APPENDIX 2
Memorandum submitted by Prospect (MS 04)
1. INTRODUCTION
1.1 Prospect (formerly known as the Institution
of Professionals, Managers and Specialists) represents 105,000
members predominantly, scientists, engineers, technologists and
professionals in the civil service, non-departmental public bodies
and other parts of the public and private sectors. We submitted
written evidence to the enquiry commissioned by the Select Committee
in 2000 covering the provision of Medical Services to the Benefits
Agency on behalf of the full-time Medical Advisers who are members
of Prospect. We welcome the opportunity to provide further evidence
to the Select Committee on developments since the enquiry and
prior to the Government's decision on whether to confirm the extension
of the Medical Services contract held by SchlumbergerSema for
a further two years.
1.2 It is not normal convention for Prospect
to submit evidence of this nature to a Select Committee unless
a change in policy has been proposed by Government. Prospect has
not been made aware of any fundamental changes to the contract
that have been imposed on SchlumbergerSema in seeking a two year
extension or of any revisions to Government policy. However, Prospect
does have considerable interest in how the contract is delivered
and the lessons that have been learnt over the past three and
a half years that the contract has been working.
1.3 Our main concern principally rests with
the apparent lack of true "partnership" with the Company.
Whilst an industrial relations forum does exist we do not believe
that it is used to its best advantage as we have experienced difficulties
in the past in persuading SchlumbergerSema to take into account
the views that the trades unions have expressed not only on employment
issues—which are of legitimate concern—but also on
issues affecting the delivery of the contract. As a consequence,
members have been left demoralised, demotivated and frustrated
in their belief that neither their views or their personal contribution
to work counts for anything. We have raised this problem with
management and we have jointly agreed that we need to concentrate
more effort into both consultation and communication in the future.
Part of the problem perceived by members is the sharper financial
focus and commercial interest which has been introduced by Schlumberger
which at times detracts from what they believe are legitimate
medical issues.
2. BACKGROUND
2.1 Following the Report of the Select Committee
on Social Security, the National Audit Office conducted a follow-up
investigation into the financial arrangements of the contract.
The NAO identified tensions inherent in the way that the contract
had been structured. There were conflicts between improving the
quality of reports while, at the same time quickening file throughput,
maintaining customer service, levering in investment and reducing
cost for the Contractor. Therefore the viability of the business
remains under acute pressure and the contract is focused on reducing
the cost of the service whilst speeding up throughout.
3. CONCERNS RAISED
ABOUT THE
QUALITY OF
MEDICAL ASSESSMENTS
3.1 In our earlier submission to the Select
Committee, we highlighted the pressure being placed on Medical
Advisers to increase the number of Incapacity Benefit (IB) examinations
completed in a 3.5 hour session. In the written evidence that
was given to the Select Committee by Sema Group Medical Services,
they stated on page 24 of their memorandum that the current workload
of Medical Advisers was based on the average number of clients
examined per session for Incapacity Benefit. The explanation put
forward by the Sema Group Medical Services was that the increase
in the number of people examined per session since they took over
the contract had resulted principally from improved management
of the scheduling process which had ensured that the Medical Adviser
was fully occupied in the examination session. Dr Hudson went
on to say in her evidence to the Select Committee that there was
no evidence that the amount of time Medical Advisers spent with
clients, producing statements or writing up reports had either
increased or decreased since cutover. The statistics that were
produced by Sema Group Medical Services suggested an average throughput
of clients of 4.3 per session which resulted to an average of
47 minutes being spent on each IB case. In its subsequent conclusions,
the Select Committee stated the following: "We recommend
that no reduction in average times spent examining claimants should
be allowed to occur, unless hard proof can be deployed to show
that there has been a genuine increase in claimant satisfaction.
We are sceptical that the two can occur simultaneously. We also
recommend that the present duration of examinations be monitored
by the Medical Quality Surveillance Group to ensure that they
are sufficient to enable the doctors to produce accurate reports
without being under pressure of time."
3.2 Since then, Prospect has raised the
issues of the quality of medical assessments, examination times,
numbers of examinations per doctor session and the effects of
the present system on Medical Advisers' health on numerous occasions
with SchlumbergerSema management without reaching totally satisfactory
solutions.
