Examination of Witnesses (Questions 40-59)|
WEDNESDAY 17 APRIL 2002
40. So the short answer is nobody in that category
(Mr Chipperfield) No.
(Mr Fisher) We do audit the whole scrutiny process
so we do check that Medical Services are applying the scrutiny
rules correctly and that includes looking at samples of cases.
41. So you have a paper transaction to start
with through an application; you have papers from the GPs; you
have papers from Sema; your scrutiny process is on paper; but
nobody gets to see the claimant?
(Dr Aylward) These patients are not people who have
minor disabilities. People who are not sent for examination are
people with quite severe or moderately severe conditionspeople
who have difficulty walking, with respiratory problems, with quite
severe mental health problemsso they are not people where
you would expect there to be any difficulty in determining their
status on paper.
42. I understand that and I fully accept that
and I am not trying to take people's money away from them. I do
not need convincing that those people are entitled to benefit
but we are talking here about contract prices and scrutiny delivers
a contract and assumptions are being made which may well be correct,
but you do not really know without occasionally just checking
on the individuals concernednot all of them, but just a
(Mr Fisher) If I can help: not only do we audit the
whole performance of this contract including a scrutiny of the
cases that are scrutinised, but we also distinguish the medical
part of this from the benefit operation, if you like. The whole
benefit operation including questions of fraud is subject to a
whole set of checks. We have quality support teams who go round
every district in the country making sure that the benefit is
43. So does that inform your scrutiny process?
(Mr Fisher) That informs in a sense the benefit part
of the process
44. No, that is not the point. Supposing somebody
goes round and finds that somebody is on the fiddle. The question
is whether that is something that should have been picked up on
the paper examination. If that exercise of going round and catching
somebody on the fiddle is not fed back into your scrutiny process,
it is not helping, is it?
(Dr Aylward) I can answer now, and I am sorry I was
not clear earlier. Yes, any evidence we obtain from fraud or mishandling
by the claimant of their claim is fed back to me, and I make sure
that we look at that case in detail. We discuss it with our fraud
investigating colleagues and other colleagues in the Department
and we make sure that the sorts of issues raised in that case
are addressed in scrutiny guidelines.
45. That is not the point, though; you are still
not quite with me. You may be addressing the guidelines but does
it inform your audit of the scrutiny process, which is not the
(Dr Aylward) I do not think that it would. The number
of cases that we see which are of such a character as to lead
us to change the guidance are so few and far between. The answer
is they do not inform the audit of the scrutiny process.
46. Can I address another aspect of whether
there is potential for financial pressures upon SchlumbergerSema
to disadvantage claimants? In our last report, we had a lot of
evidence that claimants did not feel that they had sufficient
time with the doctor to be properly assessed, and you have changed
the process from payment per session to a fee per case basis.
Starting off on a series of questions, can you tell me if SchlumbergerSema
is paid by the DWP on the basis that an assessment for Incapacity
Benefit, Disability Living Allowance or Attendance Allowance will
take a certain amount of time? This was something we explored
(Mr Chipperfield) We are paid for the output. We are
paid for the number that we do and it does not matter what the
outcome is or the decision for the decision maker in the Benefits
Agency: we are paid for the medical report.
47. But then there is a danger that, especially
within the new payment system where the doctors are paid per case,
the more cases that doctors deal with the more they are paid.
Is there not a danger that the doctors could hurry through the
examination and it becomes a conveyor belt rather than a medical
(Dr Hudson) We are very conscious of that and I think
so are colleagues carrying out the work because it is not at all
in their interests to be seen to be just pushing through people
for personal monetary gain, and we do not want to do that. The
old system, which is perhaps just before the old Select Committee,
was measured by way of a 3.5 hour session and doctors carrying
out a number of cases. That is how we calculated the length of
time that we offered you before in terms of how long the examination
took. What we have done now is removed those rather artificial
barriers of the session so that a doctor will, on a personal basis
if you like with the local medical centre, contract as to how
many cases he or she would like to examine during the course of
a period of time, which is again agreed between themselves and
the medical centre, and be paid accordingly, so there is an expectation
on the examination centre side and the doctor side as to the amount
of work, that is how many people they would be likely to examine
in an average day. That means that we can gain efficiencies of
scheduling that doctor's very valuable and scarce time and it
also gives claimants the advantage of knowing when they will be
seen and reduces the risk of those individuals being sent away.
