Select Committee on Liaison First Report

Committee Recommendations: Progress

Sixth Report: Medical Services (HC 183) Published: 20 April 2000

Committee Recommendations: Progress
Sessions 1999-2000
Sixth Report: Medical Services (HC 183) Published: 20 April 2000

Government Reply: (Cm 4780) Published: June 2000
RecommendationGovernment Response Committee Response/Follow upFurther Government Action Notes
We recommend that no reduction in average times spent examining claimants should be allowed to occur, unless hard proof can be deployed to show that there has been a genuine increase in claimant satisfaction. We are sceptical that the two can occur simultaneously. We also recommend the present duration of examinations be monitored by the Medical Quality Surveillance Group to ensure that they are sufficient to enable the doctors to produce accurate reports without being under pressure of time. The Government insists that sufficient time is given to claimants at examinations so that in providing a "fit for purpose" report for decision makers Medical Services does not compromise the achievement of claimant satisfaction.

The Government believes it is essential for doctors to provide sufficient time during an examination to enable the claimant to describe the effects of their condition in their own words. The doctor may or may not agree with the claimant's own assessment, but the Government recognises that failure to listen to the claimant increases the risk that the doctor's report will fail to advise the Benefit Agency's decision maker of relevant matters, which could affect the decision on benefit entitlement, and lead to a decision being overturned at appeal.
  All examination forms now show the time of starting and completing the assessment.   
We recommend that Medical Services design and implement a system of recruitment, training and monitoring that ensures that its doctors can perform the fundamental task of information recording to an accurate standard. Action should be taken to dismiss those doctors who consistently fail to attain the necessary standard. More rigorous recruitment criteria and procedures have been introduced as part of the contract with Medical Services. These require that doctors recruited by Medical Services must:

be fully registered with the General Medical Council; and

have at least three years' post registration experience including one year in general practice and at least six months in psychiatry, rheumatology, rehabilitation, or occupational medicine; or

have at least five years' experience in general practice.

Doctors have to be approved by the Department's Chief Medical Adviser on behalf of the Secretary of State before they are permitted to undertake examinations on claimants or render medical advice in regard to benefit claims. Medical Services must demonstrate that doctors have attended the appropriate training and have passed a formal multiple choice question paper on completion. Doctors must also have achieved a satisfactory standard on 100% audit of the first examinations or reports undertaken.

In order to address the deficiencies in the quality of EMP reports Medical Services set about the revision of guidance for EMPs. Following approval of the revised guidance by the Department's Chief Medical Adviser, it has been issued to all EMPs. In addition Medical Services has commenced an in-depth programme of EMP training, with a series of initiatives designed to improve performance. Particular emphasis will be given to assessment of mental health conditions, and to the appropriate use of personal descriptions in reports. Evaluation of the training will include robust analysis of the competencies of EMPs in gathering and recording accurate and relevant information obtained in the examination and assessment of claimants. The recent introduction by Medical Services of a comprehensive Medical Skills Database for doctors will substantially improve their ability to deal with matters of individual quality and performance. This database records details of the doctor's medical background, training received, and outcomes of quality audit of the doctor's work. The database will be further developed to also record details of complaints against the doctor.

The Government shares the Committee's views that poor performance in these competencies should not be tolerated. Action is already taken by the Department's Chief Medical Adviser to withdraw approval from those doctors who consistently fail to attain the required standards. To date 14 doctors have had their approval withdrawn for this reason.
  The DSS Chief Medical Adviser has specified three priority areas for update training in 2000/2001. These are: assessment of illness behaviour; accident determination advice; and assessment of occupational asthma. In addition, he has approved outline training plans based on a Training Needs Analysis undertaken by Medical Services.

A mechanism is in place for suspending approval of doctors who fail to undertake mandatory training as specified by the CMA.

We agree [with those who raised the matter in their evidence] that illegible reports are unacceptable. The Government also shares the Committee's view that reports which are illegible should not be tolerated. If a decision maker is unable to read a report it will be returned to Medical Services for rework. Doctors are no longer used if they fail to demonstrate fundamental skills in recording information to an accurate standard.

Work is in progress to investigate an IT based, electronically completed form, to reduce the need for doctors to produce lengthy hand-written reports.

Electronic completion of forms has been piloted, and shows considerable promise, but further work is required before the process can be implemented more extensively
We recommend that Medical Services has a dedicated training course in customer care for all new doctors, and that customer care issues also run as a 'golden thread' through all other training. There should be regular refresher training in customer care issues, delivered on an annual basis as a minimum, and such training should be assessed to ensure its effectiveness. All doctors who work for Medical Services will have several years' experience of customer care in a clinical setting, and the majority conscientiously provide a high standard of service. However the Government recognises that doctors often require additional training to provide an appropriate level of service to customers undergoing medical assessments for benefit purposes.

Medical Services already provides training on customer care issues, using training modules developed in consultation with the Department and external organisations such as The Equality Foundation and NACAB. As well as forming part of the initial training of newly recruited doctors, update training about appropriate customer care forms part of all benefit-specific training materials. For example the revised guidance for EMPs contains expanded sections on customer care and appropriate assessment techniques, comprising one third of the material.