3.3 SchlumbergerSema has introduced a system
of audit (IQAS). However, we have not been provided with evidence
that the system is working effectively or that it accurately reflects
the true quality of the medical filework or examination assessments.
We would welcome the opportunity not only to review this information
jointly with SchlumbergerSema management to ensure that the quality
audit is delivering the information that it should be, but also
to suggest improvements if we believe they can be achieved.
3.4 Last year, the preferred method by which
the sessional doctors employed by Nestor were paid to carry out
Incapacity Benefit examinations was altered from that of a sessional
fee to one of fee per examination. We have little doubt that the
reason for doing so was to provide an incentive to increase the
number of cases examined per doctor session which is normally
3.5 hours. Since the introduction of this method of payment, we
have seen certain doctors carrying out 7, 8, 9 and sometimes more
cases in a session. Indeed, we know of doctors who have regularly
carried out 10 examinations per session. At weekend sessions,
doctors have been known to complete 16 PCA reports within a 7
hour period. However, some these examinations will have included
exemptions, and whilst we do not hold the appropriate statistics,
we believe that these may have increased. In general, examinations
completed during weekend sessions do not form part of the audit
results forwarded to Impact or the Chief Medical Adviser.
3.5 The increasing number of examinations
completed per session inevitably means that less time is spent
on each individual examination. Members believe that this may
have an adverse effect on the quality of the reports being produced.
We are aware of several sessional doctors, who completed a large
number of quick Personal Capability Assessment (PCA) reports who
have now been the subject of complaint.
3.6 In addition, we have frequently been
told by our members who work as full time Medical Advisers for
SchlumbergerSema that pressure has been placed on them to increase
the number of clients seen per examination session. A recent communication
from Simon Chipperfield, the Managing Director of Medical Services
has stated that the company will pay a bonus to those doctors
achieving and maintaining, on a regular basis over 3 monthly periods,
an output of five IB cases or six IISB per session or six EMP
visits per day at least three days per week. Larger bonuses are
offered for doctors achieving six or more IB or seven IISB per
session or seven EMP visits per day on the same regular basis.
3.7 We believe that this rate of examining
is likely to have several unsatisfactory effects. Firstly, the
legibility of reports is likely to be compromised, and it is not
uncommon for the Benefits Agency to return reports for clarification
for this very reason. Secondly, we do not consider that it is
possible to assess clients' disabilities properly in such circumstances.
Inevitably, this may result in the wrong decision being made about
continuance or otherwise of Incapacity Benefit. Equally, there
is little point in carrying out PCA examinations unless clients
are fairly and properly assessed.
3.8 In relation to scrutiny of cases prior
to possible examination, the scrutiny to examination rate which
Medical Advisers have been expected to achieve has, over the years
that Incapacity Benefit has existed, greatly varied. At one time,
the rate was around 70 per cent, but it later fell to 30 to 35
per cent. One of the present work objectives, dictated by management
is for Medical Advisers to achieve a 54 per cent call rate or
"whatever rate is deemed necessary." The scrutiny guidelines
have been clarified over the past two years by the Chief Medical
Adviser, Department of Works and Pensions—principally as
a result of the recommendations of the Select Committee about
the standards and consistency of filework—and Medical Advisers
are expected to determine which clients should be called on the
basis of these guidelines. Indeed, their work is monitored to
check that they are adhering to those guidelines. Given that the
case mix of scrutiny files may vary from day to day or from area
to area, we consider that it is unreasonable for Medical Advisers
to be expected always to achieve exactly the designatedscrutiny
to examination rate while determining each case according to the
guidelines. In other words, we do not consider these two objectives
are necessarily compatible.
4. EFFECT ON
MEDICAL ADVISORS
AND ON
THEIR RECRUITMENT/RETENTION
4.1 In our opinion, the result of applying
unreasonable and sometimes mutually exclusive targets for quality
and output has had an adverse effect on the health and morale
of Medical Advisers. Many are deeply unhappy that their medical
standards are being eroded. They are demoralized by the fact that
those doctors who carry out high numbers of examinations per session
are highly regarded by management while their own attempts to
maintain medical standards are not always encouraged.
