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A. Korzybski, livres et traductions Sémantique Générale et physique quantique Sémantique générale et sciences humaines |
Documentation sur Atos Origin (1) Annexe 1 Examination of Witnesses (Questions 1-19) Wednesday 10 December 2003 Mr David Anderson, Professor Mansel Aylward CB, Mr John Sumner, and Mr Simon Chipperfield, examined. Q1 Chairman: Good afternoon, welcome to the Committee of Public Accounts. Today we are looking at the Comptroller and Auditor General's Report on Progress in improving the medical assessment of incapacity and disability benefits. We welcome David Anderson, who is the Chief Executive of Jobcentre Plus, Professor Mansel Aylward, who is Chief Medical Officer for the Department for Work and Pensions, Mr John Sumner, who is Director for Disability and Carers Service and Simon Chipperfield is Managing Director of Medical Services at SchlumbergerSema. The average waiting time has been reduced, the backlog dealt with and up to £50 million has been saved. The recommendations of this Committee appear to have been taken note of. Gentlemen, thank you very much, but do not go away yet. Could you please look at page 13, paragraphs 2.2 to 2.3? We see in those two paragraphs, which I suppose really are some of the key paragraphs in this hearing, that you managed to speed up these medical examinations and the time taken for them to be heard. How much more can you speed up this process without jeopardising quality and accuracy? Mr Anderson: That is obviously the pivotal question because we are always trying to balance value for money and quality and timeliness for the customer and those three things sometimes work in tension. The targets for improvement which we set ourselves have been pretty much met. There is some marginal improvement left to gain in some areas, but probably across the board there is not a huge step forward which can be made. Q2 Chairman: I might come back to that because it would be interesting if we could reduce the waiting time even further. Can you now look at pages 21 and 22 and paragraphs 3.2 to 3.3? You will see there that you have managed to improve the quality of medical evidence for decision-makers. Why has it not reduced the number of appeals which are successful? Mr Anderson: There are several reasons for that. First of all, it is not the case that appeals always arise because medical evidence was incorrect; in fact the proportion of cases where medical evidence was incorrect giving rise to appeals is relatively small. It is much more the case that new evidence comes out later and that the appeal is seeing a different set of facts from that seen by the original decision-makers. We would recognise that we have some room left to improve in the area of taking experience from appeals and feeding it back into the decision-making process and we are working on some ways of doing that at the moment. I still think there is more we could achieve in that area. Q3 Chairman: Could you turn over the page now and look at paragraph 3.5? I was surprised to see that it says here "Our fieldwork indicates that decision-makers and individual doctors receive no notification and are not aware of how many customers with whom they had contact challenge their medical evidence". Why is there not better feedback? I would have thought this was a key point. After all, if you do not have feedback about how you do your job, how can you ever improve? Mr Anderson: That is correct. Where medical reports are deemed unfit for purpose or are given a C grade, there is feedback to the doctors concerned and there is a close monitoring process of remedial action for those doctors if there is a high frequency of poor graded reports. What there is not, is a good process for getting every decision back to the original doctor and I do not think that would always be possible. Q4 Chairman: But you are going to try to improve the information they get back. Mr Anderson: Yes. Q6 Chairman: May I refer you now to page 30? I want you to comment on non-attendance. In particular look at paragraphs 4.10 to 4.11. I was quite surprised when I read this "Some 20 to 25% of customers fail to attend Incapacity Benefit (IB) examinations, and one office told us that they overbook by 21% to allow for non-attenders". There are two problems with this, are there not? First of all you are slotting in many more people than you are intending to see, so presumably on occasions some people do not get seen at all and have to go home. Also, I suspect you have some people who are deliberately not turning up. What happens at the moment? Explain the system to the Committee. You go to see your doctor, you say you cannot work, the doctor gives you a chit and you immediately get your Incapacity Benefit. You then have to wait an average of roughly a month, is that correct, for your proper medical? Mr Anderson: It could be longer than a month. Q7 Chairman: It could be longer, but on average 30 days, one month. You receive your Incapacity Benefit. Is there not a problem with some people deliberately knowing how the system works simply not turning up? They go on receiving their Incapacity Benefit if they do not turn up. What happens then? What are you going to do about them? Mr Anderson: The non-attendance results in the requirement for justifiable cause to be given. If that is followed by subsequent non-attendance a telephone call is made and if the answer is not satisfactory, then benefits will be stopped. There is a return to the decision-maker having had two non-attendances with justifiable cause. Obviously there is an earlier process if there is no justifiable cause, but we can probably anticipate that those you describe who wish to take advantage of the system probably know well enough to have a reasonable explanation. Q8 Chairman: I congratulated you earlier because you seem to have acted on several recommendations in our earlier report and you have reduced the average waiting time for your proper medical assessment from 52 to 30 days on average and we the taxpayers have saved £21 million doing it. How much could we save if we reduced the waiting time even further, say to two