Memorandum submitted by Michael Bachrynowski (DM 03)
1. The DWP needs to provide a service that is cognisant of the expected increased levels of sickness proportional to the actual increased levels of cancer, strokes, obesity, stress, anxiety and other ailments.
2. The DWP, by distancing itself from service delivery by outsourcing to companies such as Atos Origin, risks losing control of the quality of service delivery.
3. The DWP "de facto" targets set for the outsourced company appear to be only related to cost reduction. The DWP is not competent to set health related targets.
4. The outsourced company's primary objective is to maximise profits for share holders.
5. It appears to be not in the interest of the outsourced company to pre-screen patients as they would lose the opportunity to make a profit on each appointment.
6. It appears to be in the interest of the outsourced company to make the process as complex as possible with multiple phone calls and multiple letters involving multiple locations. It is not clear how these charges are recovered. This approach appears to have a further benefit in that it is likely to discourage claimants and thus reduce expenditure.
7. It appears to be in the interest of the outsourced company to require patients to travel long distances for appointments. If a patient can travel these long distances it does not mean they are able to work. Long distances means an increased likelihood of delays which means a patient is more likely to fail to meet the rigid fifteen minutes late time rule which in turn means a new appointment has to be made. Charges for two appointments should mean twice the profit.
8. It appears to be in the interest of the outsourced company to delay payments for travelling expenses. Commercial companies are very careful with outgoing cash flow.
9. The DWP needs to be more transparent and publish meaningful statistics.
10. The DWP is likely to seriously underestimate the cost of setting up a parallel health service which conforms to best practice of the NHS.
11. The DWP needs to consider whether it would be better to use the services of the NHS and in particular the Primary Care Trusts and their Psychological Therapy and Physical Therapy departments which currently have an obligation to promote excellence in the provision of work rehabilitation therapies. PCTs have direct access to full medical records. PCTs have well established infrastructure subject to continual scrutiny and audit.
12. Funds currently allocated to the DWP to set up and run a parallel health service should be transferred to the NHS PCTs.
13. The Health Service should be the single government department responsible for the health of a patient.
14. The Health Service should provide the DWP with authoritative comprehensive medical statements on the progress and needs of the patient and associated carers. The existing Doctor's Statement can be extended if necessary. The DWP should make payments that are in line with set rates that are appropriate for the items listed in the medical statements.
15. The DWP can draw the attention of the appropriate medical review body if statistics suggest medical statements from particular individuals or centres are out of step with the average. This should not be a patient issue.
16. If there are DWP budget constraints then published rates can be cut openly and fairly without adversely impacting a group of disadvantaged patients such as the feeble or those who are unable to deal with complex forms. Currently disadvantaged patient groups are more likely to take on the burden of cuts than others. This appears to be discriminatory.
17. When the Health Service has fully discharged the patient as fit for work the DWP can takeover the case and apply appropriate procedures such as help with employment and or training.
18. By removing the health requirement, the DWP can focus on employment and pensions.
19. There are major economies of scale to be achieved by using the established infrastructure of the Health Service to deliver "fit for work" related health assessments and treatments.
20. Consider the contrarian view, if it is a good idea for the DWP to set up a parallel health service why not other departments. The Home Office could have their doctors decide on whether a criminal is fit for trail. The MOD could have their doctors decide on whether a soldier is fit for front line duty. The NHS puts patients first. Other "quasi" health services may be more influenced by their management to keep their department or company objectives at the fore front of their thinking.
21. The following "summary items" assume that the DWP continues to operate a parallel health service.
22. A person, subject to a current Doctor's Statement, should be regarded as and treated as a patient at all times. The welfare of the patient should be paramount. A patient should be treated with dignity, respect and consideration. Reference to a patient as a "Customer" is not helpful to the patient or the culture of the DWP organisation responsible for decision making.
23. A doctor, who is appointed to undertake a medical assessment, should review the medical circumstances, travel and waiting times at least five working days prior to the appointment and, if necessary, cancel the appointment where in the opinion of the doctor, the appointment is likely to be detrimental to the health of the patient.
