Select Committee on Public Accounts Twenty-Seventh Report


TWENTY-SEVENTH REPORT


The Committee of Public Accounts has agreed to the following Report:

THE MEDICAL ASSESSMENT OF INCAPACITY AND DISABILITY BENEFITS

INTRODUCTION AND LIST OF CONCLUSIONS AND RECOMMENDATIONS

1. Disability and incapacity benefits costing over £19 billion are paid each year to some of the most vulnerable members of society. The Department for Work and Pensions (the Department) need independent medical reports and advice to help them make decisions on customers' eligibility for these benefits. The decisions are made by the Department's staff, but since 1998 medical assessments have been delivered initially by SEMA Group and since Spring 2001 by SchlumbergerSema under contract on around 1.3 million cases a year.[1]

2. On the basis of a Report by the Comptroller and Auditor General, and memoranda submitted by the Department and by SEMA, our predecessor Committee examined the Department and SEMA about the scope to improve the speed and accuracy of medical assessments and benefit decisions and the quality of service to customers.[2]

3. In Spring 2001 SEMA was the subject of an agreed takeover by Schlumberger. The Department considers that extending the contract with the new entity, SchlumbergerSema offers the best opportunity to make the service improvements needed. They have agreed amendments to the contract to set new performance and delivery conditions for the contract extension. The agreement to extend the contract is subject to confirmation by the Department by 31 May 2002.

4. In the light of our predecessors' examination, the Committee draws three overall conclusions:

  • Paying the right money to the right people at the right time requires accurate medical evidence, interpreted correctly and processed quickly so that customers get their benefit without delay and where people are ineligible they are speedily removed from the system. Some improvements had been made by SEMA following outsourcing, but the Department have been too slow in tackling delays and inaccuracies in the Benefits Agency. As a result, over 40 per cent of appeals against decisions are successful, and a quarter of successful appeals are due to failures of decision making in the Benefits Agency. At the same time, delays in reviewing entitlement for Incapacity Benefit may be costing the taxpayer £40 million a year.

  • Over 25,000 people are called unnecessarily for examination each year because of difficulties in obtaining accurate and up-to-date medical information. This is not acceptable. Over 17,000 are turned away from scheduled examinations because of deliberate overbooking of appointments. SEMA have been unable to provide same-gender doctors and interpreters to all those who want them. The Department and SchlumbergerSema need to make these public services more responsive to the needs of the citizen.

  • The absence of targets and incentives on quality in the contract with SEMA left the Department with limited leverage to enforce quality improvements. The Department have since sought to include new customer service and quality measures in the contract with SchlumbergerSema. When Departments are outsourcing core services to customers or benefit claimants, they need to get the balance right between incentives to cut costs, speed delivery and improve quality. This has not been achieved in this case.

5. Our more specific conclusions and recommendations are as follows.

On improving the speed of decisions on benefit entitlement

      (i)  Significant delays in making decisions about benefit mean that many claimants for Disability Living Allowance wait longer than they should to receive their money, and £40 million a year or more may be lost because the Department continue to pay Incapacity Benefit to people when they are not entitled. Variations across the country mean that claimants wait longer in some areas than others (paragraph 13).

      (ii)  Delays and backlogs existed before the Department outsourced the medical assessment part of the process in 1998. Shortages of doctors since then have added to the problems, but the root causes of many delays lie within the Department and the Benefits Agency. As in other parts of the social security system, poor management information and outdated information technology are likely to hinder progress for some time. But there is action the Department can take to improve their performance drawing on work already done on Income Support and Jobseeker's Allowance and on the recommendations made by the Comptroller and Auditor General. We expect them to set clear targets for performance improvement, and to let us know what they are (paragraph 14).

      (iii)  Another area where progress has been too slow is in exploring ways of using healthcare professionals other than doctors in the medical assessment process. This is an important way of offsetting shortages of doctors, speeding up the assessment process and reducing costs. The Department should look again at the requirement in legislation for the use of doctors in the medical assessment process to ensure that unnecessary red tape is not holding back progress (paragraph 15).

