Examination of Witnesses (Questions 1-19)
Wednesday 10 December 2003
Mr David Anderson, Professor Mansel Aylward CB, Mr
John Sumner, and Mr Simon Chipperfield, examined.
Q1 Chairman: Good afternoon, welcome
to the Committee of Public Accounts. Today we are looking at the
Comptroller and Auditor General's Report on Progress in improving
the medical assessment of incapacity and disability benefits.
We welcome David Anderson, who is the Chief Executive of Jobcentre
Plus, Professor Mansel Aylward, who is Chief Medical Officer for
the Department for Work and Pensions, Mr John Sumner, who is Director
for Disability and Carers Service and Simon Chipperfield is Managing
Director of Medical Services at SchlumbergerSema. You are very
welcome. I should say at the outset that we have recently had
some quite tough hearings when we have not been afraid to be critical
of witnesses. However, this is quite a good Report actually and
we last reported on this in 2001 when we were rather concerned
about the delays in getting these medical examinations. The average
waiting time has been reduced, the backlog dealt with and up to
£50 million has been saved. The recommendations of this Committee
appear to have been taken note of. Gentlemen, thank you very much,
but do not go away yet. Could you please look at page 13, paragraphs
2.2 to 2.3? We see in those two paragraphs, which I suppose really
are some of the key paragraphs in this hearing, that you managed
to speed up these medical examinations and the time taken for
them to be heard. How much more can you speed up this process
without jeopardising quality and accuracy?
Mr Anderson: That is obviously
the pivotal question because we are always trying to balance value
for money and quality and timeliness for the customer and those
three things sometimes work in tension. The targets for improvement
which we set ourselves have been pretty much met. There is some
marginal improvement left to gain in some areas, but probably
across the board there is not a huge step forward which can be
made.
Q2 Chairman: I might come back to
that because it would be interesting if we could reduce the waiting
time even further. Can you now look at pages 21 and 22 and paragraphs
3.2 to 3.3? You will see there that you have managed to improve
the quality of medical evidence for decision-makers. Why has it
not reduced the number of appeals which are successful?
Mr Anderson: There are several
reasons for that. First of all, it is not the case that appeals
always arise because medical evidence was incorrect; in fact the
proportion of cases where medical evidence was incorrect giving
rise to appeals is relatively small. It is much more the case
that new evidence comes out later and that the appeal is seeing
a different set of facts from that seen by the original decision-makers.
We would recognise that we have some room left to improve in the
area of taking experience from appeals and feeding it back into
the decision-making process and we are working on some ways of
doing that at the moment. I still think there is more we could
achieve in that area.
Q3 Chairman: Could you turn over
the page now and look at paragraph 3.5? I was surprised to see
that it says here "Our fieldwork indicates that decision-makers
and individual doctors receive no notification and are not aware
of how many customers with whom they had contact challenge their
medical evidence". Why is there not better feedback? I would
have thought this was a key point. After all, if you do not have
feedback about how you do your job, how can you ever improve?
Mr Anderson: That is correct.
Where medical reports are deemed unfit for purpose or are given
a C grade, there is feedback to the doctors concerned and there
is a close monitoring process of remedial action for those doctors
if there is a high frequency of poor graded reports. What there
is not, is a good process for getting every decision back to the
original doctor and I do not think that would always be possible.
Q4 Chairman: But you are going to
try to improve the information they get back.
Mr Anderson: Yes.
Q5 Chairman: Look over the page,
please, to paragraph 3.16, which deals with the evidence-based
medicine project. How soon will the Department's decision-makers
benefit from this, do you think?
Mr Anderson: My understanding
is that we expect this to be fully in place in March 2004.
Professor Aylward: We hope to
be rolling out the project with a particular infrastructure by
March 2004 with all the doctors being applied to it and it will
be fully operational by June 2004.
Q6 Chairman: May I refer you now
to page 30? I want you to comment on non-attendance. In particular
look at paragraphs 4.10 to 4.11. I was quite surprised when I
read this "Some 20 to 25% of customers fail to attend Incapacity
Benefit (IB) examinations, and one office told us that they overbook
by 21% to allow for non-attenders". There are two problems
with this, are there not? First of all you are slotting in many
more people than you are intending to see, so presumably on occasions
some people do not get seen at all and have to go home. Also,
I suspect you have some people who are deliberately not turning
up. What happens at the moment? Explain the system to the Committee.