weeks? That raises a further point, that if you reduced it to two weeks, it might be possible not to have to pay the Incapacity Benefit in the meantime because it would only be a two-week period between seeing the doctor for the first time and getting a proper medical examination. We could be talking about saving further large sums of public money, could we not? Mr Anderson: There are two things there. The times you described, the reduction in waiting time, are for Disability Living Allowance (DLA) and in those cases we do not pay the benefit until after the medical, so that is slightly different. Taking your point, the saving arises from preventing Incapacity Benefit customers staying on benefit longer than they would. The problem with very early medical assessment is that we would be assessing a significantly larger number of people whose claims only last for a relatively short space of time. This benefit is payable, for example, to self-employed people pretty much as soon as they become too ill to work and a large number of them would only claim the benefit for a short period of time and then return to work. The period which is left before the medical assessment is designed in fact so that most people who are on short-term claims will not get into this system. Q9 Chairman: Mr Chipperfield, would you like to comment on that? How much further can you reduce the time taken to carry out these medical examinations, do you think? Mr Chipperfield: You have rightly observed that we have reduced to 30 days from 52 days. As part of the Pathways to Work pilots we are actually trying out a 15-day target. Q10 Chairman: So you are looking now at a further reduction. Mr Chipperfield: We are doing that and we are doing that in the three current pilot areas, which are Bridgend, Renfrewshire and Derbyshire. That is part of the Pathways to Work initiative, which is a wider policy initiative about assisting people to return to work more quickly. Q13 Mr Steinberg: This is certainly a huge improvement in the way things are going, certainly from the last time we looked at this particular subject. I can remember that I was very, very critical last time, because I had had some horrendous constituency cases. However, there are always concerns in any report and it is our job to look at those concerns as well as congratulating you on doing a good job. Reading the Report and from personal experience as well still, as far as I can see, the Personal Capability Assessment (PCA) is throwing up a large number of incorrect benefit withdrawals. There have been many, many examples over the last year, particularly to the Citizens' Advice Bureaux (CAB). The CAB in my area has contacted me about it. Most cases seem to arise because the examining medical practitioners—and I have to say I have always had my doubts about them in the past and perhaps been very critical of them—employed by Schlumberger do not provide very good advice on the Personal Capability Assessment score in particular and that makes it very difficult for the DWP decision-makers. Are these doctors just going through the motions sometimes rather than actually being serious about it? I sometimes think they are. Once I have heard your answer I am going to come back. Q14 Mr Steinberg: Do you actually believe that some of these doctors are genuinely concerned about the actual people they are assessing? Or do you think they just treat them as a lump of meat and do not have a lot of compassion for them? Mr Anderson: I have no evidence at all to suggest that people are treated as a lump of meat. The customer satisfaction numbers from medical assessments are very strong. Q15 Mr Steinberg: I had a case only last Saturday morning in my surgery where a lady came along on behalf of her sister. She did not want me to take it any further, but she came along to express her dismay at the way the Attendance Allowance had been handled. She said that the doctor had actually said that he hated filling in forms. She was complaining about what had actually been said on the form: on the basis of what was put on the form the woman lost the Attendance Allowance. This is not the first instance I have heard of things like that. I have been very critical of doctors in this Committee on many, many issues. They do not seem to like doing anything which means extra work unless they are very well paid. Do you want to make any comment? The doctors are paramount, are they not? Mr Chipperfield: Yes, doctors are paramount to this service. Our doctors are experts in the field of disability analysis. They are all trained and specifically trained to do the work we ask them to do and they are continually trained to do so. That is not just about the medicine, it is also about the attitude towards the customer and the understanding of the overall policy and the benefit which they are there to support. We would thoroughly investigate any anecdotal incident which is reported to us with the doctor concerned. If we found there was any substance in it, we would take some action about it and we do so. Q16 Mr Steinberg: Turn to paragraph 3.3 on page 22 and read the second half of that paragraph, "In about a third of cases, tribunals considered the medical report had underestimated the severity of the disability" and it goes on. That seems to be backing up my argument rather than yours. How many is it? At least 51% of cases were overturned, as I read that. That to me does not seem as though they are doing their job very well in the first instance and seems to back my argument that they are not really all that bothered, are they, as long as they are getting their fee? Mr Chipperfield: I would disagree with you. Q17 Mr Steinberg: Why are the figures so high then? Mr Chipperfield: I do not think I am the best person to comment on what the appeals tribunals decide and the basis upon which they decide that. Q18 Mr Steinberg: They are your doctors though, are they not? Mr Chipperfield: Not doing the appeals. Our doctors are doing the examinations. Q19 Mr Steinberg: On their evidence. I may be wrong, but on their evidence it originally gets turned down and then they go to appeal afterwards. Mr Chipperfield: Yes, that is correct.