On improving the quality of medical evidence and benefit decisions

      (iv)  The high proportion of cases where appeals are successful (over 50 per cent appeal and more than 40 per cent of those succeed) creates confusion for claimants. Some appeals will always succeed because a claimant's condition changes or new evidence comes to light. But in a quarter of cases successful at appeal the Benefits Agency decision-maker misinterpreted the evidence, which undermines confidence in the process and wastes public resources (paragraph 28).

      (v)  The Department are now taking action to improve the end-to-end process of decision-making. A key element is the work they are doing to learn from successful appeals including feedback from the Appeals Service. The Department should reinforce these actions with targets for reducing the number of appeals that are successful because of mistakes by the Benefits Agency (paragraph 29).

      (vi)  Another key factor in getting decisions on eligibility for benefit right first time is the quality of medical assessments. SEMA's own monitoring showed a need to improve the quality of medical reports provided by their doctors, up to 10 per cent of which were substandard. The Department should strengthen their oversight of SchlumbergerSema's quality assurance arrangements, particularly over the quality of examinations carried out in the customer's home, and ensure that all sub-standard reports are returned to the contractor for improvement (paragraph 30).

      (vii)  General practitioners are paid for supplying medical evidence on Incapacity Benefit cases through their NHS contract, and directly on cases of Disability Living Allowance. Yet difficulty in obtaining accurate and up-to-date medical evidence has led to some 25,000—30,000 people unnecessarily being called for examination. Action being taken or proposed to clarify the information required and ease the burden of bureaucracy on general practitioners may help improve their responsiveness. But this will not overcome their reluctance to provide reports, either because of the effect they might have on relationships with their patients or because there might be a souring of relationships with the patient's family. The Department should work with the Department of Health to resolve this potential conflict of interest (paragraph 31).

On improving the quality of service to customers

      (viii)  Because the Department pay for each completed examination, there is a financial incentive for the contractor to overbook appointments for medical examinations. This allows them to cope with a high and unpredictable dropout rate and uncertainty over the number of attendees, and ensure that they make maximum use of their doctors. But as a result, on average around 3 per cent of customers (over 17,000 a year) have been turned away unseen, even though they have scheduled appointments (paragraph 46).

      (ix)  While some customers are not seen for valid reasons, the Department should consider whether SchlumbergerSema should pay compensation if they turn people away because of deliberately overbooked appointments or for examinations that are proved to be inferior to what is considered to be acceptable (paragraph 47).

      (x)  Although the contract with SEMA required them to comply with reasonable requests to accommodate claimants who have special needs, they have been unable to guarantee same-gender doctors for medical examinations or the availability of interpreters. New targets are now included in the contract, and we look to the Department and SchlumbergerSema to ensure that they provide responsive services to all their customers. The wider use of other healthcare practitioners in examinations may be one way of overcoming a shortage of female doctors in some areas (paragraph 48).

      (xi)  Customer satisfaction ratings on the medical assessment services are around 92-93 per cent. But there remain a number of people—around 5,000 a year—who are dissatisfied by the nature of the medical examinations they undergo. We welcome the action the Department and SchlumbergerSema are taking to improve information to customers on the examination, to improve doctor training, and to work with the Citizen's Advice Bureaux and other groups to improve their understanding of customers' concerns (paragraph 49).

      (xii)  A major weakness in the contract with SEMA was the absence of any real incentives to get the quality of service needed. Although targets for improvement in quality have now been introduced into the contract, there is a general lesson here for those outsourcing services where quality is a key factor (paragraph 50).

