Select Committee on Work and Pensions Minutes of Evidence


Examination of Witnesses (Questions 100-119)

MR MARK FISHER, DR MANSEL AYLWARD, MR PAUL KEEN, MR JOHN SUMNER, MR SIMON CHIPPERFIELD AND DR CAROL HUDSON

WEDNESDAY 17 APRIL 2002

  100. Are you confident that that has got better? The Social Security Committee in its original Report found in fact that most of the complaints were about the attitude of the doctors and their offhand nature. Indeed, I had a constituent—we must have all had them—at my surgery on Friday who had qualified for Incapacity Benefit, had an injury at work, her workplace had accepted full responsibility for her injury. She had applied for DLA, both care and the mobility element, and her doctors had taken three years to diagnose what was wrong with her and yet after a cursory glance she got the feeling that this medical examiner felt that she was trying to pull the wool over their eyes. She really did feel that she had not been treated with courtesy nor indeed had her medical condition and what she could do, her level of disability, been taken into account. Now she did not make a complaint, she came to me instead, and I think that is possibly what happens often—that people think about it afterwards. Obviously those kinds of things are still going on.
  (Dr Hudson) Yes. I think the statement that you have just made is our loss because we cannot do anything about that. You asked me am I convinced that things have improved in the last two years, the answer is an unequivocal yes. If you were to ask me are they as good as they can get, the answer would be an unequivocal no because we are still in an improvement process and always will be, I believe, given the nature of the disability assessment and given the nature of the training of doctors and what we need to do to get to the sort of state of excellence that I want to get to.

  101. My question then is how do you know because the Social Security Committee was not confident that the system of customer surveys accurately captured claimants' perceptions of the service. The National Audit Office was very critical of the system for sampling customer satisfaction and they recommended that both the Department and at the time Sema should be looking to adopt generally accepted market research industry standards. What has been done to follow up the National Audit Office's recommendations?
  (Mr Chipperfield) We have changed our customer surveys.

  102. You have done.
  (Mr Chipperfield) In the last year, 12 to 18 months. We took advice from national opinion polls in reconstructing how we go about the customer surveys. We survey around 30,000 people a year and we have made the surveys more relevant. They can always be improved further and Dr Aylward was saying earlier that we are engaged in a joint process at this very moment in taking the next step in customer survey which will be piloted towards the end of this year and that will involve an independent organisation doing the surveys. We have already made some improvements.

  103. It was also recommended that the Department should periodically exercise its right to validate these surveys and ensure that they provide a representative picture. Has the Department done this?
  (Dr Aylward) Yes. The Department has looked at the results of the surveys and the surveys which have been done by SchlumbergerSema.

  104. Are you satisfied with what you have heard this morning that, in fact, they have improved?
  (Dr Aylward) Yes, indeed. Although it may not be considered a major percentage change, although the number of complaints remains around the same and the number of complaints is not a very good measure of decisive action, I appreciate, but within the number of complaints there has been I think quite a shift in the complaints against doctor's manner, attitude and behaviour. It was 35 per cent plus, it has now dropped to 30 per cent and falling. I think that is a significant move.

  105. My next set of questions is about the overbooking of claimants for medical examinations. That was one of the big complaints, that in order to fill the gaps because lots of people were not keeping their appointments there was overbooking and as a result if everybody did keep an appointment some people were turning up for a pre-booked appointment and were not being seen. Can you tell us what progress there has been in reducing the number of people turned away unseen from examination centres?
  (Mr Chipperfield) Over the last 12 months we have moved from a trend of around four to four and a half per cent of people being turned away, these are people coming to an examination centre, and currently it is around 2.6 per cent. This is not always as a result of overbooking, let us be clear on that. There are people turned away who are not fit to be examined, there are people turned away because they turn up more than half an hour late for their appointment, it is not just because of overbooking. The biggest issue for us in this is the variability and the unpredictability of people turning up. Ultimately the only way that we will substantially improve again on customers being turned away unseen is through doing something about the predictability of people actually turning up. What we have done is we entered into a project in October last year, it is called the DNA Project, do not attend. We have been running that as a pilot in the Derby and Stoke areas throughout the latter end of last year and into the first quarter of this year. It is a new way of scheduling. It is essentially teleprogramming but it is much more than just teleprogramming. What it has proved is that we are able to manage the DNA rate down from a fluctuating 20 to 40 per cent to a more consistent fall to 10 per cent. That means that we can schedule more effectively, it means we do not have to call so many people for examination and it means we are able to give many more people examinations at a date and time which suit them. What we have done is we have now rolled that out into three other areas just to test that the pilot has proven successful. We have been doing it in Bootle, Euston and Acton. Initial results from that roll-out show a substantial improvement on the attendance rate. We are now into a full scale implementation of that new scheduling approach which will be complete by the end of June. Ultimately what it will result in is lower waiting times and less people turned away. That is how we will further improve on the improvements we have already made.

