Select Committee on Work and Pensions Minutes of Evidence


Memorandum submitted by the Department for Work and Pensions (MS 01)

1.  SUMMARY

  1.1  The Government is pleased to report that all the recommendations made by the Social Security Select Committee in its report in April 2000 of its inquiry into Medical Services have been addressed.

  1.2  Since publication of the report, and the Government's response in June 2000, Medical Services' performance has demonstrated significant and ongoing improvement in all three key areas of: service level delivery, customer care, and medical quality and professional standards. The Government and Medical Services both recognise and acknowledge that improvement is a continuous process, and that further achievements can be made. But the Government is impressed by the very tangible evidence from Medical Services of renewed determination to succeed.

  1.3  In particular, the new senior management put in place by Schlumberger when they took over Sema Group in April 2001 to form SchlumbergerSema Medical Services, has demonstrated clear commitment to working together with the Department for Work and Pensions to achieve continual improvement in performance. An extensive Change Programme has been implemented to improve service delivery. The Programme fully supports the Government's commitment to modernising the delivery of service to customers; and its commitment to helping and supporting people off benefit and back into work.

2.  IMPLEMENTATION OF THE SOCIAL SECURITY SELECT COMMITTEE'S RECOMMENDATIONS

  2.1  All the recommendations made by the Select Committee in its report on Medical Services have been addressed. Specific examples of action taken include:

    —  Development of an ongoing programme of continuing medical education for all doctors. This incorporates and extends beyond the training specified in the target set by the Government.

    —  Development of a number of specific training modules on disability awareness and customer care.

    —  Development of a system for objective evaluation of the effectiveness of training.

    —  A thorough review of complaints handling and effective remedial action.

    —  Clear information to claimants about the medical assessment process; the availability on request of interpreters or same-gender doctors; and the complaints process.

    —  Clarification of the Incapacity Benefit scrutiny guidelines, and removal of any financial incentive to clear cases by scrutiny rather than by examination.

    —  Implementation of a fee increase for doctors.

    —  Active sponsorship of the Diploma in Disability Assessment Medicine.

  2.2  Details of the action taken in response to individual recommendations are at Annex 1.

3.  PERFORMANCE AGAINST GOVERNMENT'S TARGETS

  3.1  In its response to the Select Committee's report, the Government set four targets by which tangible improvements in service and medical quality standards would be judged:

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

    —  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 per cent

    —  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 per cent

  3.2  Medical Services have delivered these targets, as monitored by the IMPACT Contract Management Team:

    —  The target for "C grade" reports relates to the proportion of "C grade" reports averaged across all benefits. This figure has fallen to 3 per cent. The most recent figure for Incapacity Benefit "C grades" is 2.4 per cent. The most recent figure for Examining Medical Practitioners (EMP) reports is 6.4 per cent, which is a significant improvement. At the time the targets were set, the proportion of "C grade" EMP reports was around 12 per cent.

    —  Non-compliance with scrutiny guidelines is also below 3 per cent.

    —  All doctors employed or contracted to work for Medical Services have received the specified training, and also a number of other training modules, relating to customer care and to assessment of specific disabling conditions. These modules form part of an ongoing programme of continuing professional education, discussed and agreed with the Department's Chief Medical Adviser.

    —  The most recent customer satisfaction surveys showed a satisfaction level of 96 per cent.

4.  MEDICAL SERVICES' PERFORMANCE

 (i)   Service Levels

  4.1  Medical Services' performance against service levels fell in late autumn 2000, particularly in relation to Incapacity Benefit examinations. There were a number of underlying factors:

    —  Doctor attrition—a number of doctors had resigned earlier in the year when work volumes were low.

    —  The effects of a catching-up exercise in continuing medical education, with training being delivered to a large number of doctors in the summer and early autumn of 2000.

    —  An increase in the Incapacity Benefit scrutiny to examination rate from around 35 per cent to around 65 per cent following clarification of the scrutiny guidelines.

  4.2  A recovery programme has been successfully implemented and has resulted in a 17 per cent increase in the number of examinations performed in 2001 compared to 2000, with a further 10 per cent increase expected in 2002.

  4.3  In autumn 2000, the number of deferred Incapacity Benefit examinations was around 250,000. All the deferred cases involve claimants in receipt of Incapacity Benefit who are due to have their entitlement reviewed. This rose to a peak of around 350,000 in spring 2001, on account of the factors outlined above. Since then the number of deferred cases has steadily reduced. It now stands at around 220,000, and is predicted to fall below 100,000 by spring 2003.