ON IMPROVING THE SPEED OF DECISIONS ON BENEFIT ENTITLEMENT

6. Incapacity Benefit, Disability Living Allowance and its sister benefit, Attendance Allowance, represent over 90 per cent by value of medically assessed benefits. Disability Living and Attendance Allowances are not paid until evidence (which may take the form of a medical assessment) has been provided to demonstrate that the customer meets the criteria, so timely assessment is especially important to avoid undue delays in customers receiving their benefits. Conversely, Incapacity Benefit customers who meet basic eligibility criteria are paid benefit immediately, and those subsequently found to be capable of work do not have their benefit payments recovered. So for Incapacity Benefit a timely medical assessment is essential to protect the public purse.[3]

7. Medical assessment forms only part of the end-to-end processing of benefit claims, but one of the reasons for the decision to outsource medical assessments was to help tackle delays and backlogs in dealing with cases. Following outsourcing, SEMA improved the efficiency of their part of the medical assessment process but delays in taking decisions and inconsistency remain. For Disability Living Allowance cases, on average the Department's Disability Benefit Centres missed the 30-day clearance targets, most by more than 10 days. These delays meant late payment and worries for disabled people. For Incapacity Benefit, the total time taken to process cases due for review ranged from 90 to 170 days across different parts of the country.[4]

8. Most of this variation was due to the variable speed of processing in the Benefits Agency rather than medical assessment. In addition, there were backlogs of Incapacity Benefit cases, where review action had been deferred beyond the recommended time. In November 2000, this backlog totalled 185,000 cases. Delays and backlogs could be costing the taxpayer £40 million or more in benefits wrongly paid. [5] The Comptroller and Auditor General identified ways in which the Department could improve workload and case management and reduce backlogs.

9. The Department told our predecessor Committee that there were a number of causes of the delays. One key issue was the need to get medical evidence from sources outside their control, including general practitioners. Another factor was that within the Benefits Agency, systems were still heavily clerical and not well supported by information technology. Introducing new technology was at the heart of the Agency's modernisation programme, but would take some time to deliver. In advance of that the Benefits Agency had been looking at ways of reducing delays in the end-to-end process. This included the way the Agency communicated with general practitioners and SEMA, and the forms claimants had to fill in. An underlying problem was a lack of management information on the length of time it took to undertake parts of the process and on variations between offices. The Agency was introducing a computerised business model and improving management information, but current systems were not geared up to deal with case management, and this too required new technology.[6]

10. The Department were seeking to tackle unacceptable variations in performance on all benefits and had already made some progress on Income Support and Jobseeker's Allowance, for example by sharing good practice across areas, and implementing changes in procedures and training. They now planned to apply similar approaches to Incapacity Benefit. One reason for variations was the way in which directorates deployed their resources across different benefits. Mostly the priority was to process claims for Income Support and to improve the accuracy of Income Support or Jobseeker's Allowance. These areas were subject to targets, and therefore were the focus of management. In the case of Incapacity Benefit, the priority was to deal with new cases, rather than to review existing cases for continued eligibility, although the Department accepted that they had not paid existing cases enough attention.[7]

11. The backlog of Incapacity Benefit cases awaiting review also varied by region, with particular problems in Wales, West of Scotland, Greater Manchester and the North West Coast.[8] The Department admitted that they had no immediate plans to deal with the backlog, indeed it had deteriorated. This was partly because during the course of 2000 the shortage of doctors to undertake medical assessments had worsened. In addition, revised guidelines issued in November 2000 to remove any uncertainty about which cases should be cleared by paper scrutiny and which should go for personal examination had led to a greater number of cases going for examination, and further pressure on a dwindling pool of doctors. Capacity had become over-stretched, and the Department had held cases back from SEMA. They and SEMA were taking action to increase the number of doctors by jointly funding a rise of 15 per cent in pay coupled with more flexible work patterns and a vigorous recruitment campaign, and they expected to restore full processing by December 2001. However, the cost of these pay increases would erode by £2 million a year the savings of around £5 million which the Department expected to achieve each year from outsourcing.[9]

12. One way of helping to overcome the shortage of doctors and reduce costs is to use other healthcare professionals to carry out some of the work involved in medical assessments. SEMA had looked to innovate in the use of such staff in its tender but plans had not moved forward, partly because the relevant social security legislation requires some work to be done by doctors. The Department told our predecessors that doctors had an essential role, particularly in regard to Disability Living Allowance, in linking diagnosis to the way disease evolves in different people and its impact on them. However, there was a role for other healthcare professionals, and the Department had been slow to progress this issue. SEMA had introduced a pilot scheme in Manchester using healthcare professionals to do part of the work and, subject to the outcome, they would roll out the approach.[10]

Conclusions

13. Significant delays in making decisions about benefit mean that many claimants for Disability Living Allowance wait longer than they should to receive their money, and £40 million a year or more may be lost because the Department continue to pay Incapacity Benefit to people when they are not entitled. Variations across the country mean that claimants wait longer in some areas than others.

