House of Commons - Employment and Support Allowance and Work Capability Assessments

Employment and Support Allowance and Work Capability Assessments - Work and Pensions Committee Contents

5 Future delivery of the face-to-face assessment

Current contractual arrangements

59. Atos is the sole contractual provider of the WCA. It carries out a range of medical assessments for DWP under the Medical Services Agreement, which has been in place since 2005. The original contract ran until 2012 and was then extended to August 2015.[91] The Government and Atos have recently agreed to terminate the contract in February 2015, with a new provider commencing work in autumn 2014. Schedule 5 of the Medical Services Agreement specifies the service standards that DWP expects Atos to meet, for example in relation to the quality of reports. Under the contract, "service credits" (or penalties) can be applied where Atos has not met the expected service level. In 2012, the National Audit Office reported that only 10% of the service credits triggered had been applied, and criticised DWP for not seeking "adequate financial redress for underperformance".[92]

CLAIMANTS' DISSATISFACTION WITH THE SERVICE PROVIDED BY ATOS

60. Our 2011 report set out a number of issues which were giving rise to claimant dissatisfaction with the service Atos provided:

· Problems in Atos call centres resulting in claimants facing long call waiting times;

· Overbooking of appointments, which meant that claimants were sometimes sent away unseen;

· Inaccessibility of Atos assessment centres for wheelchair users and inadequacy in meeting other special needs arising from disabilities or health conditions;

· Rushed appointments and claimants feeling that they were not given sufficient opportunity to explain the impact of their condition and/or Atos healthcare professionals failing to engage or interact properly with the claimant; and

· Claimants feeling that the impact of their health condition or disability on their daily lives had not been accurately assessed.[93]

Professor Harrington's first independent review focused on similar concerns.[94] The evidence that we received for this inquiry, as well as the experiences that claimants shared with us during the public meeting in Newcastle, indicated that a number of these issues still remain.[95] A further concern raised in both our inquiries related to claimants being discouraged by Atos from bringing companions into assessments and/or companions not being allowed to participate when present, despite the guidance stating that this was permitted.[96] Dr Litchfield's review recommendations included improving: the layout of the assessment rooms; and the guidance on claimants being able to bring companions into the assessment.[97]

EXPERTISE OF ATOS ASSESSORS

61. Witnesses have also suggested that assessors need to have greater specialism in conditions which are particularly difficult to assess, such as progressive and fluctuating conditions and mental and cognitive health. Mental health charities and Z2K argued that the WCA would produce more appropriate outcomes for claimants with mental health conditions if HCPs had appropriate mental health expertise, due to the complex nature of mental health problems and because claimants may find it difficult to communicate the full effects of their conditions.[98]

62. Atos's view was that their assessors were already "highly qualified" and that they needed a "breadth of experience" rather than being specialists in one area of medicine. Dr Graham pointed out that many claimants presented with multiple conditions, not just a single illness or disability. HCPs therefore needed to be able to assess the functional impact of all of these conditions effectively.[99]

63. James Bolton from DWP agreed with Atos: he emphasised that the WCA was a functional not a diagnostic assessment. However, although a specialist would not be brought in to assess an individual based on their condition, "appropriate knowledge" was available within the organisation and a case could be referred to a colleague if an individual assessor did not feel confident to deal with it.[100]

64. Following a recommendation in Professor Harrington's first review, DWP introduced Mental Function Champions from May 2011, to "spread best practice amongst Atos healthcare professionals in mental, intellectual and cognitive disabilities".[101]Atos told us that they had had 60 Champions at one point, although the number had since dropped. Nevertheless, since January 2014, Champions had dealt with 4,500 calls from assessors.[102] Dr Litchfield said there was evidence that they were being used by staff.[103] However, Mind believed that they had not made much of a difference.[104]

65. Dr Litchfield recommended that the training for HCPs in mental health should be reviewed and that DWP should "strengthen its requirements for HCPs working on the contract to have suitable and sufficient previous experience of dealing with people with mental health problems so that they can contextualise their findings at assessment." In response, DWP said that "suitable and sufficient" was "open to interpretation" and that it would be undertaking further work to establish whether it agreed with the principles behind the recommendation.[105]

QUALITY OF REPORTS

66. Reports produced by Atos are audited by both DWP and Atos. Atos is subject to a "quality target" of at least 95% of its reports being of an acceptable standard. Reports are graded A to C.