The Government expects the effectiveness of update training to be rigorously assessed by post-training evaluation and ongoing monitoring of doctors' performance. The Department will analyse Medical Services' data on complaints and claimant satisfaction to ensure that training is appropriately targeted and assiduously pursued.

The Department is working with Medical Services to ensure that all aspects of the treatment of claimants are reviewed. In particular, a task force has been set up to review all communications to claimants, to identify ways in which they might be improved.

The Department will, through the Medical Quality Surveillance Group (MQSG), chaired by its Chief Medical Adviser, continue to work closely with Medical Services to develop and monitor the effectiveness of these initiatives. The Department will give particular attention to monitoring the outcome of the regular claimant satisfaction surveys undertaken by Medical Services.
  As well as providing training in customer care as part of all benefit-specific training, Medical Services are developing a specific module addressing customer care.

The Department is assisting Medical Services to develop and refine the current system of evaluation of training, to incorporate objective and measurable outcomes.
We recommend that Medical Services review their procedures for identifying and dealing with underperforming doctors and report back to the Chief Medical Adviser on these procedures. The Department's Chief Medical Adviser will ensure that the Medical Skills Database which has been developed by Medical Services records, for each individual doctor:

Medical training undertaken before joining Medical Services;

Training received from Medical Services, and its outcome, including any need for retraining;

Feedback from medical quality audit and complaints; and

Remedial action taken and its outcome

The Department's Chief Medical Adviser will evaluate this new database as a tool for identifying underperforming doctors. Specifically the Chief Medical Adviser will monitor the following information:

the results of investigation of complaints against individual doctors which reveal poor performance and/or professional incompetence;

the results of Medical Services' internal audit which will have been undertaken to assess the quality of the work of individual doctors; and

rework data for individual doctors.
  Medical Services have provided training for all staff responsible for handling complaints. The Medical Skills Database is being enhanced to incorporate information relating to complaints about individual doctors. The Database will, from December 2000, trigger remedial action whenever a pre-determined level of complaint activity is reached.   
We recommend that Medical Services and the Benefits Agency take urgent steps to achieve better treatment of claimants: present performance is not acceptable. In drawing up rigorous and robust standards the Government insists that the following quality principles must underpin all of Medical Services' work:

professional advice is correct, complete, evidence-based and impartial;

benefit claimants are dealt with fairly and courteously;

systems are in place to continually reduce error; and

errors are dealt with promptly and efficiently and lessons are learned

To assess compliance with these principles the Government has decided to set the following targets by which tangible improvements in service, to achieve contracted medical quality standards, will be judged:

within six months to reduce the proportion of "C grade" medical reports which fail to meet the Department's standards by 10%; and within one year to reduce the proportion of "C grade" reports across all benefits to less than 5%

within one year to demonstrate improvement in compliance with the agreed medical scrutiny guidelines for Incapacity Benefit claims so that the proportion of non-compliant reports is less than 5%

within one year to deliver training to all doctors covering: the assessment of people with mental health problems; behaviours, attitudes and sensitivities for dealing with people with disabilities; and distress-avoiding techniques for the examination of people with musculo-skeletal conditions

within two years to improve customer satisfaction rates to at least 90%.

We expect Medical Services to deliver these targets. If not, further action will be taken.
  Medical Services have taken action where necessary to ensure the standard of treatment of claimants meets that specified in the Benefits Agency's Customer Care Charter.

Several improvements to forms and leaflets issued to claimants have been implemented or agreed for early implementation, to provide clear information to claimants at all stages of the claim process.

The 6 month period is deemed to commence from the date of the Government's response. However progress is being made towards achieving both the 6 months and 1 year targets. At the end of the 6 months we will provide a written report of progress.

To date training has been delivered to 75% of all doctors, and further courses have been arranged
We support the recommendation of Mind, that there be better training on [mental health] issues for all Examining Medical Practitioners [EMPs] and that there should be some specialist resource within Medical Services, which could help provide such training, and also see claimants in cases which were particularly complex. Medical Services accept the need to enhance the knowledge, skills and expertise of all doctors who assess and examine people with mental health problems. The majority of doctors working for Medical Services have experience, through their clinical work, of treating people with mental health problems. They receive additional training as part of Medical Services' overall training programme. This training emphasises the need for an empathetic approach, using open-ended questions and active listening techniques. The Government welcomes several initiatives, which Medical Services have embarked on to, produce a robust and comprehensive package of update training, based on current best practice, in assessment of mental health problems. Ongoing dialogue between Medical Services and a specialist provider of training materials using a multimedia approach offers the potential for very considerable improvements to the delivery of training on mental health issues.        
We recommend that the Chief Medical Adviser instigates a review of Medical Services' treatment of claimants with mental health problems, covering time spent with claimants, doctors' expertise, the ability of the system to assess accurately the nature of mental health problems, to assess how the system could be improved and, in particular, what scope there is for reducing distress caused to claimants. We would expect to see the outcome of such a review in due course. Existing procedures for determining claims for disability and incapacity benefits from people with mental health problems ensure that those with a severe problem are exempt from undergoing a medical examination. In all other cases, decision makers can and do obtain evidence from practitioners in primary and secondary care, and from other sources of specialist expertise and knowledge. In particularly complex cases, and in all claims for IB by people who have mental health problems, seeking such additional evidence is an integral part of the decision making process, which ensures that people with the more severe forms of mental illness are not subjected to medical examination.