Q20 Mr Steinberg: Am I getting mixed up? Mr Chipperfield: The statistic misrepresents the actuality. Q21 Mr Steinberg: Statistics do not misrepresent anything. All we can go by in any report we receive is the information the National Audit Office gives us and I found paragraph 3.3 very worrying, that so many cases are actually refused on the basis of bad medical diagnosis. That seems to substantiate what I have been saying right from the start. Professor Aylward: If you look at the figures, what we are seeing is that in around one third of the cases the report was found to be flawed because it seemed to have underestimated the disability. That is correct. In about one half of those cases, they came from Schlumberger. I have actually looked at those cases myself. I have done a random sample and I do not agree with that finding. Q22 Mr Steinberg: Wait a minute. You do not agree with this finding here. Professor Aylward: I do not. Q23 Mr Steinberg: This Report has been signed off as accurate by your Accounting Officer with the National Audit Office. It is no good coming here and saying you do not agree with the Report, when the natural presumption is that this Report is absolutely accurate and agreed by you. Professor Aylward: I am not disagreeing with the Report which the National Audit Office has produced. I am commenting upon the figures which have been produced by the Appeals Service. It is my job as Chief Medical Advisor to the Department to look at the cases where there is said to be an underestimation of disability. In my professional opinion, using my judgment, and a scientific method, I looked at those in a random way and I found that in half the cases I did not consider the disability was underestimated. May I add one more thing? If you look at the doctors who are making these decisions sitting in the Appeals Service compared with a doctors who are working for Schlumberger Medical Services we should perhaps think that one of the reasons there may be a difference here is that doctors in the Appeals Service do not receive the significant training that Medical Services' doctors do, they do not get monitored to the same extent and they are not participating in revalidation to the same extent. That may be a reason why there is a difference in opinion between the two sets of doctors. Q24 Mr Steinberg: Did you say this to the National Audit Office at the time of the Report? Professor Aylward: Yes. Mr Steinberg: It is not reported anywhere. Q25 Chairman: Could the National Audit Office comment on that? This is a very interesting exchange. Mr Lonsdale: The point which is being made is that the difference of opinion is between the decision which is made by the appeals tribunal, who have commented in 138 and 96 cases, where they think the medical report underestimated the severity of the disability, and Professor Aylward, who is saying is that when he, in his capacity, then looked at that decision made by that tribunal, his judgment was that he did not agree with the appeals tribunal. That is a medical judgment. What we have reported here are the findings of the President of the Appeals Tribunals. This is his view. 51% of cases are from Medical Services and others are from general practitioners, consultants, a combination of sources. It is a difference of opinion, a judgment on the medical evidence which was presented. Mr Burr: Everybody agrees that this is what the President of the appeal tribunals thinks. Not everybody agrees with the President of the appeals tribunals. Q26 Mr Steinberg: I had a plan of what I wanted to ask and now I have been waylaid. Coming on from that, does it not worry you—it certainly worries me—that the Incapacity Benefit is suddenly withdrawn, which could have been a person's income for years and years and years, suddenly it is lost because of some sort of sloppy short medical examination by one of your doctors; they lose their income and end up living on about £40 a week because one of your doctors has made an appalling decision? Does that not worry you, because it would worry me? Mr Chipperfield: Yes, that would worry me. All the efforts we take are to avoid that happening. That is why we are very careful about the doctors we select or recruit, very careful about the training we give to them and the ongoing monitoring and auditing, coaching and mentoring which we provide. That is also why we take action when we find doctors who are not meeting the quality standards. In the last three years, for example, about 420 doctors have been revoked and a goodly proportion of them, at least 25% of them, have been on our own specific action because we did not find them meeting the quality standards. Yes, it would concern me. What I am saying is that we take every action we possibly can and we are not complacent. We are constantly trying to improve to ensure that does not happen. Q27 Mr Steinberg: Bearing in mind the argument I have put forward, would it not be a better system, if somebody is taken off Incapacity Benefit, for them to continue to receive it until the appeal has been heard? Would that not be a fairer system? Mr Anderson: I am not entirely sure in the way regulations are written that would be possible. I cannot answer that question. It may be a fairer system in those cases where appeals are successful; clearly it would not be fair to the taxpayer in those cases where appeals are not successful. Q28 Mr Steinberg: People can see their incomes reduced to something like £43 per week, can they not? Suddenly after years of receiving Incapacity Benefit, bang, they are down to £43 a week. I could not live on £43 per week; I bet a pound to a penny you could not live on £43 per week, yet that is what they have to live on. Do you think this should be looked into? Mr Anderson: I believe that the system at the moment, where benefits are stopped when a decision-maker makes the decision, is a fair way of going through this process. We have to get those decisions as good as we possibly can, but the system has to be fair both to the people who are legitimate claimers and fair to the taxpayer who does not want to fund people who are not legitimate claimants. The decision-maker has to employ the rules as they are written. Q29 Jon Cruddas: May I refer