· A grades mean the assessment fully meets the required standards;

· B grades mean some improvements are needed in the assessment report; and

· C grades mean the report is deemed to be unacceptable and does not meet the required standards.[106]

95% of reports should therefore be graded at A or B. The Committee of Public Accounts has criticised the target for not being "particularly challenging".[107]

67. On 22 July 2013, DWP announced that an audit had "identified a reduction in the quality of written reports which are produced by Atos following assessments." Atos had been instructed to "immediately enact a quality improvement plan", which would involve retraining and revaluation of Atos assessors and 100% audit of reports produced by assessors who were below the required standard.[108] DWP has since reported that the improvement plan has led to "some real progress made by HCPs to meet the required standards."[109]

CONCERNS ABOUT TARGETS FOR ASSESSMENT OUTCOMES

68. During our 2011 inquiry, some witnesses claimed that Atos assessors were encouraged through targets within the DWP contract to find people fit for work. DWP made clear at the time that this was not the case and that the Medical Services Agreement "does not include any provisions either from the Department or from Atos Healthcare to incentivise health care professionals to find claimants undergoing the WCA fit for work". Atos confirmed that, contractually, it is paid for the number of satisfactory assessments it completes, not on the basis of the results of those assessments.[110] However, concerns seem to prevail amongst claimants that there are targets for outcomes.

69. Kaliya Franklin, a witness to this inquiry, explained how, even though targets do not technically exist, "statistical norms" arising from regional and national comparisons of assessment outcomes produced by individual assessors may have the effect of giving assessors the impression that they are required to produce outcomes that meet an expected pattern. Assessors whose outcomes lie outside the norms may become subject to 100% audit of their assessments. She believed that assessors see the 100% audit as punitive, and that the norms therefore act as a "de facto target system". She argued that, as a result, the WCA is a "norms-referenced system". [111]

70. We put these concerns to Atos witnesses. They acknowledged that this monitoring system is in place but confirmed that they have "no targets whatsoever". The purpose of the monitoring system was to ensure consistency of outcome for a claimant regardless of which assessment centre they visited, on what day, and which assessor they saw. Dr Graham of Atos Healthcare told us they went to great lengths to try to ensure assessors understood the purpose of the review system and made clear that, where an individual assessor's outcomes differed from the expected norm, this would only be identified as a problem to be addressed if the quality of the reports produced was inadequate.[112] We also asked Professor Harrington whether he had seen any evidence of Atos assessors being under pressure to reach targets. He told us:

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71. It is very difficult to assess the extent to which those who implement a particular policy or deliver services believe there are targets, even where these do not officially exist, and what impact these impressions might have. It is necessary to have monitoring systems in place which throw up results from assessors which are significantly different from their peers, to ensure that claimants are treated fairly and consistently. However, it is also very important that claimants regain confidence in the objectivity and accuracy of the WCA. DWP should be alert to the risks which norms-based monitoring may create in this respect when agreeing auditing arrangements with the new provider.

Backlog in carrying out WCAs

72. DWP told us that there were 700,000 cases referred to Atos which were awaiting WCAs being completed: 390,000 were new ESA claimants; 230,000 were existing ESA claimants awaiting reassessment; and 80,000 were Incapacity Benefit claimants awaiting reassessment for ESA. The IB migration was due to be completed by April 2014 but this target had been missed; DWP told us that a million IB claimants had been assessed to date; 145,000 were yet to commence the migration process at September 2013; and 77,000 had begun the migration process but not completed it.[114]

73. Atos's explanation for the reasons for the backlog were:

· Under-estimates in DWP referral forecasts of the impact of regional variations, particularly affecting London and the home counties; and lack of flexibility within Atos to respond.