24. The DWP should not compel doctors to undertake procedures that are likely to be detrimental to the health of a patient.
25. Doctors should be reminded that they have a duty of care to report incidents, where they are put under pressure to operate in breach of medical ethics such as undertaking procedures detrimental to the health of a patient, to the appropriate authority such as the BMA.
26. The doctors appointed by the DWP should have specialist expertise, over and above that which can be expected in a GP, in the area of evaluating fitness for work and recommending courses of treatment that can speed the recovery of a patient to be fit to return to employment.
27. The DWP should only undertake a medical assessment in cases where they have access to the patients' medical history or where this is not readily available a brief from the GP and or consultants involved in the case. The DWP should not expect a patient to recall the details of their medical history which may cover many years.
28. The DWP should obtain from the competent medical authority a list of medical conditions and treatments which are regarded as so serious that a medical assessment is not necessary. If the circumstances of a patient changes these would be reflected in a Doctor's Statement.
29. The DWP should maintain and publish statistics on medical conditions and treatments and their impact on ability to work. The objective is to identify patients where a medical assessment is not necessary. For example, it may be that, in all cases, a patient is not able to work if a patient is prescribed anti-convulsion medicine and or has been obliged to surrender a driving licence and or is exempt from prescription charges and or has multiple doctors and consultants involved in the case. This would allow the DWP to focus and target resources on those patients who need help most.
30. The DWP should maintain and publish statistics on journey time from home to the appointment centre, waiting time, actual appointment time (normally two hours), journey time to return home and whether public transport was used. The competent medical authority should be asked to review and set acceptable times. It is suggested that a maximum of thirty (30) minutes outgoing travel time, a maximum of thirty (30) minutes waiting time and a maximum of thirty (30) minutes return time is reasonable. If public transport must be used, the appointment should be scheduled outside peak travel periods. In rural areas the time could be extended to allow a journey to the next nearest doctors' surgery.
31. The DWP should provide for each appointment a suggested journey plan for both the outgoing and return journey.
32. Where possible the medical assessment should be located in the Parliamentary constituency of the patient. The DWP should maintain and publish statistics for those appointments where the DWP has required patients to travel outside their constituencies and or outside their counties or metropolitan areas and or further afield.
33. The DWP should maintain and publish statistics on the reasons for failure to make a medical assessment appointment and the number of patients who they contacted to agree an appointment for a medical assessment and for whom an appointment could not be made.
34. The DWP should maintain and publish statistics on the reasons for failure to attend a medical assessment appointment and the number of patients who failed to attend an agreed appointment for a medical assessment.
35. The DWP should maintain and publish statistics on the reasons the DWP has cancelled a previously agreed appointment, the periods of notice given to the patient and the number of patients involved.
36. The DWP should maintain and publish statistics on incidents impacting patients which, in the opinion of the patents' medical team are due to the appointment. Of particular interest are statistics relating to self harm and suicides following withdrawal of or changes to benefits.
37. The DWP should maintain and publish statistics on their performance in responding to correspondence from patients and doctors. It is suggested that the DWP should respond within a maximum of ten (10) working days.
38. The DWP should maintain and publish statistics on their performance in paying travel expenses. It is suggested that the DWP should make a payment or respond within a maximum of ten (10) working days.
39. For offices, which the DWP use for medical assessment appointments and which are not medical facilities such as doctors' surgeries, clinics or hospitals, the DWP should maintain and publish statistics on the state of offices for dealing with patients. The should include scope and frequency of cleaning, provision of cleaning gels, provision of reading materials, access to television, food and drink etc.
40. The DWP should review the approach of locating medical assessment offices in high crime areas especially as they mandate the patient to attend with passport and banking information. The guidance booklet should be reviewed and amended to state that a NHS prescription exception card is an acceptable form of identification.
41. After a medical assessment has been carried out, the DWP should provide a report to the patient and to the patient's GP within a prescribed number of days. It is suggested ten (10) days is a reasonable amount of time.
