Select Committee on Work and Pensions Written Evidence


APPENDIX 1

Evidence and Decision-Making in Medically-Assessed Social Security Benefits

A CAB SERVICE BRIEFING—JULY 2004

Purpose

  1.  The purpose of this briefing is to highlight on-going concerns about the way evidence is gathered, and the accuracy of decisions reached, by Department for Work and Pensions (DWP) decision-makers in relation to disability living allowance (DLA), attendance allowance and incapacity benefit.

  2.  This briefing reflects evidence of problems from the CAB services in Scotland, England and Wales.

Context

  3.  The evidence-gathering and decision-making processes for medically-assessed benefits has been the subject of continued investigation by Parliament and its agencies, including two recent reports from the National Audit Office (NAO).[110] Both reports found that there has been improvement in the way medical benefits are processed by the DWP and assessed by their contractors Atos Origin (formerly Schlumberger). However, the NAO highlighted areas where progress is still necessary.

  4.  A number of the NAO's recommendations are in line with the evidence held by the CAB service on the experiences of Citizens Advice Bureau clients. This evidence highlights the drastic impact that poor decisions in relation to medical benefits can have on clients' lives, particularly where medical evidence does not properly reflect the extent of their health problems. These issues have been highlighted by the service many times yet, despite on-going parliamentary investigation, we have still to see improvements in the treatment of customers.

  5.  The CAB service believes that now is a key time to address the weaknesses in the current processes for gathering evidence and making decisions on medical benefits because:

    —    The Disability and Carer's Directorate is currently being re-organised, providing an opportunity to refocus processes to ensure that decisions on customers' entitlement are right first time.

    —    Atos Origin's contract to supply medical services to the DWP ends in August 2005. The resultant tendering process can be harnessed to make sure that the right drivers are in place to deliver a better service to disabled customers.

    —    The DWP is currently piloting a number of different systems for collecting evidence on medical benefits. It is time that results were consolidated so that claimants across the country can benefit from what has been found to work.

Customer experiences

  6.  Inconsistent decision-making is causing customers to lose faith in the system. The CAB service deals with a number of clients who do not pursue new claims or appeals where their circumstances justify it, because they are afraid that they will lose the benefits that they have.

    A West of Scotland CAB reports of a client who suffered from severe angina as well as other physical problems. Her condition had been deteriorating over the past two years. However, she would not request that her DLA award was reconsidered because she was afraid that she would lose the entitlement she already had.

  7.  The effects of a decision to remove entitlement to medically-assessed benefits can have a devastating impact on the customer, in terms of both income and health. The decision may also affect the status of the customer's carer and other people living in their household.

    A West of Scotland CAB reports of a client with physical health problems and a history of alcohol dependency. He has been claiming incapacity benefit since 1996; however, his entitlement ended as a result of a personal capability assessment. He is appealing the decision. In the meantime, his income has dropped from £80 per week to £44 per week (income support with a 20% penalty because he is not actively seeking employment). The client visited the bureau because he cannot cope with living on such a low income. He is worried that he will not be able to pay his mortgage. He has managed to keep his drinking under control for the past four years but has now returned to drinking on a daily basis.

  8.  The impact of wrong decisions on DWP customers, who may be additionally vulnerable as a result of their disability, emphasises the need for very high standards regarding medical assessment and decision-making. Recent statistics on appeal outcomes (see paragraph 15) underline that this is not yet the case.

    —    Until standards are improved, the CAB service recommends that entitlement to medically-assessed benefits should remain until an appeal has taken place.

Medical evidence

  9.  Evidence of entitlement to DLA and Attendance Allowance can come from a number of sources, including social workers, community psychiatric nurses and carers. However, the most common sources are statements from a customer's GP or an examination by a DWP Medical Services doctor—supplied by Atos Origin. There are strengths and weaknesses to all these evidence sources. For instance, a GP may be more likely to favour their patient's point of view, while a Medical Services doctor will not have any knowledge of the medical history of the customer.

  10.  Nevertheless, it raises some concern that the NAO found that DWP decision-makers may be influenced by clearance time targets to choose evidence sources which will provide information quickly.[111] The NAO also found that decision-makers expressed a preference for reports by Medical Services doctors because these were seen to be reliable and independent. A total of 220,000 of these reports were requested in 2002-03.[112]

  11.  In relation to incapacity benefit, customers are examined in a medical centre by a Medical Services doctor, again supplied by Atos Origin.

  12.  The CAB service receives significant evidence of on-going problems in this area. Problems reported by CAB clients include:

    —    Doctors with a rude or insensitive manner;

    —    Incomplete consideration given to mental health problems;

    —    Inaccurate reports (eg where a doctor has made incorrect assumptions about a client's abilities);

    —    Rushed and/or incomplete examinations;

    —    Incorrect reporting of what a client has said about their own condition; and

    —    Doctors getting clients to sign reports which they have not read.

      A client from a CAB in Northern Region was unhappy with the quality of report that a Medical Services doctor provided after an examination. She suffers from rheumatoid arthritis and was visited for a DLA renewal claim by a doctor who had a poor command of English and did not seem familiar with the qualifying conditions for the benefit. As a result of the report, the client lost her mobility component, and was put to the stress of waiting four months for an appeal at which her award was reinstated.

