Examination of Witnesses (Questions 100-119)
MR MARK
FISHER, DR
MANSEL AYLWARD,
MR PAUL
KEEN, MR
JOHN SUMNER,
MR SIMON
CHIPPERFIELD AND
DR CAROL
HUDSON
WEDNESDAY 17 APRIL 2002
100. Are you confident that that has got better?
The Social Security Committee in its original Report found in
fact that most of the complaints were about the attitude of the
doctors and their offhand nature. Indeed, I had a constituent—we
must have all had them—at my surgery on Friday who had qualified
for Incapacity Benefit, had an injury at work, her workplace had
accepted full responsibility for her injury. She had applied for
DLA, both care and the mobility element, and her doctors had taken
three years to diagnose what was wrong with her and yet after
a cursory glance she got the feeling that this medical examiner
felt that she was trying to pull the wool over their eyes. She
really did feel that she had not been treated with courtesy nor
indeed had her medical condition and what she could do, her level
of disability, been taken into account. Now she did not make a
complaint, she came to me instead, and I think that is possibly
what happens often—that people think about it afterwards.
Obviously those kinds of things are still going on.
(Dr Hudson) Yes. I think the statement that you have
just made is our loss because we cannot do anything about that.
You asked me am I convinced that things have improved in the last
two years, the answer is an unequivocal yes. If you were to ask
me are they as good as they can get, the answer would be an unequivocal
no because we are still in an improvement process and always will
be, I believe, given the nature of the disability assessment and
given the nature of the training of doctors and what we need to
do to get to the sort of state of excellence that I want to get
to.
101. My question then is how do you know because
the Social Security Committee was not confident that the system
of customer surveys accurately captured claimants' perceptions
of the service. The National Audit Office was very critical of
the system for sampling customer satisfaction and they recommended
that both the Department and at the time Sema should be looking
to adopt generally accepted market research industry standards.
What has been done to follow up the National Audit Office's recommendations?
(Mr Chipperfield) We have changed our customer surveys.
102. You have done.
(Mr Chipperfield) In the last year, 12 to 18 months.
We took advice from national opinion polls in reconstructing how
we go about the customer surveys. We survey around 30,000 people
a year and we have made the surveys more relevant. They can always
be improved further and Dr Aylward was saying earlier that we
are engaged in a joint process at this very moment in taking the
next step in customer survey which will be piloted towards the
end of this year and that will involve an independent organisation
doing the surveys. We have already made some improvements.
103. It was also recommended that the Department
should periodically exercise its right to validate these surveys
and ensure that they provide a representative picture. Has the
Department done this?
(Dr Aylward) Yes. The Department has looked at the
results of the surveys and the surveys which have been done by
SchlumbergerSema.
104. Are you satisfied with what you have heard
this morning that, in fact, they have improved?
(Dr Aylward) Yes, indeed. Although it may not be considered
a major percentage change, although the number of complaints remains
around the same and the number of complaints is not a very good
measure of decisive action, I appreciate, but within the number
of complaints there has been I think quite a shift in the complaints
against doctor's manner, attitude and behaviour. It was 35 per
cent plus, it has now dropped to 30 per cent and falling. I think
that is a significant move.
105. My next set of questions is about the overbooking
of claimants for medical examinations. That was one of the big
complaints, that in order to fill the gaps because lots of people
were not keeping their appointments there was overbooking and
as a result if everybody did keep an appointment some people were
turning up for a pre-booked appointment and were not being seen.
Can you tell us what progress there has been in reducing the number
of people turned away unseen from examination centres?
(Mr Chipperfield) Over the last 12 months we have
moved from a trend of around four to four and a half per cent
of people being turned away, these are people coming to an examination
centre, and currently it is around 2.6 per cent. This is not always
as a result of overbooking, let us be clear on that. There are
people turned away who are not fit to be examined, there are people
turned away because they turn up more than half an hour late for
their appointment, it is not just because of overbooking. The
biggest issue for us in this is the variability and the unpredictability
of people turning up. Ultimately the only way that we will substantially
improve again on customers being turned away unseen is through
doing something about the predictability of people actually turning
up. What we have done is we entered into a project in October
last year, it is called the DNA Project, do not attend. We have
been running that as a pilot in the Derby and Stoke areas throughout
the latter end of last year and into the first quarter of this
year. It is a new way of scheduling. It is essentially teleprogramming
but it is much more than just teleprogramming. What it has proved
is that we are able to manage the DNA rate down from a fluctuating
20 to 40 per cent to a more consistent fall to 10 per cent. That
means that we can schedule more effectively, it means we do not
have to call so many people for examination and it means we are
able to give many more people examinations at a date and time
which suit them. What we have done is we have now rolled that
out into three other areas just to test that the pilot has proven
successful. We have been doing it in Bootle, Euston and Acton.