You go to see your doctor, you say you cannot work, the doctor
gives you a chit and you immediately get your Incapacity Benefit.
You then have to wait an average of roughly a month, is that correct,
for your proper medical?
Mr Anderson: It could be longer
than a month.
Q7 Chairman: It could be longer,
but on average 30 days, one month. You receive your Incapacity
Benefit. Is there not a problem with some people deliberately
knowing how the system works simply not turning up? They go on
receiving their Incapacity Benefit if they do not turn up. What
happens then? What are you going to do about them?
Mr Anderson: The non-attendance
results in the requirement for justifiable cause to be given.
If that is followed by subsequent non-attendance a telephone call
is made and if the answer is not satisfactory, then benefits will
be stopped. There is a return to the decision-maker having had
two non-attendances with justifiable cause. Obviously there is
an earlier process if there is no justifiable cause, but we can
probably anticipate that those you describe who wish to take advantage
of the system probably know well enough to have a reasonable explanation.
Q8 Chairman: I congratulated you
earlier because you seem to have acted on several recommendations
in our earlier report and you have reduced the average waiting
time for your proper medical assessment from 52 to 30 days on
average and we the taxpayers have saved £21 million doing
it. How much could we save if we reduced the waiting time even
further, say to two weeks? That raises a further point, that if
you reduced it to two weeks, it might be possible not to have
to pay the Incapacity Benefit in the meantime because it would
only be a two-week period between seeing the doctor for the first
time and getting a proper medical examination. We could be talking
about saving further large sums of public money, could we not?
Mr Anderson: There are two things
there. The times you described, the reduction in waiting time,
are for Disability Living Allowance (DLA) and in those cases we
do not pay the benefit until after the medical, so that is slightly
different. Taking your point, the saving arises from preventing
Incapacity Benefit customers staying on benefit longer than they
would. The problem with very early medical assessment is that
we would be assessing a significantly larger number of people
whose claims only last for a relatively short space of time. This
benefit is payable, for example, to self-employed people pretty
much as soon as they become too ill to work and a large number
of them would only claim the benefit for a short period of time
and then return to work. The period which is left before the medical
assessment is designed in fact so that most people who are on
short-term claims will not get into this system.
Q9 Chairman: Mr Chipperfield, would
you like to comment on that? How much further can you reduce the
time taken to carry out these medical examinations, do you think?
Mr Chipperfield: You have rightly
observed that we have reduced to 30 days from 52 days. As part
of the Pathways to Work pilots we are actually trying out
a 15-day target.
Q10 Chairman: So you are looking
now at a further reduction.
Mr Chipperfield: We are doing
that and we are doing that in the three current pilot areas, which
are Bridgend, Renfrewshire and Derbyshire. That is part of the
Pathways to Work initiative, which is a wider policy initiative
about assisting people to return to work more quickly.
Q11 Chairman: If we were to make
a recommendation around that 15-day target, that would not be
completely unreasonable.
Mr Chipperfield: It would be a
question of how much time it would take to organise the whole
of the system in order to cope with that, but we are just now
starting to try it out. My view is that we should see how the
Pathways to Work pilot progresses and how successful we
are in achieving that and the objectives of that particular project,
then there could possibly be a second look at it.
Q12 Chairman: My last question is
on shortages of doctors and you seem to have made some progress
in tackling that. Can you keep up the good work, the progress
you have already made?
Mr Chipperfield: It is a challenge.
It is a challenge for every organisation working in the UK delivering
any kind of clinical service and whilst we have made a lot of
progress, we are not complacent and there are still one or two
areas of the country where we would like to have more doctors.
How we are dealing with that at the moment is by moving our other
doctors around the country for a few weeks at a time or a week
at a time or a few days in order to cover those issues. That is
one of the flexibilities that we can bring. There are hotspot
areas, particularly in the North-West of England, North Wales
and West Yorkshire, where we would welcome more doctors and we
are doing everything we can to get them.