· The duration of the assessment had increased. One of the causes was changes recommended in the first Harrington Review, particularly the introduction of the "personalised summary statement" to supplement the box-ticking of descriptors. DWP had insisted that these changes should be "time-neutral" despite Atos's reservations about whether this was realistic. Atos was contractually obliged to implement such changes. It should be noted that in evidence to this Committee in March 2012 the then Minister for Employment gave this as a reason for a backlog which was then emerging, but which he stated was on track to be cleared by summer 2012.[115] If it is the case that operating this relatively modest change remains problematic two years on, this is a matter for concern. It is important that this be resolved before a new contractor takes over.

· Capacity issues, arising from an attrition rate of 27% for assessors, and difficulty in recruiting sufficient additional assessors to accommodate increased flow, because of the negativity around Atos and the WCA.[116]

74. The Minister agreed that Atos had suffered from capacity issues, partly because of the number of its staff who had left "because of the abuse and threats". Jason Feeney, the DWP Benefits Director, told us that the backlog had built up because Atos had not been able "to deliver the quality we want at the capacity we want". As a result, the IB migration had been slowed down to around 5,000 referrals a month and reassessments of existing ESA claimants had also been reduced. In contrast to Atos, DWP had improved its timescales at both ends of the claims process: the time taken to refer a claim to Atos had reduced from 60 days to 28 days (in 93% of cases) since last autumn and decision-making on eligibility had reduced from 42 days to 12-14.[117]

Atos's early exit from the contract

75. In March 2014, DWP and Atos decided to end the WCA contract six months early and a settlement has now been reached for Atos to exit the contract in February 2015. Atos told us that this had been "agreed mutually", with both DWP and Atos coming to the conclusion that it was time for them to exit.[118] The Minister's view was slightly different: he said that, because it had become clear that Atos, DWP and the public lacked confidence in Atos's ability to "perform what we were asking them to do", he had come to the conclusion that "it was best to negotiate Atos an exit". He had therefore reluctantly asked officials to negotiate with them, although breaking the contract "was the last thing I wanted to do", given its size and complexity.[119]

76. Atos told us that, in fact, they had decided some time ago not to re-bid for the new contract which was then due to be introduced in August 2015. A number of factors led them to go beyond this and seek the early exit: the key ones were the "very toxic" environment in which their staff were being asked to work, including threats and security incidents; the lack of public understanding of the separate roles of Atos, DWP and tribunals in the process, leading to Atos being blamed for withdrawal or refusal of benefit; and the contract becoming less viable financially.[120]

The new contract

77. DWP expects to award a contract to a new provider in October 2014. It will again be with a single provider. The Minister said "the most effective way to stabilise and then increase delivery is to bring in one national provider to deliver the Work Capability Assessment, initially using elements of the Atos infrastructure", although "in the longer term" he remained committed to moving to multiple providers to increase competition. He said that his "absolute priority for the new provider will be to deliver the best service possible for claimants, increase the volume of assessments carried out and reduce waiting times".[121]He was very clear that the award of the new contract would not be "based on cost alone", and he believed that this meant that it was bound to cost more.[122]

78. The Minister told us that his preference for the new contract would have been "to start completely from scratch" but this would not now be possible because of the short time available to put a new contract in place before Atos withdraws. The new contract would have to be for three years, to make it viable for the new provider. The complete redrafting of the contract would therefore have to wait until 2018.[123] DWP had decided that the new contractor would "run alongside" Atos for six months from October 2014, because switching overnight would be "a catastrophe". The new provider will also use Atos's existing IT system and many Atos staff were expected to move to the new provider.[124]

