Supplementary memorandum submitted by
Jobcentre Plus
Question 87 (Mr Bacon): The following table provides
information on doctors whose approval to deliver medical services
for, and on behalf of, the Department for Work and Pensions (hitherto
the Department of Social Security), which had been revoked because
of erasure or suspension from the Register, or continuing investigation
by the General Medical Council.
| Date(s) | Doctor
| Chronology of Events from
the Register by the GMC
| Revocation |
July-
August 2000 | GMC 1
| July 2000: In connection with incidents unconnected with Dr GMC 1's provision of medical services to the Department of Social Security, Dr GMC1's registration on the principal list was suspended for 6 months following a decision by the Preliminary Procedures Committee pending a full public hearing by the Professional Conduct Committee. Dr GMC 1 suspended from provision of medical services to the Department of Social Security.
| August 2000: On the basis of information received during the process of the GMC's decision to suspend Dr GMC 1's registration and decision to conduct a full public hearing by the Professional Conduct Committee the CMA decided on behalf of The Secretary of State to revoke Dr GMC 1's approval to provide medical services for, or on behalf of, the Department. Dr GMC1 erased from Register in August 2001.
|
May 2001-
November 2002 | GMC 2
| May 2001: In connection with incidents unconnected with Dr GMC2's provision of medical services to the department, Dr GMC 2 was erased from the Register by the GMC. The GMC found Dr GMC 2 guilty of serious professional misconduct. Dr GMC 2 appealed to the Privy Council against the GMC's decision. Dr GMC 2 suspended from provision of medical services to the Department. Dr GMC 2's appeal heard by Privy Council in January 2003. The appeal was not upheld.
| November 2002: For technical reasons in connection with Dr GMC 2's appeal to the Privy Council the doctor's suspension from providing medical services to the department was not formally revoked by the CMA on behalf of the Secretary of State until November 2002.
|
April 2001-
December 2002 | GMC 3*
| April 2001: alleged sexual assault on female companion at home of claimant visited by Dr GMC 3 in his capacity as an Examining Medical Practitioner approved for the undertaking of medical examinations on claimants for Disability Living Allowance/Attendance Allowance (DLA/AA) reported to General Medical Council. Dr GMC 3 suspended from provision of medical services to the Department of Social Security. Action subsequently taken by GMC to investigate the alleged incident.
| December 2002: On the basis of information received during the process of the GMC's Inquiry and Investigation of complaint against Dr GMC 3, the CMA decided on behalf of the Secretary of State to revoke Dr GMC 3's approval to provide medical services for, or on behalf of, the Department. Dr GMC 3 not yet arraigned before GMC because of intervening illness.
|
May-
November 2002 | GMC 4
| May 2002: Information received that Dr GMC 4 was subject of an inquiry and hearing by the GMC's Professional Conduct Committee for alleged serious professional misconduct. Dr GMC 4 suspended from providing medical services to the Department. GMC suspended Dr GMC 4's registration from June 2002 for a period of 3 months. September 2002: GMC reinstated Dr GMC 4's registration without conditions.
| November 2002: On the basis of information revealed at the GMC's hearing and subsequently the CMA decided, on behalf of the Secretary of State to terminate the doctor's suspension from providing medical services to the Department with formal revocation of approval. Despite reinstatement by GMC, the doctor has not been accepted for re-engagement as an approved doctor.
|
| |
| |
*Note: Only one doctor (GMC 3) was "pursued with the General
Medical Council" in that the alleged assault of a claimant's
female companion during his visit as an Examining Medical Practitioner
was reported by the Department's Medical Services to the GMC.
Question 94 (Mr Williams) and Question 106 (Mr Bacon): This
table sets out the monthly numbers of C Grade or sub-standard
medical reports for the period shown in Fig 12, page 23, of the
NAO Report.
Month | Actual Numbers of C Grade medical reports
| Numbers as a Percentage of all medical reports
|
April 2000 | 125
| 5.09% |
| May 2000 | 159 | 6.35%
|
| June 2000 | 153 | 6.12%
|
| July 2000 | 119 | 5.35%
|
| August 2000 | 195 | 7.91%
|
| September 2000 | 152 | 6.48%
|
| October 2000 | 136 | 5.36%
|
| November 2000 | 124 | 5.17%
|
| December 2000 | 145 | 6.33%
|
| January 2001 | 138 | 5.48%
|
| February 2001 | 76 | 2.98%
|
| March 2001 | 43 | 3.36%
|
| April 2001 | 79 | 2.68%
|
| May 2001 | 80 | 2.62%
|
| June 2001 | 87 | 2.77%
|
| July 2001 | 52 | 2.46%
|
| August 2001 | 53 | 2.19%
|
| September 2001 | 82 | 3.86%
|
| October 2001 | 79 | 3.73%
|
| November 2001 | 67 | 2.87%
|
| December 2001 | 74 | 3.06%
|
| January 2002 | 60 | 2.98%
|
| February 2002 | 52 | 2.61%
|
| March 2002 | 65 | 3.41%
|
| April 2002 | 55 | 2.69%
|
| May 2002 | 34 | 1.56%
|
| June 2002 | 46 | 2.12%
|
| July 2002 | 50 | 2.43%
|
| August 2002 | 46 | 2.29%
|
| September 2002 | 49 | 2.42%
|
| October 2002 | 39 | 2.03%
|
| November 2002 | 49 | 2.43%
|
| December 2002 | 61 | 3.1%
|
| January 2003 | 43 | 2.46%
|
| February 2003 | 41 | 2.35%
|
| |
|
Note: A graphical chart of this information can be found on the
next page.