The Government recognises the particular difficulties which may arise when assessing claimants with mental health problems, and the need for sensitive handling of these claimants. Recently as part of the Personal Capability Assessment (PCA), development and thorough evaluation of methods assessing effects of mental health problems on ability to work, have gone some way to meeting that challenge.

A programme of joint discussions with welfare rights groups, involving the Department and Medical Services, began in January 2000 and continues around the country. Although not restricted to mental health issues, this provides an opportunity to hear at first hand the views of representatives of people with mental health problems on the service which is being provided; these views are then acted upon in drawing up plans for improvements to the service.

A considerable amount of work is thus already under way or planned to address the issues raised by the Committee; a further review would inevitably cause delay to this extensive programme. In the light of this the Government believes that a separate review of Medical Services' treatment of claimants with mental health problems is not required at the present time.

Training has recently been delivered to doctors who examine claimants with mental health problems, on the sensitive handling of people with such problems, on the role of stress in precipitating or perpetuating mental health problems, and in the management and assessment of people with illnesses which have principally subjective complaints. Input to this training has been obtained from specialist resources. The Chief Medical Adviser has also set for training throughout the coming year a number of items which relate particularly to the more accurate assessment of the effects of mental health problems. Indices are also being developed with Medical Services for the thorough evaluation of the training demand in this regard.
It is of the utmost importance that claimants whose first language is not English are able to communicate effectively with EMPs. All claimants must be told clearly in their first correspondence from Medical Services that they have the right to request the presence of an interpreter if they so wish. Such correspondence should include a multi-lingual notice inviting claimants to contact the centre if they cannot read the letter. We look forward to speedy action in this area. The Government is committed to providing services which meet the cultural and linguistic needs of all claimants, and it shares the Committee's concern that claimants from ethnic minority groups should not be at a disadvantage through lack of ability to communicate effectively with examining doctors.

Current communications sent to claimants invite them to make known to Medical Services any special needs they have. The Department and Medical Services have set up a joint review of the standard of communication with claimants; the participants are senior managers within Medical Services, the IMPACT Contract Management Team, and key Benefits Agency business units. All sides are committed to ensuring effective communication on all issues. The review will investigate helping claimants with their needs for interpreters, and with special needs in other areas arising out of disability - such as preferences for alternative means of communication in place of spoken language.

The Department and Medical Services will investigate the costs, benefits, and policy implications of issuing multilingual notices.
  The wording "An interpreter will be provided if required - or you may wish to arrange for a friend or a family member to interpret for you" is being incorporated into documents accompanying appointment letters; and will be included in all relevant claim forms at the earliest opportunity.

Medical Services have subscribed to a national interpretation service.

The Department has undertaken further consultation, and is still investigating the provision of multilingual notices.
We recommend that doctors who demonstrate cultural insensitivity should receive immediate remedial training and have their subsequent performance monitored. Those doctors failing to improve their performance after such action has been taken should be dismissed. The Government does not tolerate racist or culturally insensitive behaviour. The Committee's evidence about cultural insensitivity is based on five anecdotal examples. The Department sought fuller details from the Committee Clerk to enable these cases to be investigated but he said that the cases had been presented to the Committee anonymously and it did not know the identities of the people involved. The Department was able to identify one case from the details reported to the Committee. In this case the doctor involved had already been suspended and required to follow remedial training. She has since returned to work and no further complaints have been received. The Department takes all complaints of racism or cultural insensitivity extremely seriously, and where it has occurred it takes prompt remedial action. Every single case of cultural insensitivity is unacceptable, but the Department does not believe that the evidence presented to the Committee reflects the general behaviour of Medical Services' doctors.   Medical Services will in future identify as a distinct category, complaints alleging cultural insensitivity.   
We believe that Medical Services could be laying itself open to the charge of institutional racism in two ways: in failing to train adequately doctors in issues of cultural awareness; and in failing to make claimants aware that they may request the service of an interpreter. We expect it to address both issues as a matter of priority. We recommend two further steps: that Medical Services monitor the service received by claimants from ethnic minority groups through targeted surveys and other means; and that the Commission for Racial Equality be invited to review the work of Medical Services in relation to its treatment of claimants from ethnic minority groups. Medical Services have also developed a new training module on multicultural awareness, which will be delivered to all doctors. Training on this issue began in May 2000.

Medical Services are keen to forge constructive links with the CRE. A meeting has been arranged between a senior manager from Medical Services and the incoming Chairman of the CRE, and the CRE will be invited to participate in quality assurance of future training or communication products.