  106. By the end of June that will go national?
  (Mr Chipperfield) It will have gone national, yes.

Andrew Selous

  107. Can I return very briefly to complaints and doctor's manner, just for the record. The briefing we have in front of us says the figures from SchlumbergerSema for the last quarter show that 63 per cent of complaints did actually relate to doctor's manner. I would like to raise that because the figures that Dr Aylward gave were a little different, perhaps they were taken over the year, I do not know if there has been a big jump in the last quarter.
  (Dr Aylward) Page 27 of SchlumbergerSema . . .

  108. As time is tight could I ask you to write a note to the Committee because the briefing note that we have does not quite square with that and perhaps we can tie the two up later. The next area I want to move to is the assessment of people with mental health problems. We know from the Social Security Committee's Report that this is not an easy area to deal with and I understand that you are putting more people with specialist knowledge into this area. Perhaps you could tell us what progress is being made with that? Am I right in saying that you do not in fact employ or use the services of any psychiatrists at all?
  (Dr Hudson) Not specifically to carry out Incapacity Benefit examinations. We will have people who have psychiatric qualifications who are working as a general part of the doctor pool but in terms of the Incapacity Benefit examination the doctors are trained as disability analysts and the training for the mental health assessment for Incapacity Benefit is part of what they do. I know Dr Aylward would have a view on the inclusion of specialists into the mental health process as a whole.

  109. Do you want to comment further on that, Dr Aylward?
  (Dr Aylward) Yes. What has been done in developing training for disability analysts, doctors who are conducting Incapacity Benefit examinations, is we have ensured that we have drawn upon expert advice from the Royal College of Psychiatrists to ensure that the training does deliver a pattern of handling the examination of the person with mental health problems to ensure that the effects of those health problems are picked up. Disability analysts are not truly concerned with the intricacies of diagnosis, it is more important for them to understand the limitations, the difficulties that a person with mental health problems has in the situation as described in the All Work Test where one looks at the person's day-to-day activities and how their mental health problem could affect them in the workplace, how it could affect them in their relationships with other people. We have ensured that a major expert resource has been brought in to advise on the training, to contribute to it and evaluate it.

  110. Were the Royal College of Psychiatrists happy that the medical personnel were being given appropriate training and advice in that area rather than psychiatrists themselves being employed? That was the advice the Royal College gave you, was it?
  (Dr Aylward) Yes, because the Royal College themselves have endorsed the introduction of the new Diploma in Disability Assessment Medicine which brings in a new discipline in medicine whereby the assessment of disability is the important issue. Whether or not that was undertaken by a psychiatrist, a general physician or a rheumatologist, the basic principles are best delivered by someone specialising in that area. The Royal College of Psychiatrists are quite happy with the development of this new discipline and the fact that a person does not have to be a qualified psychiatrist to enable them to assess the effects of mental health problems.

Mrs Humble

  111. One of the issues that was raised with us in our last report with regard to mental health was that the examination system is seen as a snapshot of that person's capability on that particular day and for many people who suffer from mental health problems their capability can vary depending upon how they are responding to medication, whether they are going through a particularly difficult time within the spectrum of their mental health problem. Do you feel that the new advice being given to doctors enables them to deal with that situation so people are not being disadvantaged because they are being seen by the doctor on a "good" day and, in fact, the day after their health could be dramatically different and, therefore, their capability to undertake employment equally could be dramatically different?
  (Dr Aylward) I do. Perhaps amongst all medical conditions mental health problems are notoriously variable and subject to remission and fluctuation. The doctors are after all medically qualified people and they should be aware of that anyway. In order to ensure that they are aware of that and to counter that understandable accusation of a snapshot examination we make sure that doctors look at the broad spectrum of a person's activities, look at the past, look at what might be happening in the future, look at the issues that are relevant today but how were they yesterday, how were they in the past few months. Yes, we do make a particular effort to ensure that all training is delivered in mental health and indeed in other conditions which are fluctuating for the doctor to give his opinion based upon not only what he sees today but the whole panorama of the picture.