79. Atos was very clear that the "toxicity" surrounding the WCA would not disappear simply by taking on a new provider of the assessment. Lisa Coleman told us: "it would be massively over-simplistic to say that a new provider is going to fix all of the issues. It is very difficult to separate the private provider from what the policy is […] other things would definitely need to happen."[125] When we put this to the Minister, he told us that if it was a case of simply "rebranding" with a new provider, that would not solve the problems, but DWP and the new provider intended to "learn from the shortfalls of the previous way it operated".[126]

80. Atos has become a "lightning rod" for much public dissatisfaction with the benefit decisions people receive. This is unlikely to change if the WCA is simply "rebranded" by moving to a new provider, who will inevitably face a huge challenge in delivering the new contract. We recommend that the Government takes steps to communicate clearly to claimants, the wider general public and the media, that it is DWP which decides on benefit eligibility, not the contracted provider of the WCA, and that the face-to-face assessment is just one part of the decision-making process.

SERVICE STANDARDS AND EFFECTIVE MONITORING

81. In our 2011 report on IB reassessment, we expressed concern about whether there were sufficient levers within the DWP contract with Atos to ensure that it "gets the assessment right first time". We recommended that, when the contract was re-let, DWP reviewed the performance indicators and ensured that significant financial penalties were built in.[127] DWP argues that there are already "significant service credit penalties" in the existing contract with Atos and that these have been applied when necessary. The Minister confirmed that the new contract would contain clear service standards and penalties would be specified. However, he also intended to include incentives to encourage the new provider to go beyond the contract terms where possible.[128] This is an important point. Given the high degree of negativity which surrounds the existing WCA contract, it is difficult to see that taking it on would be immediately attractive to new providers. The inclusion of incentives in the new contract might make it more appealing.

82. To ensure that the new performance standards are rigorously monitored, the Minister said that DWP staff would now be embedded with the new provider, to increase the Department's day-to-day understanding of its operations and ensure a more "joined up" approach. He explained that proper account would be taken of the fact that the new provider, through no fault of its own, would inherit a backlog of referrals and therefore part of the new contract would be "a feasible, sustainable recovery plan".[129]

83. Although some progress has been made, concerns remain about the accessibility of Atos assessment centres, the overbooking of appointments, and the manner in which some claimants are dealt with by assessors. We recommend that DWP specifies exacting service standards relating to these aspects of the claimant's experience of the WCA in the new contract. The Minister made clear that the Government is willing to pay more for a service that meets the standards that claimants and taxpayers are entitled to expect. We welcome this acknowledgement that, as assessments are to remain part of the welfare system, they should be adequately funded.

84. If claimant confidence in the process is to be restored, the new contractor will need to demonstrate that its staff have the expertise necessary to carry out effective assessments of claimants presenting with the more difficult conditions, including those which are progressive, fluctuating or relate to mental and cognitive health. We support Dr Litchfield's recommendation that assessors should have suitable and sufficient experience in mental health. We recommend that this should be set out on the face of the contract and that DWP extend this to other conditions which are acknowledged to be difficult to assess.

BALANCING VOLUME AND QUALITY OF ASSESSMENTS

85. Dr Bob Jones, an Atos HCP, told us that new arrangements were now in place allowing HCPs time "to do the work to a higher, more professionally satisfying standard." He said that the current rate of assessments was around 5 per assessor per day and that most HCPs would regard 6 reports as the right balance between productivity and quality. However, he believed that a new contractor would be under pressure to deliver 8 or more reports per assessor per day.[130] Atos confirmed that the current rate was 5.6 a day, although there had been a period when assessors were doing up to 9 day. If nothing in the policy or delivery model for the new provider changed, Atos believed that 5.6 would be about the right level.[131]

86. There have been fundamental problems with the current WCA contract in terms of meeting the requirements on throughput and quality. The current backlog of 700,000 cases awaiting assessment is unacceptable. People with health conditions and disabilities should not be left for months with uncertainty about their benefit entitlement. The fault does not lie with Atos alone; DWP has changed the contract a number of times and its own forecasts of referral levels have sometimes been inaccurate. DWP should also have done more to manage the contract effectively, to prevent the problems which have caused detriment to claimants occurring in the first place.