Any complaint brought to the attention of Medical Services will be fully investigated and appropriate action will be taken. Complaints against Medical Services' doctors alleging culturally insensitive behaviour, will also be closely monitored by the Department. An additional category of complaint will be introduced to record this information.
  Meetings with the Chairman of the CRE have been fruitful in developing a collaborative approach to cultural awareness issues

It was agreed that the CME would review and monitor the work of Medical Services in regard to the treatment of claimants from ethnic minority groups. CRE also agreed to assist Medical Services in evaluating training delivered in this area. Joint meetings are being set up between the CRE, CMA and Medical Services to oversee progress in this important operational area.
It is unfortunate that doctors have made inappropriate references to claimants' ethnic origins in reports, and it is clear why this has given offence. What is perhaps more worrying, is the suggestion that, despite undertakings having been made, effective guidelines and training on this issue had not been given. We appreciate that the undertakings were given at the time that the Benefits Agency had responsibility for the service. Now that Medical Services is Sema-run, we expect robust guidelines to be followed by all doctors, and the necessary training to be provided to help them do so. Medical Services have developed guidance to doctors on the use of personal descriptions in medical reports. The guidance, which has been approved by the Department and NACAB, has been issued to all doctors as a distance-learning package. Medical Services also invited the Commission for Racial Equality (CRE) to comment on the guidance, but received no reply.

Medical Services have also developed a new training module on multicultural awareness, which will be delivered to all doctors. Training on this issue began in May 2000.
We recommend that the availability of an examination by a female doctor should be spelt out clearly in the initial letters sent by Medical Services to claimants. The contract requires Medical Services to use reasonable endeavours to provide a female doctor when asked to do so. Medical Services have indicated that every effort is made to respond to claimants' requests for assessment by a female doctor. The aim will be to achieve a workforce which includes sufficient female doctors to meet claimants' requests for such. Medical Services' recruitment strategy will reflect this aim. All doctors must of course act in a professional manner, regardless of gender.   The wording "You may prefer that your assessment be undertaken by a doctor of the same sex and whenever possible we will try to accommodate your request. Where you feel that your assessment can only proceed with a doctor of the same sex, for example on cultural or religious grounds, you must make this clear and appropriate arrangements will be made" is being incorporated into documents accompanying appointment letters; and will be included in all relevant claim forms at the earliest opportunity.   
We are concerned that, because of the perceived failure of the complaints system, many claimants are choosing to appeal, rather than to complain. We note that Sema have recognised a problem with their complaints procedures and are conducting a review, which we welcome. We would expect to see the results of the review and we expect the Department to monitor performance in this area and push very hard for improvements to be made. At the very least we expect that details of how to complain should be drawn to the attention of each individual undergoing
an examination, wherever the
examination takes place.
The complaints procedure is intended to be used when a customer is dissatisfied with the way a medical examination was arranged or carried out. The appeals procedures are intended to be used when a customer disagrees with a decision on entitlement to benefit made by a BA decision maker. Appeals are not therefore an effective way of examining Medical Services' administrative performance or the medical quality of its doctors' work. Similarly the complaints procedure is not the right channel for seeking redress when a customer receives an unfavourable entitlement decision.

Medical Services' complaints procedures, and the investigations carried out by the Department in response to MPs' complaints on behalf of constituents, reveal that some complaints are justified, while others are not; and some, unfortunately, are impossible to determine one way or the other because of conflicting evidence. The Government is concerned that the Committee appears to have taken a number of anonymous complaints which it received from third parties at face value without investigating the allegations themselves or asking the Department to do so. This approach lacks scientific method and vigour.

Nevertheless, the Government understands the Committee's concern about the present complaints procedure. Investigations conducted by the Department have identified some discrepancies in the way in which complaints are recorded, whereby a small number of complaints received by the Department rather than directly by Medical Services, was not being counted. This has now been rectified.

The Department is also aware of dissatisfaction with the way in which Medical Services respond to complaints. The main issues were lack of a specific response to the individual complaint; unwillingness to accept responsibility and apologise for poor service; insufficient investigation into the details of complaints; and failure to link complaints to previous ones against individual doctors.

The Government agrees that every person undergoing an examination, wherever the examination takes place, should know how to complain. The Department is working closely with Medical Services to undertake a thorough review of the complaints procedure. Information about the complaints procedure is displayed in all Medical Services' examination centres. The review will encompass how better to make claimants examined in their own homes aware of the complaints procedure.
  Medical Services have developed a detailed action plan which addresses all issues relating to complaints. The plan will ensure that all complaints are captured and appropriately investigated; that response letters focus on the matters at issue which are handled with sensitivity and that remedial action is taken when justified. Moreover an Independent Tier for investigation of complaints is being put in place.