42. The DWP should maintain and publish statistics on their performance in providing post assessment reports.
43. The DWP should develop a contingency plan to be invoked in case of a nationally declared emergency such as the Swine Flu Pandemic declaration. The DWP should consider whether it is wise to insist that patients travel on crowded public transport in such circumstances.
44. I am 52, a graduate of Imperial College, London and have been a senior IT Manager for many years in leading companies. I managed teams that built major IT applications. I have expert knowledge of business processes and customer systems in particular.
45. I have direct first hand experience of the DWP Decision Making process as it relates to ESA.
46. On the 15 April 2009 at 05:30, I experienced the latest occurrence of an extremely painful fit. It was worse than before and so painful that I became unconscious. I was revived by the excellent ambulance service and emergency admitted to hospital. I spent the next ten (10) days in hospital. I received excellent care. After XRays, CT Scans and MRI scans, I was diagnosed with a primary brain tumour. As the hospital does not have neuro-surgery capabilities, I was referred to a consultant at another hospital. I was prescribed anti-convulsion medicine. As I was fine, except for periods of being extremely weak, and as nothing could be done for me, I was discharged.
47. I saw my GP, who provided a Doctor's Statement which I sent to the DWP. I was given exemption from prescription charges due to cancer. I surrendered my driving licence. My pharmacist had never had a case like mine. My GP said in her working life, she expected to deal with two or three similar cases at most.
48. Eventually I saw a Neuro-Surgeon consultant who recommended monitoring the situation and reviewing after a few months. It is likely the tumour will get worse and at some point may need to be removed by surgery and or radio therapy.
49. The doctors I saw recommended avoiding situations which could trigger further fits such as working with IT or watching television for long periods. My next consultation is scheduled for 10 September 2009 recently rescheduled due to the train strike from the 20 August 2009.
50. In a recent (2 April 2008) written answer to a Parliamentary question, the survival rate for an adult patient diagnosed with a Primary Brain Tumour was stated by the Secretary of State for Health as twelve (12.3) percent survive five years.
51. After a few weeks, I experienced a set of serious symptoms which meant I had to undergo a second urgent MRI scan as soon as possible. With the help of my excellent GP, I avoided being admitted to hospital as the GP and I knew it was pointless to occupy a bed when nothing could be done. As it turned out, the tumour appears to be unchanged and the symptoms may be related to the combination of medicines I am taking.
52. Currently I am without pain and have periods of sufficient strength to write this memorandum. I am awaiting an appointment with a neurologist to review my prescriptions and the impact on my health of working for extended periods with VDUs.
53. I have found some of the elements of the process that I have experienced worthy of Kaffka's novel "The Castle". Each "aparachuk" (bureaucrat) tries their best but are constrained to comply with a set of rules that appear to be as rigid as a railway track. The prime objective appears to be maximising the profits of the company that the DWP has chosen to outsource to.
54. My first involvement in this process was that I received a long multiple page form. I was far too weak to complete it. Any strength I did muster I wanted to use to try and settle my affairs.
55. I believed at that time the form was sent by the DWP as a mistake. The DWP had received my Doctor's Statement. I had received the prescription charges exemption. I had told the DWP of my condition and that I had surrendered my driving licence. The DWP could contact my GP for more information who could give them the details of all the other doctors and consultants involved in the case and details of the medicines I have been prescribed and their side effects.
56. I received the same form again which though very tired I completed. I am right handed and the tumour adversely impacts my right side. My handwriting was poor. The form went on and on. I listed my GP, all the doctors, consultants, medicines etc. I thought that would be the end of the matter. Every time a Doctor's Statement expired I obtained another and sent it to the DWP.
57. I received a letter on a Friday instructing me to ring "within two days of receiving this letter" i.e. Saturday or Sunday to agree an appointment. I had never heard of a government procedure working at the weekend and on a Sunday. I suspected a scam. I was very weak at the time but I struggled to phone the number.
58. An appointments clerk would not listen to what I thought was common sense and retreated to the "all I do is make the appointments" line. I was upset and too tired to think straight. I misunderstood the threat he made, which was to cut some benefit if I did not agree an appointment, to mean wrongly, that I would be immediately denied treatment. I told him I did not care what they did. I wanted nothing from him except a cyanide pill and if he did not send me that I would top myself as I could no longer do anything and I did not want to be a burden. I am ashamed that I lost control.
