for improvements to be made. At the very least
we expect that details of how to complain should be drawn to the
attention of each individual undergoing an examination, wherever
the examination takes place.
The complaints procedure is intended to be used when a customer
is dissatisfied with the way a medical examination was arranged
or carried out. The appeals procedures are intended to be used
when a customer disagrees with a decision on entitlement to benefit
made by a BA decision maker. Appeals are not therefore an effective
way of examining Medical Services' administrative performance
or the medical quality of its doctors' work. Similarly the complaints
procedure is not the right channel for seeking redress when a
customer receives an unfavourable entitlement decision.
Medical Services' complaints procedures, and the investigations
carried out by the Department in response to MPs' complaints on
behalf of constituents, reveal that some complaints are justified,
while others are not; and some, unfortunately, are impossible
to determine one way or the other because of conflicting evidence.
The Government is concerned that the Committee appears to have
taken a number of anonymous complaints which it received from
third parties at face value without investigating the allegations
themselves or asking the Department to do so. This approach lacks
scientific method and vigour.
Nevertheless, the Government understands the Committee's
concern about the present complaints procedure. Investigations
conducted by the Department have identified some discrepancies
in the way in which complaints are recorded, whereby a small number
of complaints received by the Department rather than directly
by Medical Services, was not being counted. This has now been
The Department is also aware of dissatisfaction with the
way in which Medical Services respond to complaints. The main
issues were lack of a specific response to the individual complaint;
unwillingness to accept responsibility and apologise for poor
service; insufficient investigation into the details of complaints;
and failure to link complaints to previous ones against individual
The Government agrees that every person undergoing an examination,
wherever the examination takes place, should know how to complain.
The Department is working closely with Medical Services to undertake
a thorough review of the complaints procedure. Information about
the complaints procedure is displayed in all Medical Services'
examination centres. The review will encompass how better to make
claimants examined in their own homes aware of the complaints
Medical Services have developed a detailed action plan which
addresses all issues relating to complaints. The plan ensures
that all complaints are captured and appropriately investigated;
that response letters focus on the matters at issue which are
handled with sensitivity and that remedial action is taken when
justified. Moreover an Independent Tier has been put in place
to investigate any dissatisfaction with the way a complaint has
In preparing the plan it has become apparent that full and
thorough investigation, which must include the doctor's right
to reply and to consult, as necessary, his Medical Protection
Society, results in an inevitable delay of at least several weeks
before a definitive response can be prepared. Performance against
the plan is being monitored by the IMPACT Contract Management
Team. Key performance indicators have been developed to monitor
the accuracy of recording complaints and the quality of response.
Medical Services managers who handle complaints have all received
training in this field
(o) Customer Satisfaction Surveys
We recommend that a proportion of customer surveys be conducted
with claimants after they have seen the EMPs' reports.
The Government endorses claimants' right of access to reports
used in determining benefit entitlement, and their right to express
dissatisfaction with a report. The Department is working with
Medical Services to develop and pilot a process whereby a proportion
of the claimants who are invited to complete a satisfaction survey
are sent a copy of the EMP report with the survey questionnaire.
The Department will evaluate the resource implications and the
extent to which this enhances the quality of the survey as a tool
for monitoring medical standards.
The pilot survey showed no significant difference in the
levels of customer satisfaction. However the numbers involved
were small. The Department and Medical Services continue to develop
and refine research into customer satisfaction levels.
(p) Complaints and Customer Satisfaction: Overall
Changes to the system [of complaints and monitoring customer
satisfaction] are required; allied to those more minor ones we
recommend in relation to customer surveys, an improved system
of customer feedback will give Medical Services indispensable
information which they must use to help draw up the improvements
we hope to see in their service.
The Government is concerned about the examples of poor practice
in relation to the accuracy of doctors' reports that were reported
to the Committee. The Department has identified similar examples
through Medical Services' complaints procedure and its own quality
control systems. Medical Services have already commenced action
to address these deficiencies through an updated programme of
training for EMPs.
We note that the Chief Medical Adviser and Dr Carol Hudson
of Medical Services intend to hold regular meetings with the Appeals
Service to discuss issues coming through on Appeal. We welcome
The Department's Chief Medical Adviser has for some time
held regular liaison meetings with the President of appeal tribunals,
and the Government also welcomes the inclusion of the Medical
Director of Medical Services at such meetings.