Initial results from that roll-out show a substantial improvement
on the attendance rate. We are now into a full scale implementation
of that new scheduling approach which will be complete by the
end of June. Ultimately what it will result in is lower waiting
times and less people turned away. That is how we will further
improve on the improvements we have already made.
106. By the end of June that will go national?
(Mr Chipperfield) It will have gone national, yes.
Andrew Selous
107. Can I return very briefly to complaints
and doctor's manner, just for the record. The briefing we have
in front of us says the figures from SchlumbergerSema for the
last quarter show that 63 per cent of complaints did actually
relate to doctor's manner. I would like to raise that because
the figures that Dr Aylward gave were a little different, perhaps
they were taken over the year, I do not know if there has been
a big jump in the last quarter.
(Dr Aylward) Page 27 of SchlumbergerSema . . .
108. As time is tight could I ask you to write
a note to the Committee because the briefing note that we have
does not quite square with that and perhaps we can tie the two
up later. The next area I want to move to is the assessment of
people with mental health problems. We know from the Social Security
Committee's Report that this is not an easy area to deal with
and I understand that you are putting more people with specialist
knowledge into this area. Perhaps you could tell us what progress
is being made with that? Am I right in saying that you do not
in fact employ or use the services of any psychiatrists at all?
(Dr Hudson) Not specifically to carry out Incapacity
Benefit examinations. We will have people who have psychiatric
qualifications who are working as a general part of the doctor
pool but in terms of the Incapacity Benefit examination the doctors
are trained as disability analysts and the training for the mental
health assessment for Incapacity Benefit is part of what they
do. I know Dr Aylward would have a view on the inclusion of specialists
into the mental health process as a whole.
109. Do you want to comment further on that,
Dr Aylward?
(Dr Aylward) Yes. What has been done in developing
training for disability analysts, doctors who are conducting Incapacity
Benefit examinations, is we have ensured that we have drawn upon
expert advice from the Royal College of Psychiatrists to ensure
that the training does deliver a pattern of handling the examination
of the person with mental health problems to ensure that the effects
of those health problems are picked up. Disability analysts are
not truly concerned with the intricacies of diagnosis, it is more
important for them to understand the limitations, the difficulties
that a person with mental health problems has in the situation
as described in the All Work Test where one looks at the person's
day-to-day activities and how their mental health problem could
affect them in the workplace, how it could affect them in their
relationships with other people. We have ensured that a major
expert resource has been brought in to advise on the training,
to contribute to it and evaluate it.
110. Were the Royal College of Psychiatrists
happy that the medical personnel were being given appropriate
training and advice in that area rather than psychiatrists themselves
being employed? That was the advice the Royal College gave you,
was it?
(Dr Aylward) Yes, because the Royal College themselves
have endorsed the introduction of the new Diploma in Disability
Assessment Medicine which brings in a new discipline in medicine
whereby the assessment of disability is the important issue. Whether
or not that was undertaken by a psychiatrist, a general physician
or a rheumatologist, the basic principles are best delivered by
someone specialising in that area. The Royal College of Psychiatrists
are quite happy with the development of this new discipline and
the fact that a person does not have to be a qualified psychiatrist
to enable them to assess the effects of mental health problems.
Mrs Humble
111. One of the issues that was raised with
us in our last report with regard to mental health was that the
examination system is seen as a snapshot of that person's capability
on that particular day and for many people who suffer from mental
health problems their capability can vary depending upon how they
are responding to medication, whether they are going through a
particularly difficult time within the spectrum of their mental
health problem. Do you feel that the new advice being given to
doctors enables them to deal with that situation so people are
not being disadvantaged because they are being seen by the doctor
on a "good" day and, in fact, the day after their health
could be dramatically different and, therefore, their capability
to undertake employment equally could be dramatically different?
(Dr Aylward) I do. Perhaps amongst all medical conditions
mental health problems are notoriously variable and subject to
remission and fluctuation. The doctors are after all medically
qualified people and they should be aware of that anyway. In order
to ensure that they are aware of that and to counter that understandable
accusation of a snapshot examination we make sure that doctors
look at the broad spectrum of a person's activities, look at the
past, look at what might be happening in the future, look at the
issues that are relevant today but how were they yesterday, how
were they in the past few months. Yes, we do make a particular
effort to ensure that all training is delivered in mental health
and indeed in other conditions which are fluctuating for the doctor
to give his opinion based upon not only what he sees today but
the whole panorama of the picture.