In preparing the plan it has become apparent that full and thorough investigation, which must include the doctor's right to reply and to consult, as necessary, his Medical Protection Society, results in an inevitable delay of at least several weeks before a definitive response can be prepared. Progress against the plan is being monitored by the IMPACT Contract Management Team. Key performance indicators have been developed to monitor the accuracy of recording complaints and the quality of response. Medical Services managers who handle complaints have all received training in this field
We recommend that a proportion of customer surveys be conducted with claimants after they have seen the EMPs' reports. The Government endorses claimants' right of access to reports used in determining benefit entitlement, and their right to express dissatisfaction with a report. The Department is working with Medical Services to develop and pilot a process whereby a proportion of the claimants who are invited to complete a satisfaction survey are sent a copy of the EMP report with the survey questionnaire. The Department will evaluate the resource implications and the extent to which this enhances the quality of the survey as a tool for monitoring medical standards.   The pilot is still under way and its effectiveness has yet to be evaluated.   
Changes to the system [of complaints and monitoring customer satisfaction] are required; allied to those more minor ones we recommend in relation to customer surveys, an improved system of customer feedback will give Medical Services indispensable information which they must use to help draw up the improvements we hope to see in their service. The Government is concerned about the examples of poor practice in relation to the accuracy of doctors' reports that were reported to the Committee. The Department has identified similar examples through Medical Services' complaints procedure and its own quality control systems. Medical Services have already commenced action to address these deficiencies through an updated programme of training for EMPs.        
We note that the Chief Medical Adviser and Dr Carol Hudson of Medical Services intend to hold regular meetings with the Appeals Service to discuss issues coming through on Appeal. We welcome this. The Department's Chief Medical Adviser has for some time held regular liaison meetings with the President of appeal tribunals, and the Government also welcomes the inclusion of the Medical Director of Medical Services at such meetings.   A programme of regular meetings has been implemented.   
We appreciate that allowing EMPs greater access to other medical information relating to claimants would have resource implications. However, we think it would also help raise the quality of reports produced and lower the number of successful appeals. We therefore recommend that Medical Services and the Benefits Agency explore ways in which such records can more frequently and readily be made available to EMPs. One alternative might be for EMPs to be able to request medical records in DLA/AA cases. This might provide more accurate case histories and could also prove to be more cost-effective. The Government shares the Committee's view that EMPs should have adequate appropriate information about claimants whom they are asked to assess.

Current processes provide for EMPs to be informed of the claimant's description of his or her illness or disability. The decision maker requesting the EMP report includes with the request such documentary evidence from the claimant's file as the decision maker considers necessary.

The Department has set up a working party to investigate the effectiveness of the current process. Together with Medical Services, the Department will explore options for improvement to the process.

Providing EMPs with access to medical records held by the claimant's general practitioner would be costly, would carry a risk of significant delay to the decision making process, and is unlikely to enable the EMP to significantly improve the quality of the report. The records held by general practitioners support the GP's role of making a diagnosis and planning appropriate treatment. They are unlikely to contain information about the functional effects of disability, which is relevant to the EMP's role as a disability analyst
  Plans are in hand for ensuring that, at the very least, all requests for EMP assessment will be accompanied by a proforma providing brief details of the claimant's condition and any specific points which the EMP is required to address. This will be followed by further work to assess the administrative impact of furnishing the EMP with a copy of the entire claim pack.   
We think that as a matter of quality control, Sema should be made aware if a significant proportion of successful appeals can be related to cases where particular doctors have provided the medical report. A successful appeal does not necessarily indicate that the medical report was substandard. The claimant may have submitted further evidence to the tribunal, which was not available to the doctor or to the decision maker. The decision maker may have misinterpreted earlier medical evidence; or, in weighing all the evidence, may have reached a different conclusion. The tribunal, even in the absence of further evidence, may have interpreted the medical report in a different way from the decision maker.

Although the present arrangements have no mechanism for relating the outcome of appeals, whether successful or not, to the Medical Services doctor who provided the report, the Department and the President of the appeal tribunals are investigating ways whereby this might be accomplished.
  This issue forms part of the programme of discussions between the President of the Appeals Service, the Chief Medical Adviser, and the Medical Director of SEMA Medical Services Feedback from the Appeals Service is starting to appear.   
We recommend that individual Medical Services doctors should be informed of the outcome of appeals where the Tribunal has chosen not to endorse that doctor's findings. Furthermore, we recommend that Medical Services monitor this feedback and take appropriate action where individual doctors have a higher than average proportion of such cases. Under his statutory obligations to report annually on the standards of Secretary of State decision making in cases which come before tribunals, the President has introduced arrangements for selected medical members of appeal tribunals to comment specifically on Medical Services' doctors' reports as part of the monitoring of first-tier decision-making.

Additionally, the President has agreed to draw to the attention of the Department's Chief Medical Adviser reports by Medical Services' doctors, identified in these monitoring exercises, which justify investigation of their medical quality by the Chief Medical Adviser in dialogue with Medical Services. The Government welcomes this initiative and will ensure that Medical Services institutes prompt remedial training and monitoring of its doctors whose reports fail to meet the expected standards of medical quality.
  A process has been designed and is about to be implemented to meet this recommendation.   
It seems surprising that legal advice has not been taken on the potential incompatibility of the present practice of sessional doctors sitting on Tribunals with the European Convention on Human Rights. We recommend that such advice be taken. The Committee's comments and recommendation have been drawn to the attention of the Lord Chancellor's Department, which is responsible for appointments to appeal tribunals.
We welcome the fact that the Department has now acknowledged that the Committee's concerns regarding the falling number of medical examinations being carried out were justified. However, we remain concerned that there may be structural reasons, relating to the nature of the contract with Sema Group, why this problem is occurring. The Government is committed to ensuring that the Medical Services contract represents the best value for money. Deterioration in the quality or standard of service provided will not be tolerated.

