32. The main way by which the Department obtained
feedback on the quality of SEMA's services was through monthly
reports on the results of customer satisfaction surveys. These
surveys suggested that between 75 per cent and 85 per cent of
customers were generally satisfied with the service provided and
that most were content with the conduct of examinations, although
complaints were rising. However, the Comptroller and Auditor General
highlighted three areas of particular concern:
- Incapacity Benefit customers being turned away
from scheduled examinations;
- doctors' attitudes and the conduct of examinations;
- how the service handles the different needs of
women and ethnic minorities.
33. Before outsourcing, 20 per cent of Incapacity
Benefit customers invited to attend examinations could not make
the date specified and a further 20 per cent failed to turn up.
The Department made some late substitutions, which reduced the
net dropout to 35 per cent. However, they hoped that outsourcing
would help to address this waste of resources.
34. Because payment is made for each completed examination,
SEMA had a strong incentive to ensure that as many customers as
possible attended and that their staff were fully employed on
productive work. Since outsourcing, the number of customers who
fail to attend has not reduced. To allow for this, the in-house
service practised over-booking, something which had been continued
by SEMA. However, as the number who attend any one session is
volatile, overbooking has meant that large number of customers
have been turned away unseen. On average around 3 per cent of
customersover 17,000 in any one yearwere turned
away unseen, with the North and South East contract areas turning
away a higher proportion. While overbooking was the main cause
of cancellations, other reasons included doctors taking longer
to complete examinations, customers unwilling to wait longer than
the expected time of 30 minutes and doctors cancelling sessions
at short notice.
35. SEMA told our predecessor Committee that they
shared these concerns about people being turned away unseen. SEMA
pointed out that overbooking was only one factor. A number of
people who turned up were not in a good state to be examined,
for example because they were drunk or under the influence of
drugs. One approach they had successfully piloted in Leeds was
to pay doctors on a fee per case basis, rather than a set period
of time, to encourage them to see all those patients who turn
up. They were also trying to bring greater flexibility into the
timing of sessions, had introduced new scheduling arrangements
and had made a significant investment in the development of information
technology to assist the scheduling process.
36. Where customers failed to appear for their scheduled
examination for Incapacity Benefit, there was a risk that benefit
might continue to be paid even though their circumstances had
changed. To address this, the Benefits Agency took non-attendance
into account in decisions on whether to continue to pay benefit.
The disallowance rate for failure to attend without good cause
was 38 per cent following a first failure, 37 per cent after a
second failure and 70 per cent following a third failure. In the
quarter ended 31 August 2000, 10,000 people had had their benefit
stopped as a result of either not sending a form back or of failing
to attend an examination without good cause.
37. Where customers are turned away unseen, the Department
pay the extra travel expenses but do not provide them with compensation.
They argued that they could not consider this without taking account
of what was happening in other public services, such as the NHS.
Instead, they wanted to incentivise SEMA to minimise the number
of people who were turned away, and they had set a target to reduce
this to 3 per cent in each of the three contract areas. This would
not guarantee that everyone would be seen, but would reduce the
number turned away.
38. Before outsourcing, 64 per cent of complaints
by customers about medical assessments concerned the medical examination,
including the doctor's manner (41 per cent) and the content of
examinations (17 per cent). After outsourcing, 57 per cent of
complaints were about these issues.
Our predecessor Committee also highlighted concerns from their
constituents about the nature and content of examinations, and
about doctors' attitudes.
39. The Department had redesigned their customer
satisfaction survey, and this had shown consistent satisfaction
rates of 92-93 per cent in the latter part of 2000. Complaints
were a fraction of one per cent of customers, but the Department
recognised that there could be a number of people who were seriously
aggrieved because they had been denied benefit as a result of
an examination. Following the hearing of the Social Security Select
Committee in 2000 the Department had put in place a new set of
complaints processes. Complaints were now handled by complaints
managers. Within SEMA, 86 staff had been trained to deal with
complaints. They had strengthened their links with Citizens Advice
Bureaux to ensure that they understood the nature of the problems
perceived by customers. And they were updating their information
and producing a new pamphlet on complaints.