Graph showing the monthly numbers of C Grade or sub-standard
medical reports for the period shown in Fig 12, page 23, of the
NAO Report.
Questions 103 & 104 (Mr Williams):
POSSIBLE SAVINGS FROM IMPROVED DECISIONS BY APPEALS TRIBUNALS[11]
The cost to the Department of possible errors by tribunals
in estimating the severity of disability is difficult to estimate.
Although the President's Reports identify the numbers (and percentages)
of appeals found in favour of the appellants where in the tribunal's
view reports underestimated the extent of the appellant's disability
in a sample of cases, it is by no means clear from the
data and narrative text whether this was the principal reason
for the tribunal's overall decision. The tribunal consists of
a legal member who is in the chair, a medical member, and for
Disability Living Allowance appeals, a member with experience
of disability. It would be wrong to assume that the medical opinion
is always decisive in the tribunal.
The Chief Medical Officer states that he scrutinized a sample
of 22 cases in which Tribunals had remarked, or by some other
means indicated, that disability was underestimated in the medical
reports (from Medical Services and/or external sources) which
had been available to the decision-maker at first tier. He did
not agree with the Tribunal's conclusions in that regard in 50%
(11 cases) of those papers. He made no conclusions about the overall
decision reached by individual tribunals, since the ultimate decision
of the tribunal could have rested on other issues before them
or indeed could have taken the underestimation of disability in
part, or in whole, in reaching their decision. He could not from
the paperwork know what was precisely in the mind of the tribunal
when they reached a decision.
If it is assumed that across the sample all factors had equal
weight in the tribunals' decision it is possible to estimate the
cost for one year where the appeal against the disallowance of
Incapacity Benefit was upheld because the tribunal believed the
severity of disability was underestimated. The cost for all appeals
upheld in 2002-03 where underestimating severity of the disability
was a factor in the tribunal's decisions would be between £3
and £4 million based on a cost of £17 per benefit claim
per week, assuming that payment of Incapacity Benefit would be
replacing payment of Income Support. Thus if 50% of relevant decisions
to uphold the appeal could be judged as incorrect, as suggested
by the Chief Medical Officer's exercise, the programme savings
from not upholding the appeal would be £1.5 to £2 million.
However, this is a hypothetical figure subject to a very large
margin of uncertainty. In particular, a small random sample with
the results discussed above would be subject to a margin of error
of some 22% in either direction, and further uncertainty arises
from the other assumptions discussed in this paragraph.
For Disability Living Allowance and Attendance Allowance
there are many more variables. This is because Attendance Allowance
has two rates and Disability Living Allowance has two components:
a care component with three rates and a mobility component with
two. Appeals could change decisions from rejection/a lower rate
to a lower or higher rate for the care and mobility components,
as applicable. A successful appeal for DLA could have any one
of at least 27 outcomes with a positive financial outcome for
the appellant. The sample of tribunal decisions does not record
this information about the case outcome.
Given the greater degree of uncertainty that would be involved,
it would not be appropriate to give a financial estimate of the
cost of the Disability Living Allowance and Attendance Allowance
appeals lost. Note, however, that there were 38,360 successful
appeals against Disability Living Allowance decisions in 2002-03,
4,140 against Attendance Allowance decisions and 17,610 against
Incapacity Benefit decisions.
Question 131 (Chairman):
AREAS FOR FLEXIBILITY AND INNOVATION IN THE NEW CONTRACT
The Department for Work and Pensions recognises the need
to secure improvements in the delivery of medical services and
the drive to secure value for money through re-tendering the Medical
Services contract. Consequently, the Department has identified
a number of potential areas for improvement that will be discussed
with the three short listed service providers (SchlumbergerSema
(now Atos Origin), Capita, Vertex) and their proposals for innovation
will form part of the negotiations with the Department.The four
potential areas for innovation which have currently been identified
by the Department include:
1. INFORMATION SYSTEMS/INFORMATION
TECHNOLOGY (IS/IT)
This relates to the use of IS/IT as an enabler. It will be
beneficial for the new contract if service providers were encouraged
to formulate and propose innovative IS/IT solutions that enhance
and improve the provision of the service. The Department's Modernisation
Programme recognises greater use can be made of IS/IT to deliver
medical services.Part of the DCS Change Programme entails the
procurement of an IT Provider who will then work with the Department
to procure a commercial off-the-shelf package (COTS) and to re-engineer
processes so that they may then be successfully automated.