14. Delays and backlogs existed before the Department outsourced the medical assessment part of the process in 1998. Shortages of doctors since then have added to the problems, but the root causes of many delays lie within the Department and the Benefits Agency. As in other parts of the social security system, poor management information and outdated information technology are likely to hinder progress for some time. But there is action the Department can take to improve their performance drawing on work already done on Income Support and Jobseeker's Allowance and on the recommendations made by the Comptroller and Auditor General. We expect them to set clear targets for performance improvement, and to let us know what they are.

15. Another area where progress has been too slow is in exploring ways of using healthcare professionals other than doctors in the medical assessment process. This is an important way of offsetting shortages of doctors, speeding up the assessment process and reducing costs. The Department should look again at the requirement in legislation for the use of doctors in the medical assessment process to ensure that unnecessary red tape is not holding back progress.

ON IMPROVING THE QUALITY OF MEDICAL EVIDENCE AND BENEFIT DECISIONS

16. The quality of medical assessments is an important factor in helping Benefits Agency staff take the right decisions on claims. Prior to outsourcing there were concerns about the quality of assessments, and business targets for quality standards were not being achieved.[11]

17. SEMA's own quality assurance systems, together with the low levels of reports returned as unfit by the Benefits Agency, suggested that the quality of reports had improved since outsourcing. However, between five and 12 per cent of work remained unacceptable, 20-30 per cent of scrutinies did not comply with guidelines and the Comptroller and Auditor General found that staff often failed to send back reports as unfit for purpose, because this added to delays.[12]

18. The Department and SEMA confirmed that they took the issue of medical quality very seriously. Doctors had to have a minimum of five years' experience in various disciplines including general practice. Since outsourcing, SEMA had introduced a quality audit system, improved training arrangements and better monitoring of doctors' work. Later figures suggested a further reduction in the number of unacceptable reports and a further overall improvement in totally satisfactory ones, for example to 88 per cent on Incapacity Benefit, although 10 per cent of reports on home visits were still unsatisfactory. At the same time, in response to a report by the Social Security Select Committee on Medical Services, the Department had set new targets for improving the quality of medical reports and scrutinies.[13]

19. Even the best medical evidence may result in a poor decision if not interpreted correctly by the decision-maker. The major medically assessed benefits have a high rate of successful appeals—over 40 per cent—against decisions to refuse, withdraw or reduce benefit. Analysis by the Appeals Service indicated that in some 25 per cent of those decisions they changed, the interpretation of the medical evidence, whether from SEMA or the customer's doctor, was an important factor.[14]

20. The Comptroller and Auditor General identified a number of areas where the Department could do more to ensure they had the right evidence to make accurate decisions, including:

  • improving the accuracy and completeness of evidence from general practitioners, consultants and specialists to avoid unnecessary examinations on Disability Living Allowance and Incapacity Benefit;

  • getting sufficient evidence of incapacity, by better targeting those Incapacity Benefit cases where examinations were really necessary;

  • giving decision-making staff better training and feedback, including feedback on the outcome of their decisions and the outcomes and causes of appeals.[15]

21. Some appeals will always succeed because people's circumstances changed or they were able to bring fresh evidence when they went to appeal. But the Department were disturbed by the 25 per cent of cases where the Benefits Agency decision-taker misinterpreted the evidence. This was something which they could and should do something about. And any system where 40-50 per cent of cases were overturned on appeal meant that the Department were getting the process wrong. Apart from the impact on claimants, the appeals process was expensive—each appeal cost on average £177—and savings could be achieved by taking better decisions in the first place.[16]