  4.4  The improvements which have been implemented include:

    —  Better workflow planning and management, with closer working between the Department and Medical Services.

    —  More flexible use of doctor capacity, including options to work more flexible hours, including evening and Saturday sessions.

    —  Offering additional payment to doctors agreeing to cover areas of doctor shortage.

    —  An improved pay package for doctors. Sessional doctor fees were increased by 3 per cent in September 2000, and by a further 15 per cent from April 2001.

    —  Recruitment of additional doctors, both directly employed and sessional.

  4.5  Changes have also taken place within the Benefits Agency and Jobcentre Plus. The priority of this work has been raised, and a clear steer has been given on working in partnership with Medical Services to agree the volume of referrals. Details of deferred cases by Area Directorate are shown in Annex 2.

  4.6  Previously the price for an Incapacity Benefit scrutiny report or an examination was the same. The contract has been re-priced to remove a potential perverse incentive to clear cases by scrutiny rather than by examination and to simplify commercial negotiations. The current scrutiny to examination rate, following clarification of the scrutiny guidelines in November 2000, and a series of joint seminars for scrutiny doctors by the Department and Medical Services in April 2001, is around 50 per cent. Details by contract package area are shown in Table 1.

Table 1:

SCRUTINY TO EXAMINATION RATES
Contract area December 00December 01 January 02February 02
North71.6%49.1% 48.4%49.2%
South East65.6%52.3% 51.6%53%
South West64.6%50.6% 52.3%49.5%


 (ii)   Customer care

  4.7  A number of new, contractually binding, customer care targets have been agreed, relating to:

    —  Provision of same-gender doctors on request.

    —  Provision of interpreters on request.

    —  Customer waiting time at examination centres.

    —  Customers being sent home unseen.

    —  Timeliness and quality of response to complaints.

  4.8  All customers receive clear written information about the assessment process; about the availability of interpreters or same-gender doctors on request; and about Medical Services' complaints process. The information also explains clearly the difference between a complaint and a request for reconsideration of an adverse benefit entitlement decision.

  4.9  The appointment system for examinations has been made more flexible, and now offers customers the option of evening or weekend appointments.

  4.10  The timeliness and quality of response to complaints is monitored regularly by the IMPACT Contract Management Team; and management action by Medical Services is automatically triggered if a doctor receives multiple complaints.

 (iii)   Medical quality and professional standards

  4.11  Medical Services have developed a comprehensive induction training programme for all newly-recruited doctors. They have also developed a robust and comprehensive programme of continuing medical education, which is delivered to all doctors on the basis of individual personal development plans and training needs analysis. Both training programmes have been agreed with the Department's Chief Medical Adviser.

  4.12  The Medical Skills Database which is now in place captures full details of each doctor's skills, training, and quality performance, both in terms of quality audit of the doctor's work, and any complaints received about the doctor.

  4.13  Medical Services have demonstrated their strong support for the Diploma in Disability Assessment Medicine (DDAM) by sponsoring doctors to train for and sit the examination; and by offering financial recognition to employed doctors who achieve the Diploma. Over 50 doctors currently hold the DDAM, the majority of them Medical Services doctors, and a further 25 doctors so far have expressed an interest in sitting the examination in 2002.

5.  THE GOVERNMENT'S DECISION TO EXTEND THE CONTRACT

  5.1  The contract for Medical Services was awarded for five years from September 1998, with the option of a two year extension. In November 2001 the Government announced its decision to extend the contract by two years, to August 2005. The extension is subject to confirmation, and subject to Medical Services satisfactorily delivering detailed conditions for improvement.

  5.2  Sema Group, who were awarded the contract in 1998, were taken over by Schlumberger in April 2001, to form SchlumbergerSema Medical Services. The new company installed new managers at senior level. The new management has demonstrated its commitment to close working with the Department to improve both current performance and future service delivery.

  5.3  The new senior management structure of Medical Services has from the start demonstrated a determination to succeed in delivering the contract. There has been tangible change in attitude, and in implementation of improvements. This has been demonstrated in the achievement to date of a number of new targets for performance improvement. Changes within the Department at senior management level have resulted in much closer working between the Department and Medical Services, with regular performance review at strategic, as well as at day to day, level.