40. Many complaints about the nature of the examination,
and the limited time it took, reflected confusion on the part
of customers about its purpose. The examination was not what the
customer expected. For example, the examination for Disability
Living Allowance was not diagnostic; it was to assess how the
person's disability impacted on their ability to care for themselves
or on their mobility. An assessment for Disability Living Allowance
could be made on the basis of quite a short examination. A particular
diagnosis might have a whole range of effects upon function. The
Department had defined the nature of the examination and SEMA
doctors were required to explain this to customers. SEMA had produced
better-targeted information for claimants outlining the processes
involved in making a claim and what to expect in examinations
by doctors, and were in the process of reissuing training to ensure
that doctors understand the situation from the customer's point
of view and could deal with sensitive situations.
41. The Comptroller and Auditor General noted that
under the contract, SEMA were required to "comply with any
reasonable requests to accommodate claimants who have special
needs". Provision for special needs might include, for example,
a female examining doctor where a customer so requests, or interpretation
facilities for customers whose first language is not English.
42. Interest groups who advise benefit customers
had raised with the Department concerns about what they saw as
poor customer service to ethnic minority groups; specifically
the failure to provide interpreters and female doctors, and general
cultural insensitivity. The number of actual complaints about
racial or gender discrimination or cultural insensitivity in the
treatment of customers identified was small, but interest groups
pointed out that some customers might be dissuaded from complaining.
43. Shortages of female doctors among SEMA's workforce,
especially in some inner city areas, meant that they could not
always provide a female doctor when a customer requested one.
Of 216 full-time doctors, one third were female, as were around
one sixth of the 3,000 fee-paid doctors who carried out most of
44. SEMA were seeking to improve their response where
the customer wished to be examined by a same-sex doctor, but were
constrained by the gender spread of doctors and were not in a
position to offer everything to everybody. The Department had
developed a standard statement covering, for example, interpreters
and same-gender doctors, which was being incorporated in all their
forms. Further, SEMA's new training modules included one on multicultural
awareness. SEMA told our predecessor Committee that doctors did
not routinely take chaperones with them for home visits. They
made every effort to inform people who were to be examined by
a doctor that if they wished to have a friend or carer with them
then that would be very welcome. If complaints arose about examinations
by someone of the opposite sex, they were taken very seriously.
45. While the Department required SEMA to meet certain
standards of customer service, they had limited leverage through
the contract to raise standards, as payments were not linked with
SEMA's achievements. This was because the Department had been
unable to define service quality to contractually definable standards.
Since then, and in response to recommendations by the Comptroller
and Auditor General, the Department had negotiated with SEMA,
and subsequently with SchlumbergerSema, a number of conditions
and improvements to the contract. These included new targets for
handling complaints, waiting times for customers, for the provision
of interpreters and same-gender doctors, and ensuring that fewer
customers are turned away without examination.
46. Because the Department pay for each completed
examination, there is a financial incentive for the contractor
to overbook appointments for medical examinations. This allows
them to cope with a high and unpredictable dropout rate and uncertainty
over the number of attendees, and ensure that they make maximum
use of their doctors. But as a result, on average around 3 per
cent of customers (over 17,000 a year) have been turned away unseen,
even though they have scheduled appointments.
47. While some customers are not seen for valid reasons,
the Department should consider whether SchlumbergerSema should
pay compensation if they turn people away because of deliberately
overbooked appointments or for examinations that are proved to
be inferior to what is considered to be acceptable.
48. Although the contract with SEMA required them
to comply with reasonable requests to accommodate claimants who
have special needs, they have been unable to guarantee same-gender
doctors for medical examinations or the availability of interpreters.
New targets are now included in the contract, and we look to the
Department and SchlumbergerSema to ensure that they provide responsive
services to all their customers. The wider use of other healthcare
practitioners in examinations may be one way of overcoming a shortage
of female doctors in some areas.
49. Customer satisfaction ratings on the medical
assessment services are around 92-93 per cent. But there remain
a number of peoplearound 5,000 a yearwho are dissatisfied
by the nature of the medical examinations they undergo. We welcome
the action the Department and SchlumbergerSema are taking
to improve information to customers on the examination, to improve
doctor training, and to work with the Citizen's Advice Bureaux
and other groups to improve their understanding of customers'
50. A major weakness in the contract with SEMA was
the absence of any real incentives to get the quality of service
needed. Although targets for improvement in quality have
now been introduced into the contract, there is a general lesson
here for those outsourcing services where quality is a key factor.