Examination of Witnesses (Questions 120-139)
MR MARK
FISHER, DR
MANSEL AYLWARD,
MR PAUL
KEEN, MR
JOHN SUMNER,
MR SIMON
CHIPPERFIELD AND
DR CAROL
HUDSON
WEDNESDAY 17 APRIL 2002
120. Can I move on to another specific client
group. I have been approached by the Motor Neurone Disease Association
who have been quite concerned again about inconsistencies across
the country. Obviously with motor neurone disease, once you are
diagnosed you are not going to get better, it is very rapidly
progressive and the average life expectancy for them is 14 months.
It is a pretty bleak outlook. There are special rules, I understand,
that if the client is going to die within six months then they
should automatically come under the special rules. Now in some
areas the Motor Neurone Disease Association say that as soon as
someone presents themselves with motor neurone disease, they have
got a confirmed diagnosis, the special rules apply but in other
areas that is not the case. There is an argument as to how significant
it is. These people are seriously ill, seriously disabled, and
will get progressively worse. They have asked that I raise that
with you, whether you can look into it and give us an assurance
that as soon as someone has a confirmed diagnosis of motor neurone
disease that immediately your advice to your Decision Makers are
that special rules should apply.
(Dr Aylward) I can tell you that we have been working
very closely with the Motor Neurone Disease Association for the
past year to the effect that I have had several meetings with
them. I have looked at casework which has been brought to my attention
where they have made the points that you have just raised and
they have also made presentations to the Disability Living Allowance
Advisory Board who are also working with them in updating the
chapter on motor neurone disease in the Disability Handbook. The
point they are concerned about is one where people with motor
neurone disease may have a variable life expectancy. On average,
as you say, it is about 14 months but some people can rapidly
progress with severe respiratory failure and die within six months
whereas others, like the much quoted Stephen Hawking, can live
for many, many years and be very productive, so there is a variability
there. I think the problem was that the guidance at the time,
which has now been amended, was not clear about this variability
and did not identify in sufficient detail what were the particular
factors to be picked up from the general practitioner's DS1500
report which would indicate that there was to be a rapidly spiralling
course rather than a prolonged one.
121. There is an unpredictability about life
expectancy but not an unpredictability about the rapidity of the
degeneration. I know a number of people with motor neurone disease
and while they may go rapidly downhill then they plateau but when
they plateau they are very severely disabled.
(Dr Aylward) There are various varieties of motor
neurone disease and one of those, you are quite correct, is rapid
progression and perhaps reduction in life expectancy occurs in
some but in many that is not so. The point is we have amended
the guidance, we have made sure the Decision Makers are fully
aware of this now.
122. If I can move on very quickly to ethnic
minorities, it is something that exercises us and normally Mr
Dismore is the one that picks up these questions. The Committee
was keen to see a multi-language notice attached to correspondence
inviting claimants to contact the area centre if they could not
read the letter. Now we understand that such a notice is being
developed. When do you expect it to come into effect and why has
it taken so long?
(Mr Chipperfield) I cannot comment on why it has taken
so long but it will come into effect within the next six weeks.
We are just working on the translation of the 12 different languages
at the moment.
123. How confident are the Department and Medical
Services that you are in compliance with the Race Relations (Amendment)
Act 2000 which introduced a new positive duty on public bodies
to promote race equality?
(Mr Fisher) From our point of view I think we are
confident.
(Dr Aylward) This has been taken forward. Meetings
have been held with the Commission for Racial Equality. The Department
has appointed champions who are taking this forward.
124. Are you convinced again that you have got
sufficiently robust methods of research to enable you to determine,
in line with the new provisions of the Race Relations (Amendment)
Act, that there is equality of treatment for people of different
racial groups and that there is no discrimination?
(Dr Aylward) I do not think the Department could give
a unqualified yes to that. What I can say is that the Department
are heavily engaged in developing the database and the research
to be able to answer those questions and to be able to put these
things into effect.
125. You have mentioned the CRE have agreed
to review and monitor work. Can you tell us any of the results
of what the CRE have reviewed and monitored?