you to paragraph 3.8 onwards, "The standard of medical reports has improved since 2001"? Could you explain to us the nature of the C grade indicating that a report is below Medical Services' professional standards? How many is that now? Mr Anderson: It is under 5%. Q30 Jon Cruddas: Under 5% and that has been quite a dramatic reduction since April-June 2000. What accounts for that reduction in your mind? Tougher vigilance and scrutiny of the work here and more effective sampling? Has there been a change in behaviour in terms of medical examinations themselves? Mr Anderson: I believe that the improvement is in part a result of a new target which was agreed with Schlumberger and implemented and the effect of some of the actions which Mr Chipperfield has been describing in terms of driving up the quality of the reports. The target is 5%; we have to get under and it is currently at 4%. Q31 Jon Cruddas: It has now gone to under 4% since February 2003. I want a bit of clarity about Figure 11 here on page 22 "Factors contributing to the success of appeals against incapacity and disability benefit decisions". The figures are very high: 42%—"The tribunal formed a different view of the same evidence"; 27%—"The medical report underestimated the severity of the disability"; 24%—"The tribunal formed a different view based on the same medical evidence". Do you at all detect a slight difficulty for you between the number who establish a C grade and the scale of the successful appeals? Does that indicate that there is a possibility that the C grade indication is slightly too low in terms of the effectiveness of the medical examinations themselves? Mr Anderson: That goes back to the discussion we were having before about the difference of view that doctors can take on what is a relatively subjective assessment in this area. I do not think it indicates that the reports themselves were wrong if a tribunal took a different view of the medical evidence. Mr Chipperfield: The populations are different. The 3% or 4% C grade is based on auditing of the entire population which goes through the Personal Capability Assessment process or the Disability Living Allowance assessment process. These are proportions of people who have made an appeal. Q32 Jon Cruddas: There are still 50% of appeals in the system. Mr Chipperfield: Not of all cases, no. Q33 Jon Cruddas: May I ask for clarity there? "The Committee felt that the high proportion of cases where appeals were successful (over 50% appeal . . . " Mr Chipperfield: Of those who have a decision against them. Q34 Jon Cruddas: In terms of the box on page 21, "(over 50% appeal . . .)". Mr Anderson: Where there is a decision against them. Q35 Jon Cruddas: Okay; sorry. On the question of the 22 occasions in the last year where you stopped doctors carrying out examinations, is that higher or lower than preceding years? Mr Anderson: I do not have that number. Professor Aylward: The revocations are carried out by me on behalf of the Secretary of State on the basis of information I receive from Medical Services. Since the year 2000, I have revoked 80 doctors' approval because of unacceptable quality standards, of which 22 were in the year to which the recent NAO Report refers and there have been 52 occasions during the past year when doctors had their approval revoked because of unacceptable quality standards. The remainder of doctors have revocation because of retirement and resignations. Q36 Jon Cruddas: That does not cover those who are registering C grades. Is that the lower C grades? Professor Aylward: No, it may well be that the majority of these people have obtained C grades. That is an indication of poor performance. If one or two C grades are obtained within a period of a few months then these doctors are focused upon for specific monitoring. If they do not respond to remedial training, because we think it fair for that to take place, then a recommendation comes to me to consider whether or not I should revoke. I take that very seriously, because it may affect a doctor's career, it may affect remuneration. Q37 Jon Cruddas: What I was trying to find out was, given the sheer scale of medical examinations and reports which were issued and still we have about 4% or 5% at C grade, but over the last year only 22 individual cases of them stopping to take examinations, so presumably there are many doctors out there who have registered C grades and are still carrying out examinations. Professor Aylward: No, I would not say that was so. Every doctor who registers a C grade is monitored and if their performance cannot be improved, then they are revoked. We are talking about a significant number among the 80 doctors I have mentioned to you during the last three years, 52 in the last 11 months. Q38 Jim Sheridan: May I follow up the theme Mr Steinberg raised about the difference of opinion between doctors? I am just concerned that the doctors who make these medical assessments have the appropriate time to read all the reports closely. Sometimes that can be difficult and quite time consuming. One of my own constituents has been on Incapacity Benefit for a number of years and he was told when he went to be assessed that he was being taken off Incapacity Benefit. This man had advanced mesothelioma which is incurable and can only deteriorate. Not only did they take him off Incapacity Benefit and withdraw the money, they gave him false hope that he was going to be cured. He really was in a rather pathetic position, having no money and being told he was going to be cured, yet his GP had told him consistently that there was no cure. Why does that happen? Professor Aylward: Obviously I do not know the details of the case you are speaking of, but if those are exactly right and the person was suffering from a mesothelioma, which is a highly malignant disease which can rarely be effectively treated and results in a terminal illness, I cannot imagine why that would have taken place. Both within Disability Living Allowance, Attendance Allowance and Incapacity Benefit, there are special rules which take account of people suffering from a condition like that and he would not have to be exposed to an examination. Q39 Jim Sheridan: His money was just stopped at a stroke.