A programme of regular meetings has been implemented.
(r) Appeals: EMPs' Access to Other Medical Evidence
We appreciate that allowing EMPs greater access to other
medical information relating to claimants would have resource
implications. However, we think it would also help raise the quality
of reports produced and lower the number of successful appeals.
We therefore recommend that Medical Services and the Benefits
Agency explore ways in which such records can more frequently
and readily be made available to EMPs. One alternative might be
for EMPs to be able to request medical records in DLA/AA cases.
This might provide more accurate case histories and could also
prove to be more cost-effective.
The Government shares the Committee's view that EMPs should
have adequate appropriate information about claimants whom they
are asked to assess.
Current processes provide for EMPs to be informed of the
claimant's description of his or her illness or disability. The
decision maker requesting the EMP report includes with the request
such documentary evidence from the claimant's file as the decision
maker considers necessary.
The Department has set up a working party to investigate
the effectiveness of the current process. Together with Medical
Services, the Department will explore options for improvement
to the process.
Providing EMPs with access to medical records held by the
claimant's general practitioner would be costly, would carry a
risk of significant delay to the decision making process, and
is unlikely to enable the EMP to significantly improve the quality
of the report. The records held by general practitioners support
the GP's role of making a diagnosis and planning appropriate treatment.
They are unlikely to contain information about the functional
effects of disability, which is relevant to the EMP's role as
a disability analyst
All requests for EMP assessment are accompanied by a proforma
providing brief details of the claimant's condition and any specific
points which the EMP is required to address.
Further work on evidence gathering in DLA and AA is being
undertaken in conjunction with the DLA/AA Modernisation Programme.
(s) Appeals: Use of Feedback
We think that as a matter of quality control, Sema should
be made aware if a significant proportion of successful appeals
can be related to cases where particular doctors have provided
the medical report.
A successful appeal does not necessarily indicate that the
medical report was substandard. The claimant may have submitted
further evidence to the tribunal, which was not available to the
doctor or to the decision maker. The decision maker may have misinterpreted
earlier medical evidence; or, in weighing all the evidence, may
have reached a different conclusion. The tribunal, even in the
absence of further evidence, may have interpreted the medical
report in a different way from the decision maker.
Although the present arrangements have no mechanism for relating
the outcome of appeals, whether successful or not, to the Medical
Services doctor who provided the report, the Department and the
President of the appeal tribunals are investigating ways whereby
this might be accomplished.
This issue forms part of the programme of discussions between
the President of the Appeals Service, the Chief Medical Adviser,
and the Medical Director of SEMA Medical Services informal feedback
from the Appeals Service is taking place.
We recommend that individual Medical Services' doctors should
be informed of the outcome of appeals where the Tribunal has chosen
not to endorse that doctor's findings. Furthermore, we recommend
that Medical Services monitor this feedback and take appropriate
action where individual doctors have a higher than average proportion
of such cases.
Under his statutory obligations to report annually on the
standards of Secretary of State decision making in cases which
come before tribunals, the President has introduced arrangements
for selected medical members of appeal tribunals to comment specifically
on Medical Services' doctors' reports as part of the monitoring
of first-tier decision-making.
Additionally, the President has agreed to draw to the attention
of the Department's Chief Medical Adviser reports by Medical Services'
doctors, identified in these monitoring exercises, which justify
investigation of their medical quality by the Chief Medical Adviser
in dialogue with Medical Services. The Government welcomes this
initiative and will ensure that Medical Services institutes prompt
remedial training and monitoring of its doctors whose reports
fail to meet the expected standards of medical quality.
The Appeals Service has formally been providing feedback
to an agreed protocol since the summer of 2001.
(u) Sessional Doctors Sitting on Tribunals
It seems surprising that legal advice has not been taken
on the potential incompatibility of the present practice of sessional
doctors sitting on Tribunals with the European Convention on Human
Rights. We recommend that such advice be taken.
The Committee's comments and recommendation have been drawn
to the attention of the Lord Chancellor's Department, which is
responsible for appointments to appeal tribunals.