(Dr Aylward) I think there is a difference between
the two issues here. The CRE issue which you are mentioning, I
think, is the one where CRE were approached by Medical Services
to help them with their training on ethnic diversity. Although
the CRE were approached and there were preliminary meetings with
Medical Services, ministers and the Department, the CRE, for reasons
best known to themselves, did not provide any information and
did not co-operate fully. I am sure because of the demands upon
their time. I believe that as an alternative the Medical Services
sought another organisation.
(Dr Hudson) We have met with a representative of the
CRE since the report was written and we were keen to explore our
response, how we need to respond to the Race Relations (Amendment)
Act. I am satisfied that when the Department put forward their
guidelines we will accede to those and are happy to do that.
Mrs Humble
126. We have covered all of these issues in
answer to virtually every question because, of course, at the
end of the day it is the doctors who are the important people
in doing these medical examinations. This is your opportunity
to sum up on each of the areas. First of all, on the issue of
pay, in the Committee's last report we had a lot of discussion
about the level of pay and we recommended a one-off catch-up payment
but the Department in its response said that it was a matter for
the Medical Services and yet in April of last year the DWP funded
half of the 15 per cent pay rise for sessional doctors, even though
that was not part of the contract with Sema. Does the Department
now accept some responsibility for sessional doctors' pay?
(Mr Fisher) I do not think the fact that we did that
in this particular case means that we have transferred that responsibility
to the Department, that was part of a negotiation about how we
jointly improve the service, for which ultimately, of course,
we still remain accountable. In this respect it is clearly Medical
Services who pay the doctors and decide on the remuneration rates.
That was a device really to ensure they got over a particular
difficulty.
Chairman
127. I think precedent really.
(Mr Fisher) I do not think I would call it a precedent.
128. I did not think you would call it a precedent.
It cost you £2 million.
(Mr Fisher) I would not rule out doing it again if
we had to but, on the other hand, I would not say it is a precedent
that we would always seek to follow in the future, it is going
to have to be part of a contract negotiation, part of setting
levels when we come to review contracts and so on in the future.
I do not know if you want to add anything?
(Mr Chipperfield) No.
Mrs Humble: I am not going to be churlish because
you did respond to the Committee's Report after all.
Chairman: Mrs Humble is never churlish.
Mrs Humble
129. Never. We got what we wanted at the end
of the day. There is nevertheless also the serious point about
putting in place procedures to ensure that doctors' pay is subject
to regular review. Have you done that now?
(Mr Chipperfield) Yes, we review it every year, every
12 months.
130. I can see another report coming on. We
have also covered the major problem of doctor shortages and with
sessional doctors the SchlumbergerSema report's figures show that
in two years since January 2000 you have lost almost twice as
many doctors as you have gained. I think that highlights just
how serious the problem is. You set out to recruit 100 new employed
doctors by June and have so far managed to get 48. Are you confident
that you will reach your target?
(Mr Chipperfield) Let us be clear about the two different
groups. Firstly, on the sessional doctors, we lost that number.
We lost a lot in 2000 following events early in the year. The
significant thing about sessional doctors is in the last ten or
12 months the attrition rate has halved and we are now recruiting
more sessional doctors than we are losing. That is the first point.
The second point is the 100 employed doctors, every day it increases.
We have another nine new doctors starting on Monday, I am meeting
them all this evening. It is the most successful campaign we have
ever done and we will carry on until we have 100 new doctors.
Whether we have 100 new doctors actually working by the end of
June, employed doctors, I think is debatable but we will get 100
employed doctors as soon as we can.
131. What sort of proportion are you looking
for between sessional doctors and employed doctors? Are you looking
to change that proportion?
(Mr Chipperfield) We have a resourcing model which
we have developed in the last few months. The resourcing model
is shown to the Department. That resourcing model shows with the
resources that we have and those that we know we will have we
are able to deliver the work that is required of us. I think that
is an important point, that we can do the workload that is now
required of us. There is no ideal balance. It is not an exact
science but what we are trying to achieve is to increase the employed
doctor pool to in excess of 250. That enables us to invest more
time in not just doing the examinations but doing the mentoring
and the coaching and the auditing of the sessional doctor pool.