Eventually, this automated computer system must be able to
provide the requisite electronic interfaces between the Department,
service providers and other outside contributors such as the National
Health Service (NHS). Currently, it is intended that the electronic
interface with the medical services provider will be introduced
around October 2006.
2. ACCOMMODATION
Accommodation is another core element of service provision.
The Department will encourage service providers to work collaboratively
with the Department and the lead contractor Land Securities Trillium
(LST) over time to incrementally develop and improve the estate.
However, any surrender of Departmental premises by the service
provider will be subject to a detailed cost analysis—including
the key business driver that there should be no adverse ongoing
or incurred costs to the Department. This is aligned with and
will contribute to the Departmental Estate Strategy and in addition,
this approach will provide an opportunity to refine the service
delivery model.
Service providers will have the flexibility, with the agreement
of the Department, to vacate some properties at the start of the
new contract, where a continued presence is no longer required,
or remain within the present accommodation.
The contract will be drafted in such a way as to allow for
vacation of premises throughout the Term, with the agreement of
the Department, and a further opportunity for the service provider
to opt out of accommodation arises in 2006.
3. USE OF
HEALTH CARE
PROFESSIONALS
This refers to the use of Health Care Professionals (HCPs)
instead of doctors to deliver services in the medical services
contract. Nurses, both trained and specialist trained (mental
health, learning difficulties, children) are considered to be
relevant to the current contract and the existing scope:
The following may also become relevant as a result of ongoing
and future initiatives:
— Occupational Therapists
— Occupational or Work Psychologists
The Department has clarified the legislative requirements
for the use of HCPs.
There is a general recognition within Government and in other
organisations responsible for the provision of health care advice,
both state (NHS) and private (Healthcare, Insurance) that, the
increased use of HCPs in appropriate circumstances not only adds
value but also releases valuable doctor resources for other activities.
Efficiency and quality
It is well recognised that HCPs function extremely well in
a protocol driven environment.
Such efficiency and quality would therefore be maximised
in business areas that lend themselves to being protocol driven,
and this may be enhanced by the use of an IT base.
Such efficiencies are therefore likely to apply to the Medical
Services contract insofar as:
— Much of the work is protocol driven
— There is successful ongoing development of a supporting
IT base (Evidence Based Medicine)
However, it should be noted that the above does not obviate
the need for a considerable amount of clinical judgement.
Workforce flexibility
One of the major drivers to the use of HCPs is national recognition
of the shortage of suitably qualified doctors.
Despite the success of the recent recruitment exercise undertaken
by Medical Services, it is not possible to predict with certainty
that any future service provider will be able to attract suitable
numbers of doctors to carry out Medical Services work. This is
due to a number of factors that include:
— Lack of sufficient places at medical schools
— A high drop out rate at medical schools
— Difficulty in the retention of doctors in a many
medical disciplines
— Competition between organisations for doctor services
in a restricted market and the drive to offer higher salaries,
exemplified by the current recruitment campaign that is being
undertaken by the NHS.
— Issues relating to potential dissatisfaction with
Medical Services work that may apply in the future, for example
rising numbers of complaints that may be considered to be a threat
to individual revalidation, organisational restructuring etc.
4. PROCESS RE
-DESIGN
This entails re-design of existing processes in relation
to how medical assessments are delivered. Consideration needs
to be given to the potential opportunities to change processes
and the boundaries of process design (eg, where to start and finish).
Options will be fully explored with the short listed service providers.
Conclusion
In choosing to undertake the re-tender by means of EC Negotiated
Procedure the Department has opened the door to iterative discussions
and negotiations with service providers over how the service can
or may be delivered. In addition to the areas of potential innovation
identified earlier in this paper the Department will also seek
to identify improvements in other areas of the contract and will
encourage service providers to recognise and propose innovative
delivery models. Furthermore, the unique opportunity offered by
the re-tender allows the Department to work together with providers,
customers and external advisors to produce the optimum delivery
model and commercial contract.
Question 133 (Jon Cruddas)
The most recently available information dates from April
2002. Of the 856 doctors then working for the Appeals Service,
136 (16%) also worked as examining doctors for Medical Services
through Nestor Disability Analysts.
Doctors directly employed by Medical Services do not work
for appeal tribunals.
The impartiality of doctors working for both Medical Services
and the Appeals Service has been challenged in the courts (Gillies
case). In a decision given on 28 November 2003 the Court of Session
in Scotland held that "the fact that [a doctor] carried out
examinations and provided reports for the Benefits Agency as an
EMP would not be sufficient to raise in the mind of the reasonable
and well-informed observer an apprehension as to [the doctor's]
impartiality as a member of a disability appeal tribunal. The
mere fact that the tribunal would require to consider and assess
reports by other doctors who acted as EMPs would not be such as
to raise such an apprehension".
David Anderson
Chief Executive
Jobcentre Plus
6 February 2004
11
This note has been prepared jointly by the Department for Work
and Pensions and the National Audit Office. Back
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