  13.  The CAB service recognises that assessing customers' medical problems is a difficult area, requiring the exercise of judgement. Given the importance of examinations by Medical Services doctors in the decision-making process, it is necessary that these are carried out to the highest standards, and that decision-makers' perception of the reliability of the resultant reports is justified.

  14.  We note that Atos Origin have an internal audit system in place and have halved the number of medical reports which are graded as "unsatisfactory" by this system. However, such a system considers only the content of the report after the fact, not whether the findings were justified by what happened during the examination. The examples given above relate to the actual examination process, yet they also impact on the likely reliability of any medical findings from the examination. Atos Origin has no system, other than customer complaints, to monitor this aspect of their doctors' performance.

    —    Given on-going concern about the manner in which examinations are conducted, the CAB service calls for Atos Origin to introduce something akin to a "mystery shopping" system which would monitor doctors' behaviour during the examination. The results of surveys should be available to interested parties.

Decision-making

  15.  The CAB service remains concerned about the DWP's poor decision-making in relation to medically-assessed benefits. This is evidenced by the high rates of successful appeals regarding these benefits. The figures below highlight the success rate at oral hearings for our key benefits, with the figure in brackets representing the success rate where both the appellant and their representative attend.[113]

    —    Attendance allowance—55.2% (60.5%).

    —    Disability living allowance—58.3% (68.7%).

    —    Incapacity benefit (personal capability assessment)—58.4% (73.8%).

  16.  Put in layman's terms, appellants are more likely than not to succeed in overturning the DWP's decision at appeal, and in certain circumstances, they have a two in three chance. The NAO also highlights a 45% error rate in relation to DLA and Attendance Allowance decisions, based on DWP figures.[114] These figures make a compelling case for the need to improve the accuracy of decision-making in relation to medically-assessed benefits, and evidence from CAB clients highlights the impact of poor decisions on DWP customers.

    A West of Scotland CAB reports of a client who has had mental health problems since he was a teenager. He lost entitlement to DLA after an examination two years ago. Since that time, he has had numerous admissions to hospital in relation to self-harm. He has also spent periods from two to six months as a psychiatric in-patient. The client comments that the Medical Services doctor who examined him was rude and only stayed for 10 minutes. The bureau notes that the DWP did not seek further evidence from his consultant (who confirms that the client continues to need constant supervision) or community psychiatric nurse. The client did not know he could appeal this decision, and so did not challenge it.

  17.  The most common reason for decisions being overturned at appeal was found by the president of The Appeals Service to be the presentation of new evidence not considered by the original decision-maker.[115] The NAO sees this as showing that the quality of the original medical evidence was not in question. However, the CAB service has outlined its concerns about evidence from Medical Services doctors above.

  18.  We view the president's findings as evidence that there is a clear need for decision-makers to seek and consider evidence from a wider variety of sources before reaching their decisions. Taking into account evidence from more than one source also allows decision-makers to counteract the inherent weaknesses in evidence from any individual source, leading to smarter decisions all round. Where targets on clearance time for benefits decisions interfere with the consideration of further evidence, these targets should be redefined at a level which ensures decisions which are both timeous and correct.

    —    The CAB service recommends that procedures are put in place to ensure that decision-makers consider evidence from a wider variety of sources. There is scope for greater guidance to decision-makers—eg in relation to evidence from community psychiatric nurses for those with mental health problems.

  19.  There is also evidence, highlighted above (paragraph 10), that decision-makers prefer the evidence of Medical Services doctors. Evidence from the CAB service demonstrates that this view may not always be justified. There is therefore a need for decision-makers to treat evidence from Medical Services doctors more critically.

    —    The CAB service recommends that entitlement to medically-assessed benefits should not be withdrawn by DWP decision-makers on the basis of evidence from a Medical Services doctor only, where the customer has been in long-term receipt of that benefit.

Conclusion

  20.  The CAB service has presented evidence of on-going problems with evidence-gathering and decision-making in relation to medically-assessed benefits. This evidence is generally in line with the findings of other organisations examining this area, including the NAO. The CAB service believes that changes within the DWP mean that there is currently an excellent opportunity to address these problems in a way that benefits customers. We therefore call on the DWP to respond to this briefing and the specific recommendations it contains.

Abigail Bremner

5 October 2005




110   Progress in improving the medical assessment of incapacity and disability benefits, National Audit Office, October 2003 (HC 1141) and Getting it right, putting it right-improving decision-making and appeals in social security benefits, National Audit Office, November 2003, (HC 1142). Back

111   Getting it right, putting it right, National Audit Office, November 2003. At paragraph 2.22 it is noted that decision-makers are expected to make 10 initial decisions per day, and that this may influence the medical evidence they seek. Paragraph 2.13 also highlights that decision-makers may feel under pressure to select the cheapest and quickest sources of evidence. Back

112   Ibid, para 2.14. Back

113   Quarterly Appeal Tribunal Statistics: December 2003, DWP. Back

114   Getting it right, putting it right, National Audit Office, November 2003. Para 2.5. Back

115   Progress in improving the medical assessment of incapacity and disability benefits, National Audit Office, October 2003. Figure 11. Back


 
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