The sessional doctor pool is, broadly speaking, around about the
right size at the moment. We are always looking for new people
and in some parts of the country we have a higher requirement
than in other parts of the country. It is still the case that,
for instance, it is a lot easier for us to get doctors, whether
it be employed or sessional, in the South East generally than
it is, say, for example, in North Wales or the North East of England.
I do not know if that addresses exactly your point?
132. What special measures are you taking especially
in those areas where you have difficulties in recruiting?
(Mr Chipperfield) We are using golden hello payments.
We give bonuses to our own staff if they recommend people who
are ultimately recruited. We are doing advertising. We are doing
special events. We are trying to build up contacts in some cases
with primary care trusts. We have a number of initiatives going
with a couple of primary care trusts to look at how perhaps we
might find a way of giving mutual benefit, for example we have
access to a greater number of doctors through the primary care
trust and we support them perhaps in IT or some areas like that.
There are a whole range of initiatives.
133. A question to the Department. Because of
the doctor shortages there was a huge backlog of cases that needed
medical examination. I understand in late 2000 you decided to
limit the flow of cases to Sema by holding cases in some district
offices due to their overstretched capacity. Obviously SchlumbergerSema
expected to resolve the capacity issue and allow restoration of
full processing, that was supposed to be by December of last year.
Given that there are currently 200,000 Incapacity Benefit review
cases stockpiled at district offices, is it correct that restoration
of full processing is still some way off?
(Mr Keen) Yes. We cannot be at all complacent because
the numbers are still significant. I think what is important is
the direction of travel. We had a very significant problem but
those figures are going down. We had a very clear contractual
target of reducing the figures to 100,000 by the end of the current
financial year, by next April, and we are confident that will
be met. I think the figures in the Departmental Memorandum said
220,000 and a month on that had reduced to 200,000 so you can
see that direction of travel, 20,000 in a month coming down on
the backlog is significant evidence that we are now firmly on
track and have a grip of that. I think it is significant the way
that SchlumbergerSema have increased the number of examinations
by 17 per cent last year and are committed to a further 10 per
cent increase next year. We have done a lot of very detailed work
to assess demand at all levels through the organisation jointly
with SchlumbergerSema, so we can manage the end-to-end process;
so we can anticipate demand; and so we can manage and adjust the
flow in line also with doctor availability—because there
is no point in passing on a volume or rate of cases in a particular
location if there is a doctor problem. We have also built a lot
more flexibility into the overall process, not least by the use
of a flexible doctor pool in SchlumbergerSema.
134. There are two issues there that arise out
of your response. One, speeding up the cases, the doctor examination
must not be at the expense of the quality of those examinations,
and all the questions that we have spent all morning asking you.
Secondly, are you happy with the reduction to 100,000?
(Mr Keen) No.
135. 100,000 still seems to me to be a huge
figure.
(Mr Keen) Two responses to that. On the second one,
no, 100,000 is an important milestone next year but it is not
the end of the story, we are committed to go on reducing that
backlog, we do not want any backlog in the system. On the first
part of the question, we have not planned and managed this at
the expense of quality. As I think was said earlier, many doctors
are now doing more sessions and we have built more capacity into
the system. The fact that doctors are doing more sessions means
that more time is being devoted to undertaking more examinations,
so we are not squeezing the time for individual examinations to
achieve an outcome because that would be wholly unsatisfactory.
Chairman
136. Joan Humble's questions are surely absolutely
critical. The Public Accounts Committee identified a £40
million cost to this backlog of stockpiled cases. How we got into
this situation I cannot for the life of me understand. There was
no hint that it was anything like as bad as that in 2000. What
is your reaction to the Public Accounts Committee's assessment
as reported by the Financial Times, of £40 million,
and these are people who may be claiming benefit to which under
the rules they are not entitled, so what you are saying is "don't
worry, it will only be 100,000 next year"? Does that mean
it will be £20 million we will be losing next year once we
get this sorted? What is going on?