22. The Department were looking at ways of learning from the results of appeals. They were piloting the use of presenting officers at appeals to see whether that made a difference to the outcome. They had set up a working group with the Appeals Service to get feedback. They were taking forward, with the President of Appeals Tribunals, an arrangement where they would get feedback in cases where medical evidence was considered in some way indicative of poor performance, which would allow further investigation. SEMA also welcomed closer links with the Appeals Service to understand what the outcome of appeals meant for training generally and for the training needs of individual doctors.[17]

23. Those claimants who appear in person at an appeal, or have a representative present, have a significantly higher success rate. In a sample of appeals, 49 per cent attended by the claimant were successful as were 56 per cent of those attended by a representative and 63 per cent where both attended. In contrast, only 17.2 per cent of appeals were successful where neither the appellant nor a representative appeared. The Department confirmed that information issued by the Appeals Service requests the claimant to appear and gives them advice on why this would be better than having the case decided on the basis of the papers only.[18]

24. Improving the quality of assessments depended crucially on attracting sufficient numbers of suitably trained doctors, and the steps SEMA had taken to increase pay should help to achieve this. They had introduced various measures to improve professional standards, including new training arrangements, and in future will pay doctors to attend training. Key parts of the SEMA training programme were an induction into the various benefit streams and a five-day continuing medical education programme which all doctors who are in SEMA would have taken part in by the end of 2001. In addition, SEMA was part of a new initiative put together by the Faculty of Occupational Medicine, the Royal Medical Colleges and the Department, to encourage doctors to take a Diploma in Disability Assessment Medicine, an academic qualification over and above the normal training in this type of work. By November 2000, 11 SEMA doctors had been awarded the Diploma and a further 15 were working towards it. At the same time, SEMA had taken action to stop 17 doctors working on assessments where they were found to be incompetent or where there were doubts over their registration.[19]

25. Certificates from claimants' general practitioners are a key source of medical evidence in medical assessment for Incapacity Benefit. The provision of evidence for Incapacity Benefit is part of the remuneration of general practitioners under their contracts with the NHS. For Disability Living Allowance, the Department pay general practitioners directly for the information they provide. However, the Department often experienced difficulty in obtaining accurate and up-to-date medical evidence, which could lead to unnecessary examinations by SEMA. The Comptroller and Auditor General found that some 25,000—30,000 people need not have been called for examination, had their general practitioner provided sufficient evidence.[20]

26. One factor which could impact on the quality of evidence provided by general practitioners was the increasing demands on their time. The Regulatory Impact Unit of the Cabinet Office have been studying ways of better managing demands on general practitioners, including the provision of information for benefits purposes. In their report Reducing General Practitioner Paperwork, the Unit highlighted a number of measures which were being taken, or which could be taken to relieve the burden on general practitioners. Their proposals included changes in the type of information the Department requires of customers claiming Disability Living Allowance, and piloting the use of nurse practitioners to issue medical certificates for Incapacity Benefit.[21]

27. Another factor was the impact of reports on a general practitioner's relationship with their patients. Past anonymous surveys of general practitioners have found that on occasions 10-15 per cent were very reluctant to provide reports, either because of the effect this might have on relationships with their patients or because there might be a souring of the relationship with the patient's family. More widely, general practitioners were reluctant to perform a decision-making or evidence providing role in the benefits system partly because they felt it compromised their doctor/patient relationship.[22]

Conclusions

28. The high proportion of cases where appeals are successful (over 50 per cent appeal and more than 40 per cent of those succeed) creates confusion for claimants. Some appeals will always succeed because a claimant's condition changes or new evidence comes to light. But in a quarter of cases successful at appeal the Benefits Agency decision-maker misinterpreted the evidence, which undermines confidence in the process and wastes public resources.

29. The Department are now taking action to improve the end-to-end process of decision-making. A key element is the work they are doing to learn from successful appeals including feedback from the Appeals Service. The Department should reinforce these actions with targets for reducing the number of appeals that are successful because of mistakes by the Benefits Agency.