  112. Will he have enough time? Going back to the questions that I addressed earlier to Dr Hudson, it was raised in our last report that given that complexity, given the need to examine in much more detail the past, the present and the future, does the doctor have enough time to undertake that assessment in the new fee paying system of sessional pay?
  (Mr Chipperfield) It is their decision. It is the doctor's decision. We do not decide how long the doctor spends with that individual person, they decide.

Miss Begg

  113. Can I continue on the area of mental health. When I visit agencies working in the area of mental health in my constituency and user groups I get the same story all the time and it is they have this perception that it is very difficult for them to claim DLA, that on the first claim if it is mental health problems they are automatically turned down and they always have to go to appeal. The complaint is that if you have got mental health problems it is a double anxiety, it is even worse than somebody who has a physical disability because the process of having to go through the claim, the process of having to go through the appeal, impacts on their mental well-being and is such a traumatic thing that in some cases it is not worth them even attempting to do it. It is not just one agency which has said that, I have heard that complaint consistently. What is your comment about that perception?
  (Mr Sumner) As has been previously said, certainly the mental health cases claiming DLA are a difficult area. As far as we are concerned, we have appointed a specialist in disability as a trainer within the Disability and Carer Service. She has been training all of our Decision Makers and one of the first areas that she is concentrating on is people with mental health difficulties. Effectively all our Decision Makers are in the process of receiving—we are about three-quarters of the way through that—foundation training which includes information on how to deal with claims from people with mental health problems. Obviously in the actual process of claim the individual has the opportunity to set out on the claim form their concerns and what they can and cannot do and they have the opportunity also to get people to help them with that, as many of them do. The Decision Maker then has a choice about whether there is sufficient evidence in the claim form to enable them to come immediately to decision or whether they need to take additional advice which may be from the general practitioner, it may be from a consultant psychiatrist if one is named on the form, it may be by sending an examining medical practitioner. There are a variety of areas of evidence they may choose to use or it may be a social worker or somebody, a lay person helping the claimant.

  114. Do you keep statistics about each individual Decision Maker so you can keep a track on this particular Decision Maker to see if they have a habit of turning down DLA claims by mental health customers?
  (Mr Sumner) We do not have that level of analysis. What we do is we have introduced recently a new checking regime for DLA decisions which actually will over time, when we build up the statistical evidence, give us at business unit level good information about how people are performing.

  115. How recent was that?
  (Mr Sumner) We started to introduce that last October.

  116. It is just because, again in Aberdeen, the mental health patients were convinced that the new Decision Maker—In previous years clients had managed to get the DLA and suddenly nobody was getting it. I did try at the time—which was probably about 18 months ago—to see if there was anything in their allegations. These are serious allegations. They are serious for me and as a local MP I want to find out whether people in Aberdeen are discriminated against but it is also serious for you.
  (Mr Sumner) Absolutely.

  117. If they are making these allegations, you need to know if there is any truth in it.
  (Mr Sumner) Consistency of decision making is an area that we are trying to put quite a lot of emphasis on. We have recently, with the benefit of our new IT, introduced an intranet system which will enable Decision Makers to have access to the guidance on line rather than having to go to volumes of codes, so that means that each individual Decision Maker now will have a PC where they can click on an icon and get hold of the Disability Handbook or Decision Maker's Guide which makes it an immediate and up-to-date and accessible form of guidance for them.

  118. Are you convinced that you have the mechanisms to pick up these variations of Decision Makers to make sure there is the consistency?
  (Mr Sumner) I believe that we do. In addition to this new checking procedure which has been introduced, we have also, over the last 12 months, reduced the spans of control for our managers within the service which gives the managers more time to look at how their teams are performing.

  119. In two years' time if you come back to us and I ask the question that I tried to get information about eight months ago you will be able to prove that the Decision Makers have not been inconsistent and any of these kinds of allegations which have been made you will have the proof to discount them?
  (Mr Sumner) I would like to be able to say that, I think more realistically I shall have more evidence to be able to tell you how we are performing.


 
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