Mr
Anderson: I
cannot explain that. That sounds in that particular case as
though— Mr Anderson: The way the process works at the moment, as I understand it, there is no barrier to anyone appealing and therefore there is a one-way street for everyone who gets a negative decision to appeal straightaway. In a very high number of those appeals, the changes are made because of new evidence and half the appeals, despite that, are still unsuccessful. That therefore suggests that the system would be open to widespread abuse if benefits were continued after the decision-maker had looked at the evidence. Q41 Jim Sheridan: Is that different from any other appeals procedure in terms of benefits? If people are taken off other benefits, whatever they may be, do they retain those benefits until the appeal process? Mr Anderson: I do not believe so. Mr Sumner might be able to answer that question. Mr Sumner: No, that is fairly standard across the benefit system. Once a decision-maker has made a decision adverse to the customer, the benefit ceases. There may be certain limited exceptions, but in the vast majority of cases benefit ceases until an appeal is decided in favour of the customer. Q42 Jim Sheridan: I just think we are in danger of underestimating the anxiety that causes amongst people, not only in telling them they have some hope for the future, but that they do not get any benefit money to live on. I think it is just unacceptable. Mr Chipperfield, you mentioned earlier some of the new pilot systems being introduced and you mentioned my own constituency of Renfrewshire in terms of Pathways to Work and people with disabilities being re-engaged back into the workplace. It has caused a bit of concern, certainly amongst my constituents who felt that perhaps they were being forced back to work against their will and against the best advice of their doctors. I know it is early days, but do you have any evidence that is actually working? Mr Chipperfield: I am not in a position to make any comment about that. It is very early. The pilot started in November and it is a DWP pilot. What we in Medical Services are doing is an additional assessment on top of the Personal Capability Assessment; we are doing what is known as a capability report which looks at those things the individual is capable of doing. It also makes a generalised recommendation as to whether or not that individual may benefit from some form of condition management, some form of rehabilitation to support their condition and therefore prepare them potentially for the workplace. The overall project is not my remit and perhaps one of my colleagues might wish to make a comment. Mr Anderson: It is very early days but the response to the three pilots has been very positive. I saw a report this morning which said that already 50 people had returned to work as a result of the process, who at the time they were approached had not been considering a return to work and therefore from their perspective it had been a very positive experience. Q43 Jim Sheridan: What I am finding is that it certainly gives people back some sort of self-confidence when they go back to work and there is a social aspect there as well. Mr Anderson: Absolutely. Q44 Jim Sheridan: They meet people and that kind of thing. It seems to be working reasonably well. Mr Anderson: It is a very important area. When people go onto Incapacity Benefit, around 80% of them at the time say that they would like to return to work.[1] In practice most of them end up staying on the benefit for five years or more. It is a real mismatch in terms of people's initial hope and what happens to them. We have to try to address that. Pathways is part of that process. Professor Aylward: What is being provided is extra support in addition to the NHS, not replacing the NHS but additional support for people with mental health problems, people with cardio-respiratory problems and people with musco-skeletal problems. This is a distinct step forward. Q45 Jim Sheridan: On the question of people with mental illness problems, sometimes they may find it difficult to go along for a personal capacity medical assessment. They are not all treated with the greatest of understanding and sometimes are penalised for that mental illness. Certainly questions have been asked. We should like to know what extra measures will be put in place by Schlumberger to help these people through this difficult period. Mr Anderson: We do provide extra training for our doctors for these cases and extra help for those customers in the way they are called for examination and the process. Mr Chipperfield: As part of the rollout of evidence based medicine new protocols have been developed for people suffering from some kind of learning difficulty or mental health problem. All of our doctors have been trained in the new protocols. That is not just the medicine; it is actually understanding the impact of the condition on somebody's daily life. With the implementation of the IT application which has those protocols embedded, we have now put that into the examination room and that is helping the doctors to conduct a more consistent and better examination of someone in that