Select Committee on Work and Pensions Minutes of Evidence

Supplementary Memorandum from the Department for Work and Pensions (MS 01B)

Correspondence between the Chairman of the Committee and the Secretary of State

  Dear Alistair,

  Session on Medical Services 17 April 2002

  Thank you for the very useful "progress" session with officials and representatives of Medical Services on 17 April, when the work of the Department and SchlumbergerSema in meeting the recommendations of the 2000 report of the Social Security Committee was explored.

  Inevitably, given the scale of the topic, it was not possible to fully explore every issue raised in the limited time available to us. I would therefore be grateful if the Department could further assist the Committee with one or two additional questions and points of clarification arising from the evidence given. I am also sending a copy of this letter direct to SchlumbergerSema for their information.

Claimant's feedback on medical reports

  Question 63 referred to the recommendation of the Social Security Committee that a proportion of customer surveys should be conducted to capture claimants' views about their medical reports. In response, the Government said that the Department was working with Medical Services to develop and pilot a process whereby a proportion of claimants who were invited to complete a satisfaction survey were also sent a copy of the doctor's report (paragraph 52). Further to Dr Aylward's reply on this subject, it would be helpful if you could provide further details of the customer survey questionnaire and the opportunity given to customers, in the survey questions, to give feedback on the accuracy and general quality of the medical report itself. It would also be helpful to have confirmation of the number of people to whom the questionnaire was sent, and the current proposals for a more extensive research programme to obtain the relevant feedback.


  On a point of clarification, Dr Aylward told the Committee that complaints regarding a doctor's manner had dropped to 30 per cent (Question 104). The DWP supplementary memorandum at Annex 1 indicates that, of the 1,029 complaints received in the quarter ending February 2002, when broken down by category, 648 (or 63 per cent) included a complaint about the doctor's manner. Can you explain the discrepancy between the figures?

  In Questions 87-89, Mr Selous wanted to establish whether every claimant undergoing examination received a copy of the green customer care leaflet "Medical Services—caring about customer service." Dr Hudson appeared to suggest at Question 89, that the customer care leaflet was sent out with the appointment letter. For clarification, could you explain whether all customers receive the green customer care leaflet, and, if so, at what stage. If not, please can you explain the availability of the customer care leaflet to customers.

  In Question 90, Mr Selous was referring to evidence given by Norman Heighton, then Corporate Director at DSS, to the Public Accounts Committee in March 2001. He told the Committee that the Department was itself puzzled by the disparity between apparent public levels of dissatisfaction and the volume of formal complaints made and said, "We have already had some discussion with SEMA about picking up a piece of independent research to try to tell us what the real position is." (Committee of Public Accounts, Minutes of Evidence, 21 March 2001, Q 140). In reply to the Work and Pensions Committee, Dr Aylward referred to work looking at improving SchlumberSema's own protocols. Dr Aylward may have misunderstood the question. The impression given in Mr Heighton's evidence was that the Department was looking to commission independent research, aimed at identifying the extent to which people did have complaints about their treatment by Medical Services—above and beyond those who had made a formal complaint. Was such research ever commissioned, or are there still plans to do so?

Doctor training

  In answer to Questions 96 and 97, Dr Hudson gave the Committee useful information concerning doctor training. As a point of clarification, can you explain whether Dr Hudson's information concerned the training of employed doctors only, or whether it is equally applicable to fee-paid sessional doctors. If the former, could you please provide the relevant information concerning the induction training etc given to sessional doctors.

Liaison with The Appeals Service

  At Question 70, I drew attention to the Report by the President of Appeal Tribunals concerning the Standards of Decision-Making by the Secretary of State. There was some discussion concerning the actual figures in the President's Report. Having checked the President's report for 2000-01, I believe the figures are as follows:

    —  In relation to Disability Living Allowance and Attendance Allowance, the medical member of the panel found that the medical report had underestimated the severity of the disability in 54 per cent of cases (see Table 6 of the President's Report).