The Department routinely monitors the scrutiny-to-examination (S:E) rate. A continuing downward trend in the proportion of cases examined following scrutiny alerted the Department to investigate the causes. Initial investigations and review of the data by the Medical Quality Surveillance Group revealed the multifactorial nature of the possible causes of the observed reductions in the S:E rate. Although the more recent rate of decline coincided with the progressive roll-out of the new scrutiny guidelines across the country, emerging results from audits undertaken both by Medical Services' Internal Validation Group and by the Department's Chief Medical Adviser raise concerns that the introduction of the revised scrutiny guidelines per se may not represent the most important causative factor for the observed decline in S:E rates.

The results to date of an ongoing programme of audit have revealed that some Medical Services' doctors have given advice at scrutiny which is not consistent with the revised guidelines. The Government views these findings with considerable concern. In consequence of these disquieting audit findings the Chief Medical Adviser has extended the scope, geographical boundaries and detail of the continuing audit programme to establish the extent and nature of the deviation from the revised guidelines, and to isolate and examine the underlying causes of such deviation and their relevance to the failure by some doctors properly to interpret the agreed guidelines.

Whilst accepting that the early results of the above mentioned more extensive and detailed audit need to be interpreted with caution until the samples audited can be subjected to thorough analysis by appropriate statistical methodology, the emerging data point to at least two principal causes which are to be promptly addressed. These are that certain sections of the revised guidelines, which have now been tested in the field, lack sufficient clarity and direction on some matters pertinent to the exercise of clinical judgement on the question of whether to refer for examination; and that effective and prompt remedial training of some Medical Services' doctors in the proper processes of scrutiny is urgently required. Medical Services share the Department's concerns on these matters. The Government has insisted that existing and improved programmes of training by Medical Services promptly remedy this unwelcome state of affairs.

The results of audit should identify all the causative factors involved in the observed decline in scrutiny to examination rates. If these are not a result of inappropriate application of (or lack of clarity in) the scrutiny guidelines, need for remedial training, or inability of some Medical Services doctors to adapt to the particular requirements of disability analysis, other possible causes will be vigorously researched by the Department.
  Further audit of advice given at scrutiny has confirmed a need for further clarification of the scrutiny guidelines, and has also highlighted issues relating to the quality of medical evidence available to the scrutiny doctor. The revised guidelines will be implemented imminently, and further audits will monitor progress towards the target, which has been set by the Government for compliance with the guidelines. The issue of appropriate medical evidence is also being addressed.   
We recommend that the contract be renegotiated in such a way as to ensure that there can be no question of profits being increased as a result of a policy which could cost the taxpayer millions of pounds through the payment of benefits which should not be made. We further recommend that the Committee of Public Accounts consider inquiring into this matter. The Government would view with unmitigated disapproval and take prompt and decisive regulatory action were there any substantiated evidence that the falling numbers of IB cases being examined following scrutiny are driven by commercial gain to the detriment of the judicious application of Medical Services' doctors' professional competencies and medical judgement in the application of the scrutiny guidelines.

The contract with Medical Services allows the Department to share any financial savings as a result of the fall in S:E rates. The settlement recently agreed at the Annual Review discussion with Medical Services fully reflects the reduced costs resulting from the smaller proportion of examinations of scrutiny cases. In addition, review of a number of contract clauses is under way; one outcome of which is that the link between S:E rates and profitability will be scrutinised to minimise the risks of this occurring.
  Contract renegotiations to pay separate rates for cases cleared at scrutiny and examination cases have been concluded.   
We criticise the approach taken by Medical Services which encourages doctors to produce reports which might be of a lower quality than that which the doctors might want to produce. Interfering with the judgement of medical professionals in this way is not acceptable. Quality is an integral and essential part of a medical report, but quality cannot be judged from the duration of the assessment. That will depend on the nature of the claim and the claimant's disabling condition. When interviewing and examining claimants, doctors must focus their assessment on gathering relevant information, which will enable them to provide appropriate and accurate advice. It is no advantage to the claimant if the doctor's report contains superfluous information, or if the assessment is longer than necessary for producing a thorough and focused report.        
We recommend that the Benefits Agency and the Department should monitor closely Medical Services' performance in order to ensure that, by increasing claimant numbers per session, profitability is not put before performance. The Government agrees with the Committee that any reduction in average times spent examining claimants should not occur against a background of deterioration in claimant satisfaction. On the contrary the contract with Medical Services focuses on improvement in services to claimants.   This is being monitored through the Quality Audit process.   
As we have noted, the falling number of examinations as compared to cases dealt with by scrutiny, and the increasing numbers of claimants seen per session, lead to the suspicion that standards are coming second to profitability. It would be naive to blame Sema for trying to make a profit—that is their business. The onus must be on the Benefits Agency and the Department to monitor Medical Services and, if necessary, make contractual renegotiations, in order to ensure that financial pressures do not lead to a lower quality service. Medical Services have explained that the increase in the number of claimants seen per session is the result of more efficient administrative procedures. These have achieved a reduction in the time wasted by doctors when claimants fail to turn up for examination. Doctors are not spending less time with each claimant. In the period between October 1998 and January 2000, the average number of examinations completed per three and a half hour session has increased from 3.8 to 4.4, while the average duration of an assessment for Incapacity Benefit (IB) has increased:

The contract with Medical Services allows the Department to share any financial savings as a result of the fall in S:E rates. The settlement recently agreed at the Annual Review discussion with Medical Services fully reflects the reduced costs resulting from the smaller proportion of examinations of scrutiny cases. In addition, review of a number of contract clauses is under way; one outcome of which is that the link between S:E rates and profitability will be scrutinised to minimise the risks of this occurring.
  The Department has set up a Programme Board to negotiate relevant amendments to the contract.   
We recommend that Sema examines the case for a one-off 'catch-up' increase in payments to doctors to account for the fact that their pay has not increased since 1992. We further recommend that Sema lay down a timetable for ongoing regular reviews of doctors' pay. The question of doctors' pay is an issue for Medical Services to address.