Q13 Mr Steinberg: This is certainly
a huge improvement in the way things are going, certainly from
the last time we looked at this particular subject. I can remember
that I was very, very critical last time, because I had had some
horrendous constituency cases. However, there are always concerns
in any report and it is our job to look at those concerns as well
as congratulating you on doing a good job. Reading the Report
and from personal experience as well still, as far as I can see,
the Personal Capability Assessment (PCA) is throwing up a large
number of incorrect benefit withdrawals. There have been many,
many examples over the last year, particularly to the Citizens'
Advice Bureaux (CAB). The CAB in my area has contacted me about
it. Most cases seem to arise because the examining medical practitioners—and
I have to say I have always had my doubts about them in the past
and perhaps been very critical of them—employed by Schlumberger
do not provide very good advice on the Personal Capability Assessment
score in particular and that makes it very difficult for the DWP
decision-makers. Are these doctors just going through the motions
sometimes rather than actually being serious about it? I sometimes
think they are. Once I have heard your answer I am going to come
back.
Mr Anderson: There are rigorous
quality processes in place. I should first of all say both to
yourself and to the Chairman that it is very kind of you to acknowledge
the success which has been achieved and thank you for that. The
assessment of personal capability is obviously slightly subjective
and it is always going to be a difficult area. The quality checks
which are in place and the auditing which takes place is rigorous
and it has been checked by the Department as well in terms of
the quality of reports. I think we are in territory where it is
never going to be possible to ensure that two doctors looking
at the same piece of information will always produce the same
answer. We are trying to implement things like evidence based
medicine which should reduce the subjectivity as far as possible.
We are trying to encourage doctors to take formal training in
disability assessment and the Department is pioneering that. That
ought to improve things in that area. Progress is being made.
Q14 Mr Steinberg: Do you actually
believe that some of these doctors are genuinely concerned about
the actual people they are assessing? Or do you think they just
treat them as a lump of meat and do not have a lot of compassion
for them?
Mr Anderson: I have no evidence
at all to suggest that people are treated as a lump of meat. The
customer satisfaction numbers from medical assessments are very
strong.
Q15 Mr Steinberg: I had a case only
last Saturday morning in my surgery where a lady came along on
behalf of her sister. She did not want me to take it any further,
but she came along to express her dismay at the way the Attendance
Allowance had been handled. She said that the doctor had actually
said that he hated filling in forms. She was complaining about
what had actually been said on the form: on the basis of what
was put on the form the woman lost the Attendance Allowance. This
is not the first instance I have heard of things like that. I
have been very critical of doctors in this Committee on many,
many issues. They do not seem to like doing anything which means
extra work unless they are very well paid. Do you want to make
any comment? The doctors are paramount, are they not?
Mr Chipperfield: Yes, doctors
are paramount to this service. Our doctors are experts in the
field of disability analysis. They are all trained and specifically
trained to do the work we ask them to do and they are continually
trained to do so. That is not just about the medicine, it is also
about the attitude towards the customer and the understanding
of the overall policy and the benefit which they are there to
support. We would thoroughly investigate any anecdotal incident
which is reported to us with the doctor concerned. If we found
there was any substance in it, we would take some action about
it and we do so.
Q16 Mr Steinberg: Turn to paragraph
3.3 on page 22 and read the second half of that paragraph, "In
about a third of cases, tribunals considered the medical report
had underestimated the severity of the disability" and it
goes on. That seems to be backing up my argument rather than yours.
How many is it? At least 51% of cases were overturned, as I read
that. That to me does not seem as though they are doing their
job very well in the first instance and seems to back my argument
that they are not really all that bothered, are they, as long
as they are getting their fee?
Mr Chipperfield: I would disagree
with you.
Q17 Mr Steinberg: Why are the figures
so high then?
Mr Chipperfield: I do not think
I am the best person to comment on what the appeals tribunals
decide and the basis upon which they decide that.
Q18 Mr Steinberg: They are your doctors
though, are they not?
Mr Chipperfield: Not doing the
appeals. Our doctors are doing the examinations.
Q19 Mr Steinberg: On their evidence.
I may be wrong, but on their evidence it originally gets turned
down and then they go to appeal afterwards.
Mr Chipperfield: Yes, that is
correct.
| 