situation. There is always further progress to be made and we are constantly looking at ways in which we can more effectively communicate with that group in our society, particularly to get them to attend for examination and to understand the process they are going through. We are putting some more focus on that. One of the things we are doing is working with a number of the welfare rights and disability organisations to understand better some of the training techniques we could implement in our doctor training, which would help our doctors establish a more effective rapport with people in that situation as well. We have made progress, but there is always more we can do. Professor Aylward: I agree with you about people not wishing to attend in certain circumstances, mental health problems. We are aware of that and we are working with Medical Services to try to identify the particular characteristics of those types of people so that we can prevent them attending for a medical examination. Q46 Jim Sheridan: The National Audit Office Report shows that there are some difficulties with people failing to attend for these personal assessments and I know that Schlumberger are attempting to reduce that number. There is a number of cases where benefits have been withdrawn from people not attending these assessments, despite the fact that Schlumberger were notified that they could not attend. Mr Chipperfield: I honestly do not know; I am not aware of anything of that nature. Q47 Jim Sheridan: There is evidence from the Citizens' Advice Bureaux suggesting that Schlumberger were aware of it, but no extra measures were put in place to deal with it. Mr Chipperfield: We were aware of what? Q48 Jim Sheridan: Of people who, for whatever reason, could not attend these personal assessments and their benefits were withdrawn despite them reporting. Mr Chipperfield: Our initial contact for a Personal Capability Assessment is via the phone in 70% of cases these days. If we are unable to get somebody on the phone, we do write to them and ask them to respond to us. If they do not respond, we then sent them an appointment and we send them the time and place of the appointment. If they then do not turn up, we refer the file back to the Department and then it is the Department's decision, what they call the personal adviser gets in touch with an individual to find out the circumstances of their non-attendance. On many occasions people do contact us the day before the day itself and say they cannot make it. In that situation we reschedule the appointment; we do not just refer the file back. We refer to those as "unable-to-attends". Where they actually do not attend the file goes back to the Department and they do the follow-up. We are not informed specifically about the decision that the decision-maker then takes in respect of that individual. Q49 Mr Bacon: Are your doctors subject to the same professional expectations and disciplinary regime as other doctors? Mr Chipperfield: Yes, they all have registration with the GMC, they have to have a GMC registration otherwise they cannot work for us. Q50 Mr Bacon: How were these 22 doctors who were stopped from carrying out examinations identified? Mr Chipperfield: They were identified probably through a variety of means: audit, would have been one of them; maybe because of the complaints record; possibly because of observed activity which the medical manager or other professionals who have worked with them have noticed. Q51 Mr Bacon: Professor Aylward, you referred to 52 because of unacceptable quality. Is that 52 out of the 80? Professor Aylward: No. The 80 were revoked because of unacceptable quality since the year 2000. Q52 Mr Bacon: What was the 52 you mentioned? Professor Aylward: The 52 were in the last year. Q53 Mr Bacon: Fifty-two were identified in the last year. Professor Aylward: Who had unacceptable quality and therefore had their approval revoked. Q54 Mr Bacon: I do not understand. Why do we have a figure of 22 and a figure of 52? Professor Aylward: The 22 were the number of cases reported at the time of the NAO Report. I am giving you an update. Q55 Mr Bacon: Are you saying there have been another 52 since then? It is getting worse. Professor Aylward: No; no. Mr Chipperfield: The 52 includes the 22. Q56 Mr Bacon: So another 30. It is still getting worse. Professor Aylward: Yes, in the last 12 months. Mr Chipperfield: It is not getting any worse. We are very proactively managing the quality of the doctors and the quality of the work which is performed on our behalf by those doctors. Q57 Mr Bacon: When you find doctors who are doing this poor quality work, do you pursue their cases with the General Medical Council? Mr Chipperfield: That depends on the nature of the situation. Q58 Mr Bacon: For example, if a doctor has acted in a way which would be considered grossly unprofessional. Mr Chipperfield: If a doctor has acted in a way which would contravene the regulations of the GMC, then we would report them; absolutely. Q59 Mr Bacon: Do you pursue the case with the GMC? I happen to know of a case with a constituent of mine where your company requested that the GMC stop their investigation.