  5.4  Confirmation of extension of the contract is subject to Medical Services meeting the targets set out in the IMPACT amendment document. These include achieving new performance targets for:

    —  The number of Incapacity Benefit examinations carried out.

    —  Doctor recruitment.

    —  Medical quality standards.

    —  Complaints.

    —  Contractual changes to secure continuity of service at contract end.

    —  Visibility of costs.

    —  Delivery of a number of milestones in the Medical Services Change Programme which SchlumbergerSema have introduced to improve service delivery. Details of the Change Programme are given below.

  5.5  Performance in key areas has improved, particularly in relation to Incapacity Benefit examinations and medical quality standards.

  5.6  The Government believes that an extension to the contract offers the best opportunity to make the service improvements it wishes to see, and Medical Services are on target to deliver the required improvements, and to participate fully in the Department's future programme of work in support of the Government's objective to modernise delivery to customers, and to help people into work.

6.  MEDICAL SERVICES CHANGE PROGRAMME

  6.1  Medical Services have embarked on a Change Programme to improve service delivery. They are working in close co-operation with the Department on a series of projects:

    —  Evidence gathering.

    —  Evidence based medicine.

    —  Viable doctor pool.

    —  "Did Not Attend".

    —  Governance and key performance indicators.

Evidence gathering

  6.2  This project aims to ensure that doctors advising on Incapacity Benefit claims have access to all relevant medical information from the claimant's own GP case notes. A pilot is under way in Rotherham and Sheffield, with GPs and claimants who have given their consent, for Medical Services to access GP case notes and extract the relevant information, instead of asking the GP to provide a written report. The pilot has been well received by the BMA, and also supports the Cabinet Office initiative to reduce the burden of paperwork for GPs.

Evidence based medicine

  6.3  This project aims to secure consistency in conducting medical examinations and selection of appropriate functional descriptors in the Incapacity Benefit Personal Capability Assessment (PCA). It is based on use of fully researched medical protocols for examination, associated with an IT application. Four protocols are being developed, covering musculo-skeletal, cardiovascular, respiratory, and mental health conditions. The outcome will be high quality, consistent reports, based on best medical practice, which will contribute significantly towards consistent and robust decision making. Computer-generated printouts will ensure legibility.

  6.4  A pilot will start in June 2002, with phased roll out to all examination centres over the next two years. Doctors will be in a position to implement training in the best medical practice approach from an early stage of roll out, but time is needed to install the necessary IT in all 200+ examination centres.

Viable doctor pool

  6.5  This is a project to ensure recruitment and retention of the right number of doctors, with the right medical and interpersonal skills, in the right places to deliver the required service levels at a satisfactory quality standard. The selection process looks at the doctor's interpersonal skills, aptitude for the work of disability assessment, and willingness to adapt to the new skills required, as well as their previous clinical experience. More than 40 new offers of employment have been accepted since December 2001, with more than 20 new doctors having already joined the organisation.

  6.6  It is more than a recruitment project: it also develops a career path in disability assessment medicine for employed doctors. It ensures appropriate personal professional development; and that all doctors working for Medical Services will meet the professional standards required for revalidation by the General Medical Council (GMC). The outcome will be a skilled and motivated workforce, which sees a future in disability assessment medicine, thereby enhancing retention of doctors as well as recruitment.

  6.7  Medical Services and the Department have embarked on improved joint forecasting of resource requirement, to enable better planning of the medical workforce required to meet service levels.

  6.8  Sponsorship of the DDAM is part of this project. Medical Services are committed to sponsor a minimum of 20 employed doctors to sit the Diploma this year, and up to 35 doctors in each of the next two years. A comprehensive training plan is being developed for aspiring candidates. The Department is sponsoring sessional doctors who carry out work on its behalf; up to 20 bursaries per year will be available to cover examination fees.

  6.9  Recruitment of sessional doctors also continues, and a number of these have received induction training over the past few months.

"Did Not Attend"

  6.10  This project, having successfully completed its pilot stage, is being rolled out nationally. Its aim is to better manage the appointment scheduling system for examinations, to reduce the number of claimants who are given an appointment but fail to attend. Through a combination of offering claimants greater flexibility and choice of appointment times and dates, and a telephone booking system, the "Did Not Attend" (DNA) rate has been very significantly reduced in the pilot areas.