    —  In relation to Incapacity Benefit, the medical report was found to have under-estimated the severity of the disability in 54 per cent of cases (see Table 8 of the President's Report).

  Dr Aylward thought the figures in the President's report were not as high. Can you please confirm that my figures are correct.

  I would also like to press you on the systems in place to ensure that Medical Services receives feedback where the Appeals Service has identified any report supplied by Medical Services as below professional standards. Could you explain the systems currently in place? At Question 78, Dr Hudson suggests that more formalisation of the existing process would probably help. What would this mean in practice?

  In its report, the Social Security Select Committee recommended that SEMA should be made aware if a significant proportion of successful appeals could be related to cases where particular doctors have provided the medical report. Are the systems now in place to monitor the relative frequency with which reports of individual doctors feature in the decisions going to appeal, particularly where those appeals are successful?

  The Committee also recommended 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. Can you confirm that this is now done?

Involvement of the CRE

  The Department's memorandum to the Committee (Annex 1, box (k)) gives details of two areas of agreement reached between Medical Services and the Chairman of the CRE. Firstly, the CRE "would review and monitor the work of Medical Services in regard to the treatment of claimants from ethnic minority groups". Secondly, the CRE had agreed to assist in evaluating relevant training. In answer to Question 125, Dr Aylward dealt with the second area of liaison. Can you please advise the Committee of what work has been done with the CRE to take forward the agreement reached with the Chairman, that the Commission would review and monitor Medical Services' treatment of claimants from ethnic minority groups?

Archy Kirkwood

22 April 2002

Letter to the Chairman of the Committee from the Secretary of State

  Dear Archy,

  Session on Medical Services 17 April 2002

  Thank you for your letter dated 24 April, on behalf of the Work and Pensions Committee. I am pleased that the progress session on Medical Services on 17 April was useful. There has clearly been a significant change in attitude and approach since SchlumbergerSema took over Sema Group, and this is reflected in the improved performance of Medical Services in the past year.

  The information and clarification requested in your letter is contained in the attached note, which also takes into account information provided by Medical Services. The note also picks up a number of issues where further information or clarification was requested at the session with officials and Medical Services on 17 April.

Alistair Darling

17 May 2002

Additional Information Requested


  1.  This document provides additional information requested by the Work and Pensions Select Committee as a result of the update oral hearing held on 17 April 2002.

Service levels not met (question 4)

  2.  The Department's evidence referred to Medical Services' failure to meet two out of 45 service level targets set in relation to confirmation of the decision to extend the contract. Two individual clearance time targets were missed in one contract package area in March 2002. These were examination clearance time for Incapacity Benefit (target 95 per cent, achievement in South East contract package 89.1 per cent) and examination clearance time for Disability Living Allowance (target 95 per cent, achievement in South West contract package 87.2 per cent).

  3.  All service levels have improved, and these two service level targets were met in April.

Value of contract to SchlumbergerSema (questions 7/8)

  4.  The actual and projected net costs of the contract are shown in the table:

Cost (£million)

  5.  The contract was not let on an "open book" basis, therefore SchlumbergerSema are not obliged to divulge their profit margins. This information is regarded as commercial in confidence.

Sum returned to the Department as a result of fall in scrutiny to examination rate (questions 14/15)

  6.  As part of annual review commercial settlements with Sema Group in the first and second years of the contract the department recovered a total of £2 million. This figure was used to offset legitimate commercial claims from Sema Group during the annual review negotiations.

Differential price for scrutiny and examination (question 18)

  7.  For Incapacity Benefit the cost of an examination is £84.81, and the cost of a case cleared by scrutiny is £17.88.

Scrutiny Guidelines (question 22)

  8.  A copy of the clarified scrutiny guidelines is attached at Appendix 1. [9]

Information available to EMPs (question 61)

  9.  All requests for EMP assessments are now accompanied by information about the diagnosis given by the claimant and by the claimant's doctor, together with information about current treatment, plus any other information felt to be of relevance to the EMP.

  10.  The DLA/AA Modernisation Programme project on medical evidence gathering continues to investigate the optimum use of further evidence from the most appropriate sources.