(Mr Fisher) There are several points. The first is
that we are determined, as Mr Keen said, to get to grips with
it and reduce it as quickly as we can. We have set pretty ambitious
targets for the organisation to do that. Even within that 100,000
there is, in a sense, a normal flow of work in there, it is not
all actual backlog, there is in a sense the normal flow of work
which we want to get down to. This is one of the many reasons
why we are not approaching this from squeezing more cost out of
the total system, we are not approaching the contract negotiations
with a view to squeezing further costs out, we are not approaching
the resourcing of teams within what is now Jobcentre Plus dealing
with Incapacity Benefit from the point of view of squeezing costs
out, squeezing numbers out. We see the £40 million, which
is programme money, as a reason for making sure we resource the
system properly. If we continue to squeeze money out of the admin
of it we may see the £40 million go up, which is not what
we want to do at all, so we are approaching it from a need to
put resources in. We have set robust targets for managers throughout
Jobcentre Plus to deal properly with Incapacity Benefit. We have
given them a new target, which is new for this year, which is
to do with the speed with which they make decisions on cases following
medical examination. That is one of their top level targets set
by the Secretary of State and that is new. This is all designed
to increase the profile of Incapacity Benefit for the organisation
as a whole - to make sure that managers in Jobcentre Plus focus
on what they can do to manage this process. There is clearing
the backlogs, there is focus on the speed of decision making and
there is a focus on claims clearance. This is all designed to
ensure that this has the right priority within Jobcentre Plus.
We will not be satisfied until we have got this situation back
to a normal flow of work. The trend is moving in the right direction
and we want to keep the pressure on to do that.
(Dr Aylward) I would like to assure you that quantity
is not going to be at the expense of quality. We are ensuring
that the quality process, looking at auditing, joint audits, is
done regularly as at great a level that we were doing two years
ago and making sure that if a doctor begins to take on more cases
than his usual amount and decreases the amount of time spent with
a claimant then that will trigger an individual audit of that
doctor.
Mrs Humble
137. Can I ask you finally to sum up on doctor
training. Again, this has been mentioned several times and Dr
Aylward has given us some examples of the more sophisticated training
and especially raising the awareness of disability issues, carers
and the whole package. Is there anything that you want to add
to the area of doctor training that you have not already said?
Again, Dr Aylward mentioned briefly in an earlier comment the
existence of the new Diploma in Disability Assessment. In the
Committee's last Report we did recommend that all doctors involved
in this area should undertake that diploma and from my recollection
at the time only about 12 people had been assessed within the
terms of the new diploma. Have more doctors undertaken the qualification?
How many more do you expect to undertake that qualification? How
does it fit in with the overall training package that you have
put together now?
(Dr Hudson) Starting at the bottom of your very short
shopping list, yes, the Diploma in Disability Assessment Medicine
was very, very new at the time of the first hearing which was
why there were so very few people. There are now altogether about
50 people who have the diploma, 35 of them are from SchlumbergerSema,
a number of them are from our subcontractor, Nestor Disability
Analysis, and they have been sponsored by the Department. We have
sponsored our doctors and have created a training course which
the next group of doctors will be attending in the very near future,
so the diploma will be taken by some 20 of our doctors this year
plus doctors from other areas either from the Department or, indeed,
from outside the Department. After that we intend to make it so
that up to 35 doctors a year from SchlumbergerSema will continually
go through the assessment process for the Diploma in Disability
Assessment Medicine. From our point of view it has been a great
success in both raising the standards and giving external validation
of quality of some of our doctors which clearly we need.
138. From what you were saying earlier you seem
to think your training has improved.
(Dr Aylward) Yes.
139. Are you satisfied that it has?
(Dr Aylward) Most definitely satisfied. I am also
satisfied that it has moved away from the perfunctory "doctors
will do five days training". It is more based upon what is
the training and analysis that we need in doctors delivering this
new discipline and we focus upon those issues. It may be more
than five days, it may be less than five days, depending on the
individual doctor. Again, we also look at the outcome of our training
and feed those outcomes back into new training. In addition, looking
at the Diploma in Disability Assessment Medicine, the Department
is highly committed to it, as we have indicated before, and we
are funding each year 20 bursaries for people outside of Sema-directly
employed doctors.
Mrs Humble: Thank you very much.
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