112. Will he have enough time? Going back to
the questions that I addressed earlier to Dr Hudson, it was raised
in our last report that given that complexity, given the need
to examine in much more detail the past, the present and the future,
does the doctor have enough time to undertake that assessment
in the new fee paying system of sessional pay?
(Mr Chipperfield) It is their decision. It is the
doctor's decision. We do not decide how long the doctor spends
with that individual person, they decide.
Miss Begg
113. Can I continue on the area of mental health.
When I visit agencies working in the area of mental health in
my constituency and user groups I get the same story all the time
and it is they have this perception that it is very difficult
for them to claim DLA, that on the first claim if it is mental
health problems they are automatically turned down and they always
have to go to appeal. The complaint is that if you have got mental
health problems it is a double anxiety, it is even worse than
somebody who has a physical disability because the process of
having to go through the claim, the process of having to go through
the appeal, impacts on their mental well-being and is such a traumatic
thing that in some cases it is not worth them even attempting
to do it. It is not just one agency which has said that, I have
heard that complaint consistently. What is your comment about
that perception?
(Mr Sumner) As has been previously said, certainly
the mental health cases claiming DLA are a difficult area. As
far as we are concerned, we have appointed a specialist in disability
as a trainer within the Disability and Carer Service. She has
been training all of our Decision Makers and one of the first
areas that she is concentrating on is people with mental health
difficulties. Effectively all our Decision Makers are in the process
of receiving—we are about three-quarters of the way through
that—foundation training which includes information on how
to deal with claims from people with mental health problems. Obviously
in the actual process of claim the individual has the opportunity
to set out on the claim form their concerns and what they can
and cannot do and they have the opportunity also to get people
to help them with that, as many of them do. The Decision Maker
then has a choice about whether there is sufficient evidence in
the claim form to enable them to come immediately to decision
or whether they need to take additional advice which may be from
the general practitioner, it may be from a consultant psychiatrist
if one is named on the form, it may be by sending an examining
medical practitioner. There are a variety of areas of evidence
they may choose to use or it may be a social worker or somebody,
a lay person helping the claimant.
114. Do you keep statistics about each individual
Decision Maker so you can keep a track on this particular Decision
Maker to see if they have a habit of turning down DLA claims by
mental health customers?
(Mr Sumner) We do not have that level of analysis.
What we do is we have introduced recently a new checking regime
for DLA decisions which actually will over time, when we build
up the statistical evidence, give us at business unit level good
information about how people are performing.
115. How recent was that?
(Mr Sumner) We started to introduce that last October.
116. It is just because, again in Aberdeen,
the mental health patients were convinced that the new Decision
Maker—In previous years clients had managed to get the DLA
and suddenly nobody was getting it. I did try at the time—which
was probably about 18 months ago—to see if there was anything
in their allegations. These are serious allegations. They are
serious for me and as a local MP I want to find out whether people
in Aberdeen are discriminated against but it is also serious for
you.
(Mr Sumner) Absolutely.
117. If they are making these allegations, you
need to know if there is any truth in it.
(Mr Sumner) Consistency of decision making is an area
that we are trying to put quite a lot of emphasis on. We have
recently, with the benefit of our new IT, introduced an intranet
system which will enable Decision Makers to have access to the
guidance on line rather than having to go to volumes of codes,
so that means that each individual Decision Maker now will have
a PC where they can click on an icon and get hold of the Disability
Handbook or Decision Maker's Guide which makes it an immediate
and up-to-date and accessible form of guidance for them.
118. Are you convinced that you have the mechanisms
to pick up these variations of Decision Makers to make sure there
is the consistency?
(Mr Sumner) I believe that we do. In addition to this
new checking procedure which has been introduced, we have also,
over the last 12 months, reduced the spans of control for our
managers within the service which gives the managers more time
to look at how their teams are performing.
119. In two years' time if you come back to
us and I ask the question that I tried to get information about
eight months ago you will be able to prove that the Decision Makers
have not been inconsistent and any of these kinds of allegations
which have been made you will have the proof to discount them?
(Mr Sumner) I would like to be able to say that, I
think more realistically I shall have more evidence to be able
to tell you how we are performing.
| 