4.2 A large number of Medical Advisers have
complained to the union about the unfair pressure and resulting
stress that is being applied to them. After a number of meetings
with their management, SchlumbergerSema eventually agreed to carry
out a Stress survey of the doctors. However, despite the fact
that this survey was completed several months ago, and Prospect
have been promised a report on the findings, this has not been
forthcoming. Prospect conducted its own stress survey and amongst
the reasons for this work related stress, we would cite the following:
— Unsympathetic management.
— Lack of control over the pace of
work and hence the ability to maintain quality of work.
— Lack of proper medical control over
medical aspects of the work, leading to erosion of the ability
to maintain professional standards.
— Emphasis on performance related pay
and, more recently, on non-consolidated, non pensionable bonuses
for levels of work output which we do not regard as sustainable
in the long term.
— SchlumbergerSema's reluctance to
discuss, with Prospect, the introduction of an incremental pay
structure which would allow doctors who joined the service within
in the last seven years to catch up with the pay of longer established
colleagues.
4.3 Long term sickness absence for Medical
Advisers was recently estimated by us to be around 10 per cent.
While we do not have access in every case to the reasons for their
prolonged absence from work, we are of the opinion that the level
of work related stress encountered by Medical Advisers has contributed
to this high absence rate.
4.4 A significant number of doctors have,
within the past three years, reported work related upper limb
problems (WRULD) because of the amount of writing involved, particularly
when completing IB reports. Far from dealing satisfactorily with
these legitimate health and safety issues, which have been brought
to their attention on several occasions, the increasing pressure
on doctors, by management, to complete more reports in a given
time has, in our opinion, exacerbated the problem. The Prospect
stress survey indicated that at least one-third of all Medical
Advisers had experienced work related upper limb disorders during
various times of their employment. Only in isolated occasions
has the problem been dealt with by the provision of voice- activated
software in order that computerized reports may be completed.
It is to be hoped that the proposed introduction of evidence based
medicine and computerised reports at some time in the future will
help to reduce the incidence of upper limb problems.
4.5 In their conclusions, the Select Committee
recommended a one off catch up increase in payment to doctors
followed by ongoing regular reviews of doctors' pay. Unfortunately,
we have to report that the pay of medical advisors employed for
SchlumbergerSema has fallen behind on average by 6.5 per cent
compared to other Medical Advisers employed in the Civil Service.
4.6 We are concerned that there may be insufficient
doctors in the future to service the Impact contract adequately.
Since SchlumbergerSema took on the contract in September 1998,
we would estimate the number of Medical Advisers employed has
fallen from approximately 220 to 186. Some of this reduction will
be accounted for by ShlumbergerSema's inability to recruit Medical
Advisers, but others have been moved, either in whole or in part,
from Impact contract work to occupational health work for which
the company has secured a number of contracts with the Civil Service
and the public sector. Last year, SchlumbergerSema indicated to
Prospect that they intended to recruit a further 50 to 100 new
Medical Advisers. Whilst, we are encouraged that the recruitment
of new Medical Advisers appears to be moving in the right direction
and that a number have already accepted appointments and others
are arranging start dates, this needs to be sustained in order
to meet the delivery of targets.
5. CONCLUSION
5.1 In summary, we are concerned that the
present policy with regard to examining claimants for the various
state benefits and pensions can be maintained in the longer term,
given the current shortage of full-time Medical Advisers, the
levels of job dissatisfaction of Medical Advisors already working
for SchlumbergerSema, which may give rise to a greater turn over
in staff.
5.2 We are concerned that commercial pressures,
including the terms of the Medical Services contract, may result
in a policy of encouraging Medical Advisers and sessional doctors
to carry out examinations at a speed which is not conducive to
producing legible, well considered and well justified reports
as required by Benefits Agency Decision Makers.
5.3 We are also concerned about what the
present system is achieving in terms of ensuring that the correct
levels of benefit are awarded to the right people and, where clients
are found fit to work, that they receive adequate rehabilitation
to assist their return to work.
5.4 Prospect would be happy to meet with
any members of the Select Committee to give further oral evidence
if this is required.
Glossary
NB. Full-Time Medical Staff employed by SchlumbergerSema
are referred to as "Medical Advisers" Sessional medical
staff employed by Nestor are referred to as "doctors"
Geraldine O'Connell
National Officer
27 March 2002
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