Response to this issue by The Lord Chancellor's Department
is awaiting the outcome of a judicial review.
(v) Cases Determined by Scrutiny and by Examination
We welcome the fact that the Department has now acknowledged
that the Committee's concerns regarding the falling number of
medical examinations being carried out were justified. However,
we remain concerned that there may be structural reasons, relating
to the nature of the contract with Sema Group, why this problem
is occurring. The Government is committed to ensuring that the
Medical Services contract represents the best value for money.
Deterioration in the quality or standard of service provided will
not be tolerated.
The Department routinely monitors the scrutiny-to-examination
(S:E) rate. A continuing downward trend in the proportion of cases
examined following scrutiny alerted the Department to investigate
the causes. Initial investigations and review of the data by the
Medical Quality Surveillance Group revealed the multifactorial
nature of the possible causes of the observed reductions in the
S:E rate. Although the more recent rate of decline coincided with
the progressive roll out of the new scrutiny guidelines across
the country, emerging results from audits undertaken both by Medical
Services' Internal Validation Group and by the Department's Chief
Medical Adviser raise concerns that the introduction of the revised
scrutiny guidelines per se may not represent the most important
causative factor for the observed decline in S:E rates.
The results to date of an ongoing programme of audit have
revealed that some Medical Services' doctors have given advice
at scrutiny which is not consistent with the revised guidelines.
The Government views these findings with considerable concern.
In consequence of these disquieting audit findings the Chief Medical
Adviser has extended the scope, geographical boundaries and detail
of the continuing audit programme to establish the extent and
nature of the deviation from the revised guidelines, and to isolate
and examine the underlying causes of such deviation and their
relevance to the failure by some doctors properly to interpret
the agreed guidelines.
Whilst accepting that the early results of the above mentioned
more extensive and detailed audit need to be interpreted with
caution until the samples audited can be subjected to thorough
analysis by appropriate statistical methodology, the emerging
data point to at least two principal causes which are to be promptly
addressed. These are that certain sections of the revised guidelines,
which have now been tested in the field, lack sufficient clarity
and direction on some matters pertinent to the exercise of clinical
judgement on the question of whether to refer for examination;
and that effective and prompt remedial training of some Medical
Services' doctors in the proper processes of scrutiny is urgently
required. Medical Services share the Department's concerns on
these matters. The Government has insisted that existing and improved
programmes of training by Medical Services promptly remedy this
unwelcome state of affairs.
The results of audit should identify all the causative factors
involved in the observed decline in scrutiny to examination rates.
If these are not a result of inappropriate application of (or
lack of clarity in) the scrutiny guidelines, need for remedial
training, or inability of some Medical Services' doctors to adapt
to the particular requirements of disability analysis, other possible
causes will be vigorously researched by the Department.
Further audit of advice given at scrutiny confirmed a need
for clarification of the scrutiny guidelines, and also highlighted
issues relating to the quality of medical evidence available to
the scrutiny doctor.
Clarified scrutiny guidelines were implemented in November
2000, and a series of seminars for scrutiny doctors was held in
the spring of 2001. Joint audit by the Department and medical
Services in 2001 showed 97 per cent compliance with the guidelines.
The issue of appropriate medical evidence is being addressed
through the Evidence Gathering project.
We recommend that the contract be renegotiated in such a
way as to ensure that there can be no question of profits being
increased as a result of a policy which could cost the taxpayer
millions of pounds through the payment of benefits which should
not be made. We further recommend that the Committee of Public
Accounts consider inquiring into this matter.
The Government would view with unmitigated disapproval and
take prompt and decisive regulatory action were there any substantiated
evidence that the falling numbers of IB cases being examined following
scrutiny are driven by commercial gain to the detriment of the
judicious application of Medical Services' doctors' professional
competencies and medical judgement in the application of the scrutiny
The contract with Medical Services allows the Department
to share any financial savings as a result of the fall in S:E
rates. The settlement recently agreed at the Annual Review discussion
with Medical Services fully reflects the reduced costs resulting
from the smaller proportion of examinations of scrutiny cases.
In addition, review of a number of contract clauses is under way;
one outcome of which is that the link between S:E rates and profitability
will be scrutinised to minimise the risks of this occurring.