Medical Services consider that the current levels of remuneration reflect market prices. They question that the current levels hinder the ability to attract high quality doctors. In areas where there have been problems with recruitment, these reflect a general shortage of skilled doctors.

Medical Services have recently announced an increase in fees for EMPs who undertake home visits in remote areas, in recognition that visits in these areas involve much greater than average time spent travelling.

Medical Services have also stated that they will keep other fees under constant review.
  Medical Services continue to hold dialogue with the BMA and will be informing doctors of the outcome of their review of fees.   
We recommend that, in exercising their overall responsibility for the service, Ministers act speedily to remove confusion as to where day-to-day responsibility rests for detailed aspects of the service. The Government considers that this recommendation has been fully met through the Minister's letter to the BMA of 17 January 2000, a copy of which was given to the Committee, in which he has clearly stated that responsibility for doctors' fees rests with Medical Services. This letter was agreed with Medical Services before it was sent to the BMA.

While the Minister acknowledged in his evidence to the Committee that political accountability for the performance of Medical Services rests with him, responsibility for the day to day running of the service in all its aspects rests with Medical Services.
As a minimum, we recommend that Medical Services meet their contractual obligations to provide 5 days training to all doctors annually. We deplore the fact that Sema has failed to meet this contractual obligation to date. The Government is concerned by Medical Services' failure to deliver the specified number of days' training to all their doctors. It is also concerned that training plans and outcomes have not been sufficiently closely correlated with doctors' training needs.

On reflection, the Government takes the view that measuring training performance solely by the number of days' training delivered does not provide a satisfactory measure of the success of training because it does not measure outcomes - improved skills in clinical assessment, report writing, or customer service. The content and duration of training should reflect the needs of individual doctors, to bring them to the required level of competence in the required range of medical and customer service skills which will enable them to deliver a quality service.

The Department is renegotiating this aspect of the contract with Medical Services, to focus on a training requirement which will be most likely to achieve the desired outcomes.

Delivery of training over the next 12 months will focus on the perceived priority areas of:

The assessment and examination of people with a mental health problem;

The appropriate behaviour, attitudes, and sensitivities required when assessing people with disability, including multicultural awareness; and

Examination of the musculoskeletal system which is evidence-informed and focused on techniques designed to avoid causing distress to claimants

Medical Services are working closely with the Department's Chief Medical Adviser in developing training materials, to ensure that they meet the required standards. The Department will continue to monitor the delivery of training throughout the remainder of the contract period, and will monitor the outcomes against its set criteria.

Medical Services also have in place a programme of continuing medical education to develop the wider skills of their doctors. This is linked to requirements for revalidation by the General Medical Council, and also to providing appropriate training for doctors planning to sit the examination for the Diploma in Disability Assessment Medicine
  Contract amendments have been made to change the emphasis to more focused delivery of a training plan which targets training needs and which has the approval of the Chief Medical Adviser.

The Chief Medical Adviser will consider and recommend what action should be taken with doctors who fail to undergo the required training.
We recommend that if the Department are serious about achieving a step change in quality in the delivery of Medical Services they should make it a long term objective that all sessional doctors attain it and they should set a timetable in which this will be achieved. There should be a financial incentive available to encourage doctors to undertake the Diploma. The Department should begin to explore funding options to this end. The Government endorses the Committee's welcome of the new Diploma in Disability Assessment Medicine, an initiative which it wholeheartedly supports. The first examination was held in March/April 2000 and resulted in 12 candidates achieving the Diploma. A further sitting is scheduled for November/December 2000.

The Diploma was developed as an academic qualification denoting a beacon of excellence in the field of disability assessment medicine. The examination for the Diploma is rigorous, probing in depth the candidate's knowledge, written problem solving skills, and clinical interview and assessment skills. Success in the examination indicates a doctor who has attained a higher than average degree of achievement in all these areas, to an extent significantly greater than that required for satisfactory performance as a Medical Services doctor.

In consequence, while it would wish to encourage all Medical Services doctors to sit the examination in time, the Department does not feel it is realistic to set an objective that all fee paid doctors should attain the Diploma.