  6.11  In some areas, the DNA rate was as high as 30 per cent. This meant that, to avoid wasting scarce resources, Medical Services operated a policy of overbooking examination sessions. However, if all claimants called turned up, a proportion would have to be sent home unseen. The project has reduced the DNA rate from around 30 per cent to around 4 per cent in the pilot areas of Derby and Stoke; and there has been similar success since the recent roll out to Bootle. This reduction in DNA rate allows for more accurate scheduling of examination sessions, and in turn, a reduction in the number of claimants sent away unseen on account of overbooking.

  6.12  This initiative has also introduced a mechanism to provide Decision Makers with more comprehensive information in the event of a claimant failing to attend. If a claimant is unable to show "good cause" for failing to attend an examination, the Decision Maker can disallow Incapacity Benefit. The initiative will allow Decision Makers to make more robust disallowance decisions in this circumstance, with the aim of minimising the number of cases which go around the loop.

Governance and key performance indicators

  6.13  This project has looked at management information available to monitor performance against contractual obligations, to reduce gathering and scrutiny of excessive amounts of information while at the same time ensuring that key information regarding performance measures is collected, analysed, and used by both Medical Services and the Department to ensure continual improvement.

  6.14  Governance arrangements have also been reviewed, and a new structure for interface meetings, with more focused terms of reference, has been developed. This will facilitate closer working at all levels within Medical Services and the Department, and joint ownership of performance within the end-to-end Medical Testing process.

27 March 2002

Annex 1

Committee Recommendations: Progress Update March 2002

Sessions 1999-2000

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

Government Reply: (Cm 4780) Published: June 2000

 (a)   Time Spent With Claimants

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  All examination forms now show the time of starting and completing the assessment.

  Examination sessions are booked more flexibly, to allow doctors to decide how many claimants to see in a session. If a doctor sees more than his or her average in a session, the reports for that session are automatically monitored.

 (b)   Inaccurate or Distorted Recording of Information

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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 per cent 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.

FURTHER GOVERNMENT ACTION:

  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.

 (c)   Legibility of Reports

RECOMMENDATION:

  We agree [with those who raised the matter in their evidence] that illegible reports are unacceptable.

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  Electronic completion of IB report forms is being piloted as part of the Evidence Based Medicine project, with full roll out to all examination centres expected to have taken place by March 2004. Doctors whose hand-written reports remain illegible are asked to provide typed transcripts.

 (d)   Training in Customer Care

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  As well as providing training in customer care as part of all benefit-specific training, Medical Services have developed a specific module addressing customer care.

  Evaluation of training has been developed and refined to incorporate objective and measurable outcomes.

 (e)   Dealing with Poor Performance

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  Medical Services have provided training for all staff responsible for handling complaints. The Medical Skills Database has been enhanced to incorporate information relating to complaints about individual doctors. Remedial action is now automatically triggered whenever a pre-determined level of complaint activity is reached.

 (f)   Treatment of Claimants: Overall Conclusion

RECOMMENDATION:

  We recommend that Medical Services and the Benefits Agency take urgent steps to achieve better treatment of claimants: present performance is not acceptable.

GOVERNMENT RESPONSE:

  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 per cent; and within one year to reduce the proportion of "C grade" reports across all benefits to less than 5 per cent;

    —  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 per cent;

    —  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 per cent.

  We expect Medical Services to deliver these targets. If not, further action will be taken.

FURTHER GOVERNMENT ACTION:

  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 to provide clear information to claimants at all stages of the claim process.

  All the Government targets have been met.

 (g)

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

 (h)

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  Training has 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 have been developed with Medical Services for the thorough evaluation of the training demand in this regard.

  The Department is also evaluating mechanisms for assessing IB review claims involving mental health problems in a way which minimises the need for further medical examination.

 (i)   Claimants from Ethnic Minority Groups: Interpretation Services

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  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" has been 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.

  A multilingual notice advising claimants of the availability of an interpreter is sent with all appointment letters.

 (j)   Claimants from Ethnic Minority Groups: Cultural Insensitivity

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  Complaints alleging cultural insensitivity are being identified and monitored as a distinct category.

 (k)

RECOMMENDATION:

  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.   

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  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.

 (l)

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  All doctors receive training in multicultural awareness as part of their induction training.