Mr
Chipperfield:
I
am not aware— Mr Chipperfield: It depends; there are degrees of what we would consider to be unacceptable or poor quality. If you are talking about doctors who we would consider had acted inappropriately in contravention of the GMC ethics and regulations, then we would inform the GMC and initiate the investigation with the GMC. Q61 Mr Bacon: You said earlier that you were very careful about how you selected doctors. Mr Chipperfield: Absolutely. Q62 Mr Bacon: A doctor can apply by printing off an application form from your website. I have one here. Indeed he can apply on-line, but if so he has to send in a completed and signed declaration form which has to be sent in separately. Assuming you post in the whole thing, what then normally happens? Is there normally a face to face interview before the doctor starts work? Mr Chipperfield: Yes, there is a screening process and we screen out a lot of candidates at that stage. In the last two years I would say that of the original applications no more than 20% or 25% have ended up being employed. They go through a very thorough screening process. Q63 Mr Bacon: Do they have a face-to-face interview? Mr Chipperfield: Everyone has face-to-face interviews. Q64 Mr Bacon: Just one? Mr Chipperfield: At least one; in some cases it is more than one. Q65 Mr Bacon: Can you tell me the total revenue your company receives from doing assessments? Mr Chipperfield: It is round about £80 million. Q66 Mr Bacon: Eight zero. Mr Chipperfield: Yes, in this current financial year. Q67 Mr Bacon: I was surprised when I read on your website that you are in fact the largest employer of doctors in the United Kingdom after the Health Service. Is that still correct? Mr Chipperfield: If you include all of the doctors we use across all of our medical services and you include the doctors who work under sub-contract for us via Nestor Healthcare Group, then yes, I believe so. Q68 Mr Bacon: If I phone Directory Inquiries should they be able to find you in the phonebook under Sema Medical Services or Schlumberger Medical Services? Mr Chipperfield: SchlumbergerSema or Schlumberger, yes. Q69 Mr Bacon: I spent about an hour on the phone giving every combination I possibly could and you do not appear to be in the phonebook. Are you aware of this? Mr Chipperfield: We are in the phonebook. Q70 Mr Bacon: You are not trying to hide as a company. Mr Chipperfield: Absolutely not. Q71 Mr Bacon: If I phone up Directory Inquiries and ask for Schlumberger Medical Services when I get back to my office, I should be given the phone number. Mr Chipperfield: Schlumberger Medical Services is not a company. The company's name is Schlumberger and we trade as SchlumbergerSema. Q72 Mr Bacon: You are a very important company, are you not? Mr Chipperfield: The legal entity is called Sema UK Limited. Q73 Mr Bacon: You can get Schlumberger, but it is quite difficult to find the person you need to speak to on the doctor side, the Medical Services side. Mr Chipperfield: I get phone calls all the time. Q74 Mr Bacon: Are you satisfied with how your serious complaint investigation team operates? Mr Chipperfield: Yes, I am. We have an experienced team of people; it is a mix of medical professionals, medical managers and non-medical managers who get involved in our serious complaints. Q75 Mr Bacon: If there is a serious complaint, do you interview both sides? Mr Chipperfield: Yes, we do. Q76 Mr Bacon: Always? Mr Chipperfield: If they are willing to comply. Q77 Mr Bacon: Mr Sumner, when tribunals meet to consider a case do they take evidence from both sides? Mr Sumner: They will have a submission from the decision-maker in the Department and they will take evidence from both sides, yes. Q78 Mr Bacon: Do you agree that the rules of financial justice in English common law require that there is a duty to give persons affected by a decision a reasonable opportunity to present their case? Mr Sumner: If those are the rules of common law, then clearly that is the case, yes. Q79 Mr Bacon: It is one of the first principles.
Mr
Sumner:
Yes. Mr Sumner: That would depend on the circumstances of the case. It is difficult to generalise but clearly in a situation where somebody had wilfully and negligently not followed a ruling of a tribunal, then there would have to be an investigation as to why that was the case. Q81 Mr Bacon: Does that happen? Mr Sumner: If it is deemed appropriate, yes. Q82 Mr Bacon: Do you review the quality of the tribunal service? Mr Sumner: The quality of the tribunal service is a matter for the Appeals Service. Certainly, as far as we were concerned, we would get feedback from them on the quality of our submissions and the President's report gives us information on that. Q83 Mr Bacon: Professor Aylward, you are the person who makes recommendations to the Secretary of State that somebody be removed from the list of those suitable for giving medical assessments, is that right? Professor Aylward: That is right. Q84 Mr Bacon: Once that is done, what else do you do? Anything else? Do you pursue it with the General Medical Council? Professor Aylward: I have pursued it with General Medical Council if the matter suggests there is an element of serious professional misconduct. Q85 Mr Bacon: You have done. Professor Aylward: I would do. Q86 Mr Bacon: You would continue. Professor Aylward: In four cases. Q87 Mr Bacon: I do not want you to go into them now, but is it possible that you could let the Committee have a note with details of the cases you have pursued with the General Medical Council? Professor Aylward: Of course.