There is always an expectation that an examination is going to
take not five minutes and not three hours but somewhere in the
middle of that, and Incapacity Benefit in particular has been
around since 1995-96 so there is a great deal of experience amongst
the doctors carrying out the examination as to how long an examination
will take. That being said, if there is a complex case, if there
is somebody who has mental health problems or has a number of
disabilities which do need exploring, the doctor will be expected
and does take sufficient time to carry out that examination. So
the payment system does not adversely affect our interaction with
the individuals who are claiming benefits.
48. Yet we have had evidence from two different
sources that contradict that. We have been told by DIAL UK in
the evidence they have been gathering on the experiences of people
undergoing medical assessments over the last six months, that
60 per cent of people felt that not enough time was spent on their
assessment. Basically they did not think they had been given enough
time to explain their disability and how it affected their daily
activities so that ought to be a worry for you and, from the other
end, Prospect tell us that examinations completed during weekend
sessions do not form part of the audit results forwarded to the
Department and the Agency, and yet they say they know of doctors
who at weekend sessions complete some 17 PCA reports within a
seven hour period and that these cases should be monitored. So,
on the one hand, you have disability groups saying that these
examinations are being hurried, and then doctors' representatives
as well saying there is a big variation between the number of
examinations taking place during weekdays and at weekends?
(Dr Hudson) I can help on both of those. In terms
of the Prospect statement that cases are not subject to audit
if they are carried out at the weekends, that is not true. Our
process is very carefully constructed to ensure that all cases
have an equal chance of being audited. I have no doubt and do
know about isolated cases, which there always will be, when a
set of doctor's case work has not been audited at the time of
the official audit, but I know that colleagues within the Department
have picked that up and have come in and audited under those circumstances.
In terms of the DIAL comment, yes, I think DIAL does have a great
deal of value to add in the information they collect. I recently
had a meeting with the social policy unit of DIAL and found that
the information we collect and the information they collect does
not necessarily match in a number of areas and I want to work
with themand they have agreed to do soin terms of
sharing information, albeit on an anonymised basis, because the
point that DIAL made was that many people who are complaining
about the system are not necessarily going to raise a formal complaint
with us or the Benefits Agency for a personal fearwhich
I could not assuagethat their benefit would be in some
way implicated. We do look at the complaints that claimants raise
and the length of time of the examination and the nature of the
examination are two categories that we specifically capture and
do look at very carefully. The other thing we are doing and increasingly
improving is the customer surveys, so we have a more proactive
stance towards claimants who come away from examination centres
so that immediately they are able to say whether they feel they
are being offered a good service within the course of the examination
49. We will explore the issue of customer surveys
and satisfaction in a little while but I have to tell you that
as a constituency MP I regularly get people coming to me saying
that they have not had a proper opportunity to explain to the
examining medical practitioner the impact of their disability
upon their everyday life, and in a way it is not always that the
claimant feels they need the time to explain. Sometimes a new
claimant who has not been through the system before assumes that
the doctor already has an understanding about their medical condition
and therefore will also have an understanding about how that impacts
upon their daily lives, then finds they are not giving the doctor
sufficient information to make a decision on benefit entitlement.
They then feel aggrieved when they are turned down and then they
come to me. There are many occasions when I am told, if it is
a Disability Living Allowance case, for example, that the doctor
comes to their house and asks them very cursory questions and
it is not until after the doctor has gone that they say, "I
should have said this, the other, but I did not feel I had the
time, and anyway, he is a doctor; he should know what being tetraplegic
means", and I have to explain the system to them. So what
reassurances can you give to me as a constituency MP, let alone
a member of this Committee?
Dr Hudson: As a constituency MP, not being able
to have access to your constituents, I would be more than happyand
so would some of our medical advisersto come and talk to
people who do feel under those circumstances aggrieved. Secondly,
I would hope that, when you do have information that your constituents
are able to share with us, you would pass that on to us as complaints.