The contract has been renegotiated to pay separate rates
for cases cleared at scrutiny and examination.
(x) Pressure to see more Claimants
We criticise the approach taken by Medical Services which
encourages doctors to produce reports which might be of a lower
quality than that which the doctors might want to produce. Interfering
with the judgement of medical professionals in this way is not
Quality is an integral and essential part of a medical report,
but quality cannot be judged from the duration of the assessment.
That will depend on the nature of the claim and the claimant's
disabling condition. When interviewing and examining claimants,
doctors must focus their assessment on gathering relevant information,
which will enable them to provide appropriate and accurate advice.
It is no advantage to the claimant if the doctor's report contains
superfluous information, or if the assessment is longer than necessary
for producing a thorough and focused report.
We recommend that the Benefits Agency and the Department
should monitor closely Medical Services' performance in order
to ensure that, by increasing claimant numbers per session, profitability
is not put before performance.
The Government agrees with the Committee that any reduction
in average times spent examining claimants should not occur against
a background of deterioration in claimant satisfaction. On the
contrary the contract with Medical Services focuses on improvement
in services to claimants.
This is being monitored through the Quality Audit process.
Doctors are now offered greater flexibility in the duration of
sessions and the number of claimants they wish to see. Any increase
in the number of claimants seen, above the average rate for the
individual doctor, automatically triggers quality audit.
(z) Financial Pressures: Conclusions
As we have noted, the falling number of examinations as compared
to cases dealt with by scrutiny, and the increasing numbers of
claimants seen per session, lead to the suspicion that standards
are coming second to profitability. It would be naive to blame
Sema for trying to make a profitthat is their business.
The onus must be on the Benefits Agency and the Department to
monitor Medical Services and, if necessary, make contractual renegotiations,
in order to ensure that financial pressures do not lead to a lower
Medical Services have explained that the increase in the
number of claimants seen per session is the result of more efficient
administrative procedures These have achieved a reduction in the
time wasted by doctors when claimants fail to turn up for examination.
Doctors are not spending less time with each claimant. In the
period between October 1998 and January 2000, the average number
of examinations completed per three and a half hour session has
increased from 3.8 to 4.4, while the average duration of an assessment
for Incapacity Benefit (IB) has increased:
The contract with Medical Services allows the Department
to share any financial savings as a result of the fall in S:E
rates. The settlement recently agreed at the Annual Review discussion
with Medical Services fully reflects the reduced costs resulting
from the smaller proportion of examinations of scrutiny cases.
In addition, review of a number of contract clauses is under way;
one outcome of which is that the link between S:E rates and profitability
will be scrutinised to minimise the risks of this occurring.
The Department has set up a Programme Board to negotiate
relevant amendments to the contract.
(aa) Doctors' Pay
We recommend that Sema examines the case for a one-off "catch-up"
increase in payments to doctors to account for the fact that their
pay has not increased since 1992. We further recommend that Sema
lay down a timetable for ongoing regular reviews of doctors' pay.
The question of doctors' pay is an issue for Medical Services
Medical Services consider that the current levels of remuneration
reflect market prices. They question that the current levels hinder
the ability to attract high quality doctors. In areas where there
have been problems with recruitment, these reflect a general shortage
of skilled doctors.
Medical Services have recently announced an increase in fees
for EMPs who undertake home visits in remote areas, in recognition
that visits in these areas involve much greater than average time
Medical Services have also stated that they will keep other
fees under constant review.
Medical Services awarded a 3 per cent fee rise in September
2000, with a further 15 per cent rise in April 2001. They continue
to hold dialogue with the BMA.
(bb) Responsibility for the Service
We recommend that, in exercising their overall responsibility
for the service, Ministers act speedily to remove confusion as
to where day-to-day responsibility rests for detailed aspects
of the service.
The Government considers that this recommendation has been
fully met through the Minister's letter to the BMA of 17 January
2000, a copy of which was given to the Committee, in which he
has clearly stated that responsibility for doctors' fees rests
with Medical Services. This letter was agreed with Medical Services
before it was sent to the BMA.
While the Minister acknowledged in his evidence to the Committee
that political accountability for the performance of Medical Services
rests with him, responsibility for the day to day running of the
service in all its aspects rests with Medical Services.