30. Another key factor in getting decisions on eligibility for benefit right first time is the quality of medical assessments. SEMA's own monitoring showed a need to improve the quality of medical reports provided by their doctors, up to 10 per cent of which were substandard. The Department should strengthen their oversight of SchlumbergerSema's quality assurance arrangements, particularly over the quality of examinations carried out in the customer's home, and ensure that all sub-standard reports are returned to the contractor for improvement.

31. General practitioners are paid for supplying medical evidence on Incapacity Benefit cases through their NHS contract, and directly on cases of Disability Living Allowance. Yet difficulty in obtaining accurate and up-to-date medical evidence has led to some 25,000-30,000 people unnecessarily being called for examination. Action being taken or proposed to clarify the information required and ease the burden of bureaucracy on general practitioners may help improve their responsiveness. But this will not overcome their reluctance to provide reports, either because of the effect they might have on relationships with their patients or because there might be a souring of relationships with the patient's family. The Department should work with the Department of Health to resolve this potential conflict of interest.

ON IMPROVING THE QUALITY OF SERVICE TO CUSTOMERS

32. The main way by which the Department obtained feedback on the quality of SEMA's services was through monthly reports on the results of customer satisfaction surveys. These surveys suggested that between 75 per cent and 85 per cent of customers were generally satisfied with the service provided and that most were content with the conduct of examinations, although complaints were rising. However, the Comptroller and Auditor General highlighted three areas of particular concern:

  • doctors' attitudes and the conduct of examinations;

33. Before outsourcing, 20 per cent of Incapacity Benefit customers invited to attend examinations could not make the date specified and a further 20 per cent failed to turn up. The Department made some late substitutions, which reduced the net dropout to 35 per cent. However, they hoped that outsourcing would help to address this waste of resources.[24]

34. Because payment is made for each completed examination, SEMA had a strong incentive to ensure that as many customers as possible attended and that their staff were fully employed on productive work. Since outsourcing, the number of customers who fail to attend has not reduced. To allow for this, the in-house service practised over-booking, something which had been continued by SEMA. However, as the number who attend any one session is volatile, overbooking has meant that large number of customers have been turned away unseen. On average around 3 per cent of customers—over 17,000 in any one year—were turned away unseen, with the North and South East contract areas turning away a higher proportion. While overbooking was the main cause of cancellations, other reasons included doctors taking longer to complete examinations, customers unwilling to wait longer than the expected time of 30 minutes and doctors cancelling sessions at short notice.[25]

35. SEMA told our predecessor Committee that they shared these concerns about people being turned away unseen. SEMA pointed out that overbooking was only one factor. A number of people who turned up were not in a good state to be examined, for example because they were drunk or under the influence of drugs. One approach they had successfully piloted in Leeds was to pay doctors on a fee per case basis, rather than a set period of time, to encourage them to see all those patients who turn up. They were also trying to bring greater flexibility into the timing of sessions, had introduced new scheduling arrangements and had made a significant investment in the development of information technology to assist the scheduling process.[26]

36. Where customers failed to appear for their scheduled examination for Incapacity Benefit, there was a risk that benefit might continue to be paid even though their circumstances had changed. To address this, the Benefits Agency took non-attendance into account in decisions on whether to continue to pay benefit. The disallowance rate for failure to attend without good cause was 38 per cent following a first failure, 37 per cent after a second failure and 70 per cent following a third failure. In the quarter ended 31 August 2000, 10,000 people had had their benefit stopped as a result of either not sending a form back or of failing to attend an examination without good cause.[27]

37. Where customers are turned away unseen, the Department pay the extra travel expenses but do not provide them with compensation. They argued that they could not consider this without taking account of what was happening in other public services, such as the NHS. Instead, they wanted to incentivise SEMA to minimise the number of people who were turned away, and they had set a target to reduce this to 3 per cent in each of the three contract areas. This would not guarantee that everyone would be seen, but would reduce the number turned away.[28]

38. Before outsourcing, 64 per cent of complaints by customers about medical assessments concerned the medical examination, including the doctor's manner (41 per cent) and the content of examinations (17 per cent). After outsourcing, 57 per cent of complaints were about these issues.[29] Our predecessor Committee also highlighted concerns from their constituents about the nature and content of examinations, and about doctors' attitudes.