Claimants' feedback on medical reports (question 63)

  11.  In September 2000 a pilot was conducted in which a representative proportion (25 per cent) of claimants invited to complete a customer satisfaction survey were also given a copy of the medical report. Standard survey questionnaires were issued to facilitate direct comparison with the main survey. Of 209 surveys with medical reports issued, only 83 were returned.

  12.  The survey questionnaire was not designed to test the doctor's report, so it contained no direct questions about this. The questionnaire included questions about the overall rating of the doctor, and how the examination compared with the claimant's expectations, in terms of duration and thoroughness. Of the 83 completed returns, only 3 contained a comment on the medical report.

  13.  An overall review of customer satisfaction surveys was initiated earlier this year, in response to the NAO recommendation that surveys should be revised to ensure they meet Industry Standards. Specifications for the revised survey methodology are expected by the end of May, following which costed proposals will be submitted to the Department. The proposals will include the development of a process for validation of survey results. The plan is to test the revised survey process in September, with full roll out from November 2002. Further work on surveying claimants who have received a copy of their medical report forms part of this review, with the specific objective of identifying ways to improve the poor response rate experienced in the earlier pilot.

Liaison with Appeals Service (questions 70, 78)

  14.  The figures quoted by the Committee Chairman are correct. The Report by the President of Appeal Tribunals on the standard of decision making gives figures in Tables 6 and 7 of 54 per cent of medical reports underestimating the severity of disability in DLA and IB respectively. The oral evidence given to the Committee, that the figures were not as high as that, referred to Table 3, which shows the outcome for all cases overturned by a Tribunal, and in this table the figure for medical reports underestimating the degree of disability is 34 per cent. This figure is lower because Table 3 includes benefits which do not involve medical reports.

  15.  The President's Report did not distinguish between reports prepared by Medical Services examining doctors and those provided by the claimant's own doctor.

  16.  A feedback system has been developed and agreed with the Appeals Service, and has been in operation since July 2001. Reports completed by Medical Services doctors which are considered by Appeal Tribunals to cause concern because they fall substantially below professional standards, are referred to the Department's Chief Medical Adviser. The agreed protocol offers guidance to Appeal Tribunal members, but it is not prescriptive. Features which might put a report into this category include reports which substantially fail to address the medical issues; or are completely out of touch with informed medical opinion; or are full of inconsistencies; or conspicuously fail to relate to the individual concerned; or are substantially illegible.

  17.  Reports referred to the Chief Medical Adviser are forwarded to Medical Services for investigation and confirmation that appropriate action has been taken. Feedback is always given to the doctor concerned.

  18.  The current process, which has been in operation for almost a year, is due for review. The Department also continues to work with the President of Appeal Tribunals to better understand concerns about medical reports which do not fall into the above category but nevertheless are felt by Appeal Tribunal members to need improvement. There have been only 13 referrals under the protocol, which is significantly less than the number of reports where the Appeal Tribunal felt the severity of disablement had been underestimated, as reflected in the President's Report. Detailed feedback on these reports would be valuable in improving standards. The Department will explore with the Appeals Service how this feedback might be achieved.

  19.  With the exception of cases referred under the protocol, there is currently no other monitoring of the relative frequency with which reports of individual doctors feature in cases going to appeal. A successful appeal does not necessarily mean that either the original decision, or the evidence upon which it was based, were faulty. The President's Report acknowledges the significant part played by additional evidence put before the Appeal Tribunal, and that in a number of cases, the Tribunal takes a different view of the same evidence. However, this issue will form part of the review of the current arrangements for feedback from Appeal Tribunals. One proposal which is being considered is to hold regular regional meetings between Medical Services and Appeal Tribunal chairmen, to discuss medical quality issues.

Customer care leaflet (questions 87-89)

  20.  All claimants who are to have a medical assessment receive an appointment letter which explains the assessment process, advises claimants to contact Medical Services if they have special needs (for example, if they need an interpreter), and provides information about the action to take if the claimant is unhappy with the standard of service. The information includes details of how to obtain a customer service leaflet. Leaflets are available from all Medical Services' customer helpdesks, from customer relations managers, at medical examination centres, and from visiting examining doctors.