Thirdly, we are improving and have improved the information that
goes to people who are claiming either both Incapacity Benefit
and Disability Living Allowance in order to let them know that
there is going to be a difference between this examination and
an examination carried out by a consultant for the purposes of
therapy or treatment.
Fourthly, we are very much concentrating on
the education of examining medical practitioners who carry out
DLA examinations to make them sure that they understand the sensitivity
of the examination that they take out in people's homes and that
they are being audited and that their times are being measured.
There is a whole package of things that we are trying to do to
improve the service to people who are examined in their own homes.
Mrs Humble: All too often I have had people
come to me who say "I have been turned down for benefit"
or the benefit has been taken away and it is to their financial
disadvantage, usually because they have not had enough time with
the doctor, but I have heard what you have said. Thank you very
50. Could I talk about the quality of medical
reports. Could you tell the Committee what progress has been made
over the last two years when the Government told the Social Security
Committee that you were investigating an IT based, electronically
completed medical examination form to reduce the need for handwritten
(Mr Chipperfield) In terms of quality, we have significantly
reduced the number of "C" grade reports. I think we
were averaging, it was reported last time, 10 per cent. That is
now below 5 per cent across everything that we do. Within individual
strands of examination or scrutiny it varies from that but we
are below 5 per cent now in terms of what you might call sub-standard
reports. The IT based system is the evidence based medicine project
that I was talking of earlier. There have been various prototypes
over the last 12 to 18 months and there will now be a full project,
pilot and then implementation. Implementation starts in May and
it will take, as I say, 18 to 20 months to implement everywhere
in the country. We have to do the muscular skeletal protocols,
the first one has been implemented, that is the IT system which
supports that, the software application is ready. That will be
rolled out between now and April of next year. On the back of
that we will roll out the protocols which support the cardiovascular,
respiratory and mental health examinations. That will take until
about March 2004.
51. So you will eventually eliminate all handwritten
(Mr Chipperfield) For Incapacity Benefit, yes, which
is about 70 per cent of the examinations we do. About 20 per cent
is DLA and the other 10 is a mixture of war pensions, industrial
injuries and various other things.
52. What feedback have you had from the medical
examiners about producing an IT based electronic report? Presumably
there are some traditionalists who would prefer it was handwritten.
(Mr Chipperfield) It is mixed. The vast majority are
excited about it and are looking forward to using it. That is
both within our organisation and outside. We found it to be very
attractive in our recruitment campaign that we will be able to
offer this more modern working environment for our doctors. Within
our organisation many doctors are saying "the sooner the
better, we can't wait". There are a few who are nervous about
the use of information technology and that is why in the roll-out
programme a large amount of the investment was in training, not
just in training for using the medical protocols but actually
IT training so they are able to use a keyboard and the application
and everything that goes with it.
53. Is it simplistic to say that it is more
attractive to younger doctors and not so attractive to older doctors?
It is not just related to age presumably but are there any factors
you have picked up on?
(Mr Chipperfield) I would not say that it is as simple
as that. Many of our doctors are familiar with using computers.
A lot of the sessional doctors, the contracted doctors, are general
practitioners and a lot of them are using computers in their working
lives, it is not just down to age.
54. You have touched on the next question already,
which was the issue about the Department setting a target of reducing
"C" grade medical reports across all benefits to less
than 5 per cent. In Mr Fisher's terms earlier, the "C"
grade were reports that do not pass muster. If across all benefits
this has been achieved, how has this reduction in unsatisfactory
reports been achieved in practice?
(Mr Chipperfield) Carol may wish to add things. It
has been achieved through training. I think it has partially been
achieved through the fact that we are using fewer doctors now
than we were two or three years ago but they are doing more work
and the more that you do the better the quality that you produce.
If you are doing three or four sessions a week rather than just
one session a week then generally you are much more familiar with
what you are doing, you can produce better quality. It is a combination
of training, more work per doctor, the audit methods, a combination
of various factors. In fact, it is running at about three per
cent across everything.
55. Have you been weeding out some of the doctors
who have higher "C" grade reports than others? Is there
any system there that you look at?