39. The Department had redesigned their customer satisfaction survey, and this had shown consistent satisfaction rates of 92-93 per cent in the latter part of 2000. Complaints were a fraction of one per cent of customers, but the Department recognised that there could be a number of people who were seriously aggrieved because they had been denied benefit as a result of an examination. Following the hearing of the Social Security Select Committee in 2000 the Department had put in place a new set of complaints processes. Complaints were now handled by complaints managers. Within SEMA, 86 staff had been trained to deal with complaints. They had strengthened their links with Citizens Advice Bureaux to ensure that they understood the nature of the problems perceived by customers. And they were updating their information and producing a new pamphlet on complaints.[30]

40. Many complaints about the nature of the examination, and the limited time it took, reflected confusion on the part of customers about its purpose. The examination was not what the customer expected. For example, the examination for Disability Living Allowance was not diagnostic; it was to assess how the person's disability impacted on their ability to care for themselves or on their mobility. An assessment for Disability Living Allowance could be made on the basis of quite a short examination. A particular diagnosis might have a whole range of effects upon function. The Department had defined the nature of the examination and SEMA doctors were required to explain this to customers. SEMA had produced better-targeted information for claimants outlining the processes involved in making a claim and what to expect in examinations by doctors, and were in the process of reissuing training to ensure that doctors understand the situation from the customer's point of view and could deal with sensitive situations.[31]

41. The Comptroller and Auditor General noted that under the contract, SEMA were required to "comply with any reasonable requests to accommodate claimants who have special needs". Provision for special needs might include, for example, a female examining doctor where a customer so requests, or interpretation facilities for customers whose first language is not English.[32]

42. Interest groups who advise benefit customers had raised with the Department concerns about what they saw as poor customer service to ethnic minority groups; specifically the failure to provide interpreters and female doctors, and general cultural insensitivity. The number of actual complaints about racial or gender discrimination or cultural insensitivity in the treatment of customers identified was small, but interest groups pointed out that some customers might be dissuaded from complaining.[33]

43. Shortages of female doctors among SEMA's workforce, especially in some inner city areas, meant that they could not always provide a female doctor when a customer requested one. Of 216 full-time doctors, one third were female, as were around one sixth of the 3,000 fee-paid doctors who carried out most of the examinations.[34]

44. SEMA were seeking to improve their response where the customer wished to be examined by a same-sex doctor, but were constrained by the gender spread of doctors and were not in a position to offer everything to everybody. The Department had developed a standard statement covering, for example, interpreters and same-gender doctors, which was being incorporated in all their forms. Further, SEMA's new training modules included one on multicultural awareness. SEMA told our predecessor Committee that doctors did not routinely take chaperones with them for home visits. They made every effort to inform people who were to be examined by a doctor that if they wished to have a friend or carer with them then that would be very welcome. If complaints arose about examinations by someone of the opposite sex, they were taken very seriously.[35]

45. While the Department required SEMA to meet certain standards of customer service, they had limited leverage through the contract to raise standards, as payments were not linked with SEMA's achievements. This was because the Department had been unable to define service quality to contractually definable standards. Since then, and in response to recommendations by the Comptroller and Auditor General, the Department had negotiated with SEMA, and subsequently with SchlumbergerSema, a number of conditions and improvements to the contract. These included new targets for handling complaints, waiting times for customers, for the provision of interpreters and same-gender doctors, and ensuring that fewer customers are turned away without examination.[36]

Conclusions

46. Because the Department pay for each completed examination, there is a financial incentive for the contractor to overbook appointments for medical examinations. This allows them to cope with a high and unpredictable dropout rate and uncertainty over the number of attendees, and ensure that they make maximum use of their doctors. But as a result, on average around 3 per cent of customers (over 17,000 a year) have been turned away unseen, even though they have scheduled appointments.