87. The new WCA contract needs to balance the quality of assessment reports with specified levels of throughput of referrals which avoid backlogs and delays to claimants. Achieving this balance will depend heavily on DWP providing accurate forecasts of referral levels, as well as the efficiency of the provider. To ensure transparency, we recommend that DWP publishes the forecast levels of referrals which will be specified in the new contract. These will need to include different levels to take account of: the initial period when the backlog is being cleared; the period when the IB reassessment is being completed alongside new claims continuing; and then the period when steady state is achieved and only ESA new claims and reassessments of existing claims are being processed.

88. We recommend that DWP takes all necessary steps to assure itself that the new provider has the capacity to deliver both quality and quantity of assessments. Performance indicators should be challenging and transparent and financial penalties should be applied if specified standards are not met. However, given the extreme negativity around the existing contract, the WCA is unlikely to appeal to the few private contractors with the necessary capacity to take it on. DWP's willingness to offer incentives in the new contract, as well as imposing penalties, is therefore welcome.

89. DWP also needs to demonstrate that it has sufficient expertise and capacity to manage a contract of this size and complexity, to ensure value for public money and that claimants receive an acceptable level of service. This does not appear to have been the case with the Atos contract. If this capacity does not currently exist, we recommend that it be developed as a matter of urgency, bringing in expertise from other parts of Government if necessary. We welcome the Government's plans, in the longer term, to bring in multiple providers. This makes it even more important that DWP should develop its contract management expertise. Once the new contractor has been selected, we recommend that DWP make public the cost of the contract to the public purse (and how far that differs from the previous contract), the way payments will be calculated, and the basic service standards, including the average number of assessments to be carried out per assessor per day. Greater transparency on such matters would avoid some of the controversy which has dogged this benefit. The Government may also wish to take this opportunity to consider whether, in the light of the negativity around the delivery of the face-to-face assessment by a private provider, it would be more appropriate for the assessment process to be taken back in house.

91 Work and Pensions Committee, The role of incapacity benefit reassessment in helping claimants into employment, paras 82-84 Back

92 National Audit Office, Department for Work and Pensions - Contract Management of Medical Services, Report by the Comptroller and Auditor General, October 2012, Session 2012-2013, HC 627, Summary, para 8, and part 3 Back

⁹³Work and Pensions Committee, The role of incapacity benefit reassessment in helping claimants into employment, Chapter 3 Back

94 Professor Malcolm Harrington, An Independent Review of the Work Capability Assessment - year one, November 2010 Back

95 See for example Qq330-337 (on overbooking policy); National Rheumatoid Arthritis Society (WCA0174) para 1.2, and Inclusion London (WCA0182) para 3.25 (on accessibility of assessment centres); Crisis (WCA0158), para 2.6 and National Autistic Society (WCA0150), para 4.8 (on rushed assessments); and Action for ME (WCA0096), para 4.7 and Disability Benefits Consortium (WCA0173) paras 38 and 45 (on claimants feeling that they did not have an adequate chance to explain the effect of their condition). Back

96 Oral evidence taken on 18 May 2011 on Incapacity Benefit reassessment, HC 1015-I, Q90; National Autistic Society (WCA0150) paras 5.1-5.5 Back

97 Dr Paul Litchfield, An Independent Review of the Work Capability Assessment - year four, December 2013, Chapter 4, para 40 Back

98 Centre for Mental Health, Hafal, Mental Health Foundation, Mind, Rethink Mental Illness, Royal College of Psychiatrists, Scottish Association for Mental Health, (WCA0142) paras 25-26; and Z2K (WCA0119) paras 35 and 36 Back

99 Q361 Back

100 Qq472-3 Back

101 Professor Malcolm Harrington, An Independent Review of the Work Capability Assessment - year one, November 2010, Chapter 5, para 47 Back

102 Q361 Back