As a minimum, we recommend that Medical Services meet their
contractual obligations to provide five days training to all doctors
annually. We deplore the fact that Sema has failed to meet this
contractual obligation to date.
The Government is concerned by Medical Services' failure
to deliver the specified number of days' training to all their
doctors. It is also concerned that training plans and outcomes
have not been sufficiently closely correlated with doctors' training
On reflection, the Government takes the view that measuring
training performance solely by the number of days' training delivered
does not provide a satisfactory measure of the success of training
because it does not measure outcomesimproved skills in
clinical assessment, report writing, or customer service. The
content and duration of training should reflect the needs of individual
doctors, to bring them to the required level of competence in
the required range of medical and customer service skills which
will enable them to deliver a quality service.
The Department is renegotiating this aspect of the contract
with Medical Services,to focus on a training requirement which
will be most likely to achieve the desired outcomes.
Delivery of training over the next 12 months will focus on
the perceived priority areas of:
the assessment and examination of people with
a mental health problem;
the appropriate behaviour, attitudes, and sensitivities
required when assessing people with disability, including multicultural
examination of the musculo-skeletal system which
is evidence-informed and focused on techniques designed to avoid
causing distress to claimants.
Medical Services are working closely with the Department's
Chief Medical Adviser in developing training materials, to ensure
that they meet the required standards. The Department will continue
to monitor the delivery of training throughout the remainder of
the contract period, and will monitor the outcomes against its
Medical Services also have in place a programme of continuing
medical education to develop the wider skills of their doctors.
This is linked to requirements for revalidation by the General
Medical Council, and also to providing appropriate training for
doctors planning to sit the examination for the Diploma in Disability
Contract amendments have been made to change the emphasis
to more focused delivery of a training plan which targets training
needs and which has the approval of the Chief Medical Adviser.
Doctors who fail to undergo the required training have their
approval to carry out the work revoked by the Chief Medical Adviser.
(dd) Diploma in Disability Analysis Medicine
We recommend that if the Department are serious about achieving
a step change in quality in the delivery of Medical Services they
should make it a long term objective that all sessional doctors
attain it and they should set a timetable in which this will be
achieved. There should be a financial incentive available to encourage
doctors to undertake the Diploma. The Department should begin
to explore funding options to this end.
The Government endorses the Committee's welcome of the new
Diploma in Disability Assessment Medicine, an initiative which
it wholeheartedly supports. The first examination was held in
March/April 2000 and resulted in 12 candidates achieving the Diploma.
A further sitting is scheduled for November/December 2000.
The Diploma was developed as an academic qualification denoting
a beacon of excellence in the field of disability assessment medicine.
The examination for the Diploma is rigorous, probing in depth
the candidate's knowledge, written problem solving skills, and
clinical interview and assessment skills. Success in the examination
indicates a doctor who has attained a higher than average degree
of achievement in all these areas, to an extent significantly
greater than that required for satisfactory performance as a Medical
In consequence, while it would wish to encourage all Medical
Services doctors to sit the examination in time, the Department
does not feel it is realistic to set an objective that all fee
paid doctors should attain the Diploma.
However, the Government will encourage Medical Services to
set objectives so that a very substantial proportion of their
Employed Doctors will have gained the Diploma within five years
from now, and that newly appointed Employed Doctors will have
gained the Diploma within five years of commencing work with Medical
Services. The Department is also investigating the feasibility
of funding a number of bursaries to contribute towards the training
costs and fees for doctors who wish to sit the examination.
The Department's goal is to have doctors holding the Diploma
in each Medical Services Centre, and then to encourage all sessional
doctors to obtain the qualification.
Medical Services are actively sponsoring the Diploma for
employed doctors, by paying tuition and examination fees, and
by provision of in-house training and support; and financial recognition
for those doctors who achieve the Diploma.
The Department offers sponsorship to sessional doctors through
bursaries to cover examination fees.
(ee) Performance Since Contractorisation
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.