[2] Mr Bacon: I have reason to believe there is a case which warranted being pursued and I am not sure that it was. Q88 Mr Williams: Looking at page 23, just as a matter of interest because I am trying to work out why you have done what you have done, Figure 12 and the footnote, from September to November 2002 you used a three-month rolling average instead of the previous figure. Why have you done that? Mr Anderson: The process for monitoring quality was assessed by the Department's internal assurance team. That specific change in this table I cannot comment on; it may be the way the information is presented here. In general terms the way that the quality of reports is audited has been assessed outside Schlumberger by the DWP internal assurance team who check the methodology for checking reports and give substantial assurance that they believe that this is a rigorous approach to checking the quality of the reports. Q89 Mr Williams: But it produces peaks and troughs statistically, does it not? NAO, does this not have the effect of actually making the graph blander, so you cannot identify individual monthly peaks and monthly troughs? Switching to a rolling average must mean that, must it not? Mr Lonsdale: I cannot really comment. Q90 Mr Williams: Is there no statistician here? Mr Anderson: It must be true, yes. Taking a three-month rolling average would reduce the peaks and troughs in the individual months. Q91 Mr Williams: So why? I accept you have done it in good faith. I am not suggesting you were trying to pull a fast one over us. It is just that is the effect it could have if there were one dramatic month which we might want to inquire into. Mr Anderson: It is a question of why the report is produced. The purpose of this statistic internally is to make sure that the trend in this particular statistic is going in the right direction. If you are trying to identify a trend and manage a longer term position, then in those circumstances a three-month rolling average would be a better number to use than the monthly average which, by its very nature, might be more volatile, as you suggest. If you were trying to understand a specific peak or trough, then I would agree with you, that would be better. Q92 Mr Williams: The reality is that it would be very simple just to produce the monthly changes with a trend line incorporated in it, would it not? Then you would have clear information. It could well be that we would want to know why in one month there was a sudden leap or massive drop in the figures, but we cannot interpret this now. Mr Anderson: I am sorry, I did not choose the graph which went in the Report. It may well be that we could produce that information if the Committee would like to see it. Q93 Mr Williams: It is just a matter of interest. It just puzzles me. I do not feel you have gained anything. I actually think that statistically you have lost accuracy and that is not good in terms of analysing events. That is all I am trying to get at. I would ask you to look at it again. I would ask NAO to look at it again, have a discussion and if you think there is anything— Mr Burr: I think the intention was simply to show the falling trend, hence the desire to smooth the figures. We could certainly produce the monthly more fluctuating series. Q94 Mr Williams: If you are saying it is just to do that, why three-monthly, why not six-monthly, why not twelve-monthly? The Chancellor works on twelve-monthly trends. Why three-monthly trends? Would you both look at it and drop us a note about it?[3] I do not want to make a big fuss about it. It just puzzles me that it is achieving nothing good and concealing information which could be of value. What concerned me again was on the opposite page to discover that there have been attempts to analyse what has been going wrong, but there is no feedback to the doctors. "Doctors suggested that it is at this level that feedback needs to be improved to ensure that both they and decision-makers are aware if they are systematically misinterpreting the guidance". That seems to me to be logical. Coming back to Professor Aylward's point about different quality of doctors in one part of the process and another, it would be helpful, would it not, to practitioners in this process, if they knew they were consistently getting things wrong, particularly if they knew they were persistently getting the same thing wrong? Why, having this information, do you not make proper use of it? Mr Anderson: I did comment at the beginning of this conversation that I believe the area of feedback to decision-makers from appeals and to doctors from appeals is something which we need to continue to work on and I acknowledge that. The processes in place do ensure that doctors are made aware when reports are sub-standard. They are not necessarily made aware when another doctor takes a different view and that is a different thing. It would require a very major systems development process to feed back to original doctors out of that decision. What we are trying to do is put together medical representatives and decision-makers with regional appeals chairmen to look at the trends happening here so they can have a substantive discussion. That process is being implemented. Q95 Mr Williams: Professor, I may have misunderstood something you said in answer to Mr Steinberg. I tried to jot it down. I did not get which end of the process was the better. You said that the doctors at one stage of the process are better trained, if I understood it correctly, than doctors at the other stage. Was it that the doctors doing the initial assessment are better trained or the doctors doing the appeal are better trained? Professor Aylward: I would argue that the evidence points to doctors at the first tier, the beginning of the process, receiving better training, they receive more monitoring and they are subject to quality assurance to a greater extent, to a more significant extent in a structured way than are doctors who sit on the appeals tribunals except for those who work for the Appeals Service and also work for Medical Services. Q96 Mr Williams: Why should this be so? What leads to that situation? Obviously what we need, if we are to cut out inappropriate payment and inappropriate non-payment, both of which are of interest to this Committee, is for those who deserve the money to have it and we want those who do not deserve the money not to be having taxpayers' money. Why is it? This obviously must be a persistent thing for you to make the point. Why has it persisted? Professor Aylward: I find difficulty in responding to that because I think this is a matter for the Appeals Service and not directly for me. I am working very closely with the President of the Appeals Service to ensure that difference is remedied, particularly in regard to the criteria which doctors now need to meet in order to remain on the medical register in the process of GMC revalidation. Q97 Mr Williams: Can anyone else answer about the