59. I took a risk and decided on my own to lower my dose of anti-convulsion medicine. I needed to do something to get some strength.
60. It was impressed upon me that it was not wise to change the dose without checking with my GP. Eventually I saw my GP who agreed the change. I felt stronger and sorry for the appointments clerk just obeying orders. I asked about the appointment and was told the GP could write an additional note to say I could not travel but if I felt fit enough I could go. It would be a useful test. I could relate it to how I felt when I used to commute.
61. Mistakenly I thought I would meet a medical expert who could advice me on how soon after the tumour had been dealt with I could be back at work. In addition I wanted to know what I could do to improve strength and stamina.
62. I phoned and made an appointment. I could not believe the nearest location was so far away in Highgate. I live in Broxbourne, Hertfordshire. I told him I was not allowed to drive and was told there was public transport. I said I took medicine that required frequent access to toilet facilities and that I was concerned about my tiredness. The appointment clerk was not interested. The target was to make an appointment within a target time for a conversation.
63. I received the appointment letter and the recommended journey plan. I could not believe the plan had an outgoing duration of 108 minutes and involved seven (7) changes involving walking and buses. No return journey plan was provided.
64. I wrote a letter dated 28 June to which I still have not had a reply. This asked a number of questions and pointed out that the maximum time of the journey was supposed to be ninety (90) minutes.
65. I was anxious about the appointment. Two days before the appointment I received a letter rescheduling the appointment. The replacement appointment had a journey time of seventy four (74) minutes involving walking, train and tube and a waiting time of an hour. It should be noted due to weakness since April I had made only two journeys by public transport; my sons wedding and the trip to the consultant. Due to weakness I am confined to walking locally near my house. I have made two other visits to my local hospital for a heart test and for the emergency MRI scan (which I had to wait ten (10) days for).
66. I attended the appointment at Highgate on Friday 24 July 2009 at 15:30. I was seen at 16:10 forty (40) minutes late. No excuse was made for the lateness except that a doctor was not available! The appointment lasted until 17:50.
67. The doctor spent all but ten minutes filling in an online form and asking me about my medical history as she had no access to my medical file. The ten minutes of medical tests involved an eye test, blood pressure measurement (high) and superficial muscle strength checks. The doctor was not a specialist. She agreed that the procedure was not beneficial to my health. She was just following orders. I informed her I would be writing a letter of complaint and would be taking this up with those in a position of authority who might be able to get things changed. I left home at 13:25 and returned home at 19:50. The office had no cleaning gels. It had drinking water and nothing else. It was bleak and oppressive. I had to stand on the Tube and train due to peak time travelling. I was too tired to do anything when I got home except to go to bed.
68. While I was waiting, a young lady, a sick looking, pallow skinned, tired patient, turned up twenty minutes after the set time for her appointment. She was turned away and told to ring the appointment centre for a new appointment. I was seen forty minutes after the set time for my appointment. I could not see any operational reason why the patient was turned away. I could only justify this in commercial terms as two appointments should mean double the profits. The patient had difficulties standing; an easy mark! It felt Dickensian. I was ashamed that my country could treat sick people this way.
69. It took me four (4) days to recover my strength to write a letter of complaint. This was dated 29 July. This letter in addition contained my travelling expenses claim form. I have not had a reply to either my letter of 28 June or that of the 29 July. My travelling expenses have still not been paid. I have not received a report of the assessment findings.
70. I am outraged at the treatment I have received through the services provided by Atos Origin. I hope my experience is atypical. Without transparency it is a matter of speculation.
71. My main recommendation is that patients should be treated with compassion, dignity and respect.
72. I further recommend that when next an MP or someone known to the committee becomes sick, they go through the standard procedure e.g. informing the DWP. They can, at first hand, see if my experience is typical of the treatment the DWP applies to patients.
73. My other recommendations are in the summary above.
7 August 2009