Independent customer research (question 90)

  21.  This issue is being considered as part of the review of customer satisfaction surveys mentioned at paragraph 13 above.

Doctor training (questions 96, 97)

  22.  All doctors, whether employed or sessional, receive the same benefit-specific initial training. This varies in detail and duration according to the benefit involved, but follows a similar basic pattern of:

    —  Trainer-led theoretical training, including such aspects as principles of disability assessment, professional standards, and customer care.

    —  Demonstration of understanding of the training, assessed by multiple choice test paper.

    —  Practical training in a controlled environment. For examination centre based assessments, the trainee is initially supervised and appraised by an experienced medical adviser. For domiciliary assessments, initial reports are monitored immediately on return, to allow feedback to be given without delay.

    —  Demonstration of understanding of the training, assessed by audit. All initial reports produced by the trainee are monitored, and training is not considered complete until the trainee has demonstrated an acceptable standard. Feedback is given on any problems identified, and if necessary the doctor will be required to repeat the training process. Continued lack of progress will mean the doctor being informed that no further training, and no work, can be offered.

    —  Approval by the Department's Chief Medical Adviser. Separate approval is required for each benefit area in which the doctor is involved, and is dependent on successful completion of all stages of training, and ongoing demonstration that the work is of a satisfactory standard.

  23.  In addition to core training, all employed and contracted doctors participate in Medical Services' programme of Continuing Medical Education (CME). The programme is developed in response to a training needs analysis conducted by Medical Services in close collaboration with the Department's Chief Medical Adviser. The precise details of each doctor's training plan will vary, mainly according to the benefit areas in which they work; but all doctors will receive around five days per year of CME. All doctors receive the three mandatory CME modules on mental health assessment, sensitivities for dealing with people with disabilities (including multicultural awareness), and clinical skills training in distress-avoiding techniques for clinical examination.

  24.  In January 2002, to coincide with the latest recruitment campaign, Medical Services introduced an eight-day induction course for all new employed doctors. The course includes the standard four-day Incapacity Benefit theoretical course; the three mandatory CME modules; and additional input on the skills of the disability analyst. This added input is considered necessary because as employed doctors, they will be called upon to guide and advise the sessional doctors as they progress in their careers with Medical Services.

Complaints (question 104)

  25.  Medical Services' Update Memorandum to the Select Committee states:

    "Of these new complaints, issues relating to doctor manner has declined from 35 per cent for the quarter ending August 01 to 30 per cent of all issues during the quarter ending February 02" (paragraph 8.9).

  26.  These percentages relate to the total number of issues within all complaints received. There is often more than one issue contained within a complaint, and sometimes more than one issue relating to doctor manner. For example, the doctor may not have been punctual and may also have been considered to be rude.

  27.  For the quarter ending February 02, 1,029 new complaints were received, and within these there were 2,164 issues in total. Therefore, 648 issues within the doctor manner category represents 30 per cent of all issues.

  28.  As an individual complaint may contain more than one issue relating to the doctor's manner, it would not be accurate to report that 63 per cent of complaints in this quarter included an issue about the doctor's manner.

Involvement of CRE (question 125)

  29.  Despite the apparent promise of early meetings with the Chairman of the CRE, repeated subsequent approaches by both the Department and Medical Services have been disappointing in their outcome. Invitations to comment on training modules have gone unanswered, as have invitations to hold further meetings. Medical Services have therefore successfully forged relationships with alternative advisory groups, such as The Equality Foundation, which has been very co-operative in assisting with development of multicultural awareness training.

  30.  Complaints alleging cultural insensitivity have steadily decreased. In the quarter ending February 02, there were five such complaints (0.5 per cent of the total number of complaints). All complaints alleging cultural insensitivity are reviewed by Medical Services senior managers.

May 2002

9   Not Published. Back

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