(Dr Hudson) We do look at the doctor's "C"
grades and if they become unacceptably high we do have mechanisms
for making sure that we have mentoring and retraining for those
doctors. If they simply cannot adapt to the nature of disability
analytical medicine then we would cease using them. I think that
is a necessary part of what we do. Our emphasis on training and
feedback and mentoring has been a much more positive and productive
method of improving the system than simply counting the "C"
grades, necessary though that is.
56. Still on that, you have said some positive
things about the "C" grades but there are still 6.4
per cent of examining medical practitioners' reports that are
unsatisfactory. How many examination reports is this altogether
as a ballpark figure? What remedies are being applied? Earlier
you were saying that you have got stricter targets for next year.
What are the stricter targets?
(Mr Chipperfield) That is for Disability Living Allowance
exams. It is variable but we would all do between 200,000 and
220,000 DLA exams over the next 12 months I would expect. The
target is to reduce that below 5 per cent. Currently it is oscillating
between 6.5 and 8 per cent on DLA exams per se and the
target is from November this year we need to achieve 5 per cent
and we will do so.
57. The Government's response to the Committee's
Report said that you were investigating the obstacles to Decision
Makers returning unacceptable reports for rework. The National
Audit Office found that Decision Makers did not bother because
it took too long and the reworked reports were often little better.
What are you doing to ensure that all unacceptable reports are
returned for rework?
(Dr Aylward) The initiatives that have been undertaken
so far have involved a bulletin being issued to Decision Makers
to guide them on the issues and factors which they should be taking
into account in returning reports which are unacceptable. That
is linked in with the audit process which looks at whether or
not the report is medically sound. Although there is not a direct
correlation between the rework and level of "C" rates,
because that takes into account medical issues which we would
not expect the Decision Makers to be aware of, nonetheless by
ensuring that there is feedback from how many "C" grade
reports there are for individual doctors to the type of rework
that doctor also obtains we are able to ensure that those reports
which are not fit for purpose in allowing the Decision Maker to
take into account in coming to a decision, that these are in fact
all returned as required. Certainly across the country the rate
of return is still below 1 per cent. What we have seen is as a
result of this extra tuition and feedback to Decision Makers,
in some parts of the country there was initially quite a large
increase, and when I say a large increase perhaps two or three-fold
above the 1 per cent, which indicated that they were in fact taking
account of the guidance and that was resulting in a more effective
process. Subsequently, even in those parts of the country now
the rate of rework is around 1 per cent. We do feel that the measures
that have been taken have alerted Decision Makers to ensure that
they do return work which is not acceptable.
58. What else are you doing to ensure that doctors
fully understand the information given to them by claimants and
their carers and are not underestimating the severity of the disability,
a situation which is leading to very expensive appeals?
(Dr Aylward) I think what we are doing is ensuring
that the training which is being delivered to doctors covers wide
aspects which relate particularly to disability awareness; to
sensitive handling of people with mental health problems and disabilities,
ensuring that the examinations that are undertaken are undertaken
with minimal intervention and are as pain free and as comfortable
as possible. That, together with the introduction of a number
of modules which are looking at the best way of handling and understanding
the concerns of people with disabilities and understanding the
limitations imposed by disabilities, particularly those which
are based upon subjective complaints like chronic fatigue syndrome
or fibromyalgia, and mental health problems which occur in response
to distress. Doctors not only undertake this training but an innovation
with Medical Services is we are ensuring that the outcomes of
our training are measured. Just delivering the training is not
enough, it must change behaviour. The measures of training delivery
have been undertaken in the last year to demonstrate that doctors
are responding in a way in which they have less "C"
reports in that particular area of concern and particularly that
the service is being delivered in a better way because of the
training that has been delivered.
59. So, for example, touching on what you have
just said, there is a particular sensitivity we need to engender
to deal with people suffering from ME for example?
(Dr Aylward) Yes. That is one of the modules that
we have made sure has been given to all doctors: chronic fatigue
syndrome and fibromyalgia. Not only that, we have got a very close
relationship also with those organisations representing people
with those subjective disorders and we make sure that the Disability
Handbook, which is published by the Department, has chapters on
these particular conditions and we make sure that the views of
people with these disabilities themselves and their organisations
are being put into the advice which is given in that Handbook
and which is used by both doctors, who undertake examinations
on behalf of the Department, and by Decision Makers.