47. While some customers are not seen for valid reasons, the Department should consider whether SchlumbergerSema should pay compensation if they turn people away because of deliberately overbooked appointments or for examinations that are proved to be inferior to what is considered to be acceptable.

48. Although the contract with SEMA required them to comply with reasonable requests to accommodate claimants who have special needs, they have been unable to guarantee same-gender doctors for medical examinations or the availability of interpreters. New targets are now included in the contract, and we look to the Department and SchlumbergerSema to ensure that they provide responsive services to all their customers. The wider use of other healthcare practitioners in examinations may be one way of overcoming a shortage of female doctors in some areas.

49. Customer satisfaction ratings on the medical assessment services are around 92-93 per cent. But there remain a number of people—around 5,000 a year—who are dissatisfied by the nature of the medical examinations they undergo. We welcome the action the Department and SchlumbergerSema are taking to improve information to customers on the examination, to improve doctor training, and to work with the Citizen's Advice Bureaux and other groups to improve their understanding of customers' concerns.

50. A major weakness in the contract with SEMA was the absence of any real incentives to get the quality of service needed. Although targets for improvement in quality have now been introduced into the contract, there is a general lesson here for those outsourcing services where quality is a key factor.


1   C&AG's Report, paras 1-3 Back

2   C&AG's Report, The Medical Assessment of Incapacity and Disability Benefits (HC 280, Session 2000-01); Ev, p1 and Ev, p2 Back

3   C&AG's Report, para 6 Back

4   ibid, paras 2, 7-8, 2.2-2.14  Back

5   ibid, paras 2.12-2.19, Figure 16 Back

6   Qs 1-4, 7, 141-142, 156-171 Back

7   Qs 156-171 Back

8   C&AG's Report, paras 2.16, Figure 16 Back

9   ibid, Figure 7; Qs 5-6, 12-15, 28-32; Ev, p1, Ev, p2 Back

10   C&AG's Report, paras 1.21, 3.17; Qs 109-111, 150-151 Back

11   C&AG's Report, paras 2, 3.2-3.6, Figure 17 Back

12   ibid, paras 11-14, 3.2-3.6, Figure 17 Back

13   ibid, paras 3.9-3.11, Appendix 9; Qs 9-10, 37-42, 53-54, 63 Back

14   C&AG's Report, para 15; Qs 16-17 Back

15   C&AG's Report, paras 3.18-3.31 Back

16   Qs 16-17, 118-125, 154-155 Back

17   Qs 8, 16-17, 66-67, 72 Back

18   Qs 8, 68-71 Back

19   C&AG's Report, paras 3.11; Qs 12, 42, 53-55, 58, 63, 112-117 Back

20   C&AG's Report, paras 3.19-3.22 Back

21   ibid, para 3.22; Q19; Making a Difference: reducing General Practitioner paperwork, Public Sector Team of the Regulatory Impact Unit, 19 March 2001 (not printed here) Back

22   Qs 18-20, 126-130 Back

23   C&AG's Report, paras 19-20, 4.3-4.6 Back

24   ibid, paras 4.14-4.15 Back

25   ibid, paras 4.16-4.20, Figures 27, 28 Back

26   Qs 11, 86-88; Ev, p2 Back

27   Qs 131-132, 172-176 Back

28   Qs 79-90, 133-139, 144-150 Back

29   C&AG's Report, para 4.6, Figure 24 Back

30   Qs 26-27, 52, 105-106 Back

31   C&AG's Report, paras 4.11-4.13; Qs 22, 26-27, 42-50, 99-100, 104, 107-108; Ev, p2 Back

32   C&AG's Report, para 4.21 Back

33   ibid, paras 4.22-4.23 Back

34   ibid, para 4.26 Back

35   Qs 91-98; Ev, p2 Back

36   C&AG's Report, paras 18-21, 4.2; Ev, p2 Back


 
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