 (m)   Female Claimants

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  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" has been incorporated into documents accompanying appointment letters; and will be included in all relevant claim forms at the earliest opportunity.

 (n)   Complaints

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  Medical Services have developed a detailed action plan which addresses all issues relating to complaints. The plan ensures 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 has been put in place to investigate any dissatisfaction with the way a complaint has been handled.

  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. Performance 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

 (o)   Customer Satisfaction Surveys

RECOMMENDATION:

  We recommend that a proportion of customer surveys be conducted with claimants after they have seen the EMPs' reports.

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  The pilot survey showed no significant difference in the levels of customer satisfaction. However the numbers involved were small. The Department and Medical Services continue to develop and refine research into customer satisfaction levels.

 (p)   Complaints and Customer Satisfaction: Overall Conclusion

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

 (q)   Appeals

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  A programme of regular meetings has been implemented.

 (r)   Appeals: EMPs' Access to Other Medical Evidence

  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.

GOVERNMENT RESPONSE:

  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

FURTHER GOVERNMENT ACTION:

  All requests for EMP assessment are accompanied by a proforma providing brief details of the claimant's condition and any specific points which the EMP is required to address.

  Further work on evidence gathering in DLA and AA is being undertaken in conjunction with the DLA/AA Modernisation Programme.

 (s)   Appeals: Use of Feedback

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  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 informal feedback from the Appeals Service is taking place.

 (t)

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  The Appeals Service has formally been providing feedback to an agreed protocol since the summer of 2001.

 (u)   Sessional Doctors Sitting on Tribunals

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.

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  Response to this issue by The Lord Chancellor's Department is awaiting the outcome of a judicial review.

 (v)   Cases Determined by Scrutiny and by Examination

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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 GOVERNMENT ACTION:

  Further audit of advice given at scrutiny confirmed a need for clarification of the scrutiny guidelines, and also highlighted issues relating to the quality of medical evidence available to the scrutiny doctor.

  Clarified scrutiny guidelines were implemented in November 2000, and a series of seminars for scrutiny doctors was held in the spring of 2001. Joint audit by the Department and medical Services in 2001 showed 97 per cent compliance with the guidelines.

  The issue of appropriate medical evidence is being addressed through the Evidence Gathering project.

 (w)

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  The contract has been renegotiated to pay separate rates for cases cleared at scrutiny and examination.

 (x)   Pressure to see more Claimants

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.  

 (v)

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  This is being monitored through the Quality Audit process. Doctors are now offered greater flexibility in the duration of sessions and the number of claimants they wish to see. Any increase in the number of claimants seen, above the average rate for the individual doctor, automatically triggers quality audit.

 (z)   Financial Pressures: Conclusions

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  The Department has set up a Programme Board to negotiate relevant amendments to the contract.

 (aa)   Doctors' Pay

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  Medical Services awarded a 3 per cent fee rise in September 2000, with a further 15 per cent rise in April 2001. They continue to hold dialogue with the BMA.

 (bb)   Responsibility for the Service

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

 (cc)   Training

RECOMMENDATION:

  As a minimum, we recommend that Medical Services meet their contractual obligations to provide five days training to all doctors annually. We deplore the fact that Sema has failed to meet this contractual obligation to date.

GOVERNMENT RESPONSE:

  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 musculo-skeletal 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.

FURTHER GOVERNMENT ACTION:

  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.

  Doctors who fail to undergo the required training have their approval to carry out the work revoked by the Chief Medical Adviser.

 (dd)   Diploma in Disability Analysis Medicine

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  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.

  Medical Services are actively sponsoring the Diploma for employed doctors, by paying tuition and examination fees, and by provision of in-house training and support; and financial recognition for those doctors who achieve the Diploma.

  The Department offers sponsorship to sessional doctors through bursaries to cover examination fees.

 (ee)   Performance Since Contractorisation

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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 per cent of reports requiring rework. To date the overall levels of rework have been consistently below 1 per cent. 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.

FURTHER GOVERNMENT ACTION:

  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.

 (ff)  

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

 (gg)

RECOMMENDATION:

  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.

GOVERNMENT RESPONSE:

  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.

FURTHER GOVERNMENT ACTION:

  There have been overall improvements in Sema's performance. Factors which robustly and objectively measure medical quality have been developed and validated, and are now being applied.




 
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