Select Committee on Work and Pensions Minutes of Evidence

Examination of Witnesses (Questions 40-59)



  40. So the short answer is nobody in that category is re-examined?
  (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 conditions—people who have difficulty walking, with respiratory problems, with quite severe mental health problems—so 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 concerned—not all of them, but just a sample.
  (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 paid accurately.

  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 same?
  (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.

Mrs Humble

  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 last time.
  (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 assessment?
  (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 them—and they have agreed to do so—in 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 fear—which I could not assuage—that 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 process.

  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 happy—and so would some of our medical advisers—to 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 much.

Mr Stewart

  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 reports?
  (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 reports?
  (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.

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