However, the Government will encourage Medical Services to set objectives so that a very substantial proportion of their Employed Doctors will have gained the Diploma within five years from now, and that newly appointed Employed Doctors will have gained the Diploma within five years of commencing work with Medical Services. The Department is also investigating the feasibility of funding a number of bursaries to contribute towards the training costs and fees for doctors who wish to sit the examination.
  The Department has sponsored five doctors through a contribution towards tuition and examination fees, for the examination to be held in November 2000. The Department's goal is to have doctors holding the Diploma in each Medical Services Centre, and then to encourage all sessional doctors to obtain the qualification.   
We recommend that the Benefits Agency explores the reasons why decision makers appear to demand reworked cases so infrequently and makes systemic reforms to ensure that unsatisfactory reports are never accepted. The Government agrees with the Committee that reports by Medical Services which are not "fit for purpose" should never be accepted by Benefits Agency decision makers. A report is not "fit for purpose" if the decision maker cannot fully and effectively use it as part of the evidence considered in reaching an accurate decision on benefit entitlement. All such reports returned to Medical Services are reworked at Medical Services' expense. Comprehensive guidance about rework has been provided to decision makers, and procedures for dealing with rework are in place in all Benefits Agency offices.

The Department is investigating current guidance and will ensure that decision makers fully understand how to deal with reports which in their opinion are not "fit for purpose", and to identify what further opportunities exist to provide feedback to Medical Services. To this end the Department's Chief Medical Adviser and his staff will be working closely with the Benefits Agency to identify any obstacles perceived by decision makers that may limit the return of unacceptable medical reports to Medical Services for rework. The Government welcomes these initiatives and looks to the Chief Medical Adviser and his staff to review in company with the Benefits Agency current guidance for decision makers so as to instil confidence and assertiveness in returning reports which fail to meet decision makers' needs.

Decision makers are not medically qualified. While they can, and do, challenge such quality measures as legibility, clarity, consistency, and adequacy of Medical Services' reports, they are not in a position to challenge the medical reasoning behind the report.

The contract specifies a tolerance level of no more than 1% of reports requiring rework. To date the overall levels of rework have been consistently below 1%. This is not incompatible with Medical Services' reported levels of "C grade" reports identified through their own monitoring programme. Medical Services' programme applies much more rigorous quality standards than those required for a report to be considered "fit for purpose", hence a report recorded as unsatisfactory by Medical Services will not necessarily affect the outcome of the benefit entitlement decision.
    The Benefits Agency has issued a bulletin to remind staff of the correct procedures when substandard reports are submitted by Medical Services. Work is ongoing to understand and address any barriers to the return of substandard reports.   
We recommend that the sample of reports audited be larger, especially for IB cases, and that the audit be carried out by an outside body, so as to increase confidence that it is an independent and objective exercise. Medical Services undertake monthly audit of medical reports and advice for all benefits. The number of reports audited has been calculated, with the help of the Department's Analytical Services Division, to provide a statistically valid representative sample. The work of all doctors is, over time, included in the regular audit programme.

Reference has already been made to the Department's Chief Medical Adviser's instigation of an extensive audit of IB scrutiny advice in cases randomly selected from Medical Services Centres. As part of this continuing programme a further audit of the work of each individual doctor will commence in the autumn to assess the effectiveness of Medical Services' remedial action taken with doctors whose advice is not in keeping with the agreed scrutiny guidelines.

The function of disability assessment in connection with benefit claims is unique to doctors in the Department and those working for Medical Services. There is currently no expertise in this field in either clinical or academic medical circles from which auditors external to the Department could readily be drawn. The Department considers that audit by its Chief Medical Adviser meets the need for independent and objective assessment of the quality standards of Medical Services doctors.
The Committee has not been convinced that there has been an improvement in the quality of examinations and reports since contractorisation. Some efficiency improvements have been made: the challenge now must be to improve the quality of reports and the treatment of claimants. Given that there is pressure on doctors to see more patients more quickly it is difficult to see how this can be achieved. Ministers should ask themselves whether one of the goals of contractorisation—improved service to the public—has really been achieved. If they conclude, as we do, that it has not, they should take steps to renegotiate the contract, or otherwise influence performance to ensure that this goal is met. The Government acknowledges that all the objectives for contracting out Medical Services have not yet been fully achieved, particularly in relation to provision of an improved service to the public and improving medical quality standards. While it is recognised that there has as yet been no significant improvement in these areas, there has been a very significant improvement in operational efficiency. Of particular merit are the new business processes and information systems introduced by Medical Services to provide comprehensive management information that greatly facilitates the monitoring, control and assurance of quality standards. In addition there has been improvement in turnaround times for clearing advice and examination cases.

The Government is pleased that the Department is working closely with Medical Services on a number of initiatives designed to bring about the necessary improvements in medical quality standards and customer care. These include:

Comprehensive updated training for doctors in all aspects of customer care;

A review of communications and information sent to claimants;

A comprehensive review of complaints procedures; and

Development of the Medical Skills Database which will provide information about the performance of individual doctors

In order to ensure that the quality principles are adhered to and that medical quality standards are achieved, the Department will regularly review Medical Services' performance against the service targets set by the Government as described in the Introduction. In addition the Department will regularly review Medical Services' quality assurance procedures to ensure they are valid, reliable, and correctly identifying and addressing substandard performance. The Department will also review the role and training of Benefits Agency decision makers to ensure that they are better able to identify and return for rework any advice which does not meet the required standard.


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