The Government agrees with the Committee that reports by
Medical Services which are not "fit for purpose" should
never be accepted by Benefits Agency decision makers. A report
is not "fit for purpose" if the decision maker cannot
fully and effectively use it as part of the evidence considered
in reaching an accurate decision on benefit entitlement. All such
reports returned to Medical Services are reworked at Medical Services'
expense. Comprehensive guidance about rework has been provided
to decision makers, and procedures for dealing with rework are
in place in all Benefits Agency offices.
The Department is investigating current guidance and will
ensure that decision makers fully understand how to deal with
reports which in their opinion are not "fit for purpose",
and to identify what further opportunities exist to provide feedback
to Medical Services. To this end the Department's Chief Medical
Adviser and his staff will be working closely with the Benefits
Agency to identify any obstacles perceived by decision makers
that may limit the return of unacceptable medical reports to Medical
Services for rework. The Government welcomes these initiatives
and looks to the Chief Medical Adviser and his staff to review
in company with the Benefits Agency current guidance for decision
makers so as to instil confidence and assertiveness in returning
reports which fail to meet decision makers' needs.
Decision makers are not medically qualified. While they can,
and do, challenge such quality measures as legibility, clarity,
consistency, and adequacy of Medical Services' reports, they are
not in a position to challenge the medical reasoning behind the
The contract specifies a tolerance level of no more than
1 per cent of reports requiring rework. To date the overall levels
of rework have been consistently below 1 per cent. This is not
incompatible with Medical Services' reported levels of "C
grade" reports identified through their own monitoring programme.
Medical Services' programme applies much more rigorous quality
standards than those required for a report to be considered "fit
for purpose", hence a report recorded as unsatisfactory by
Medical Services will not necessarily affect the outcome of the
benefit entitlement decision.
The Benefits Agency has issued a bulletin to remind staff
of the correct procedures when substandard reports are submitted
by Medical Services. Work is ongoing to understand and address
any barriers to the return of substandard 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.
Medical Services undertake monthly audit of medical reports
and advice for all benefits. The number of reports audited has
been calculated, with the help of the Department's Analytical
Services Division, to provide a statistically valid representative
sample. The work of all doctors is, over time, included in the
regular audit programme.
Reference has already been made to the Department's Chief
Medical Adviser's instigation of an extensive audit of IB scrutiny
advice in cases randomly selected from Medical Services Centres.
As part of this continuing programme a further audit of the work
of each individual doctor will commence in the autumn to assess
the effectiveness of Medical Services' remedial action taken with
doctors whose advice is not in keeping with the agreed scrutiny
The function of disability assessment in connection with
benefit claims is unique to doctors in the Department and those
working for Medical Services. There is currently no expertise
in this field in either clinical or academic medical circles from
which auditors external to the Department could readily be drawn.
The Department considers that audit by its Chief Medical Adviser
meets the need for independent and objective assessment of the
quality standards of Medical Services doctors.
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 publichas
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.
The Government acknowledges that all the objectives for contracting
out Medical Services have not yet been fully achieved, particularly
in relation to provision of an improved service to the public
and improving medical quality standards. While it is recognised
that there has as yet been no significant improvement in these
areas, there has been a very significant improvement in operational
efficiency. Of particular merit are the new business processes
and information systems introduced by Medical Services to provide
comprehensive management information that greatly facilitates
the monitoring, control and assurance of quality standards. In
addition there has been improvement in turnaround times for clearing
advice and examination cases.
The Government is pleased that the Department is working
closely with Medical Services on a number of initiatives designed
to bring about the necessary improvements in medical quality standards
and customer care. These include:
comprehensive updated training for doctors in
all aspects of customer care;
a review of communications and information sent
a comprehensive review of complaints procedures;
development of the Medical Skills Database which
will provide information about the performance of individual doctors.
In order to ensure that the quality principles are adhered
to and that medical quality standards are achieved, the Department
will regularly review Medical Services' performance against the
service targets set by the Government as described in the Introduction.
In addition the Department will regularly review Medical Services'
quality assurance procedures to ensure they are valid, reliable,
and correctly identifying and addressing substandard performance.
The Department will also review the role and training of Benefits
Agency decision makers to ensure that they are better able to
identify and return for rework any advice which does not meet
the required standard.
There have been overall improvements in Sema's performance.
Factors which robustly and objectively measure medical quality
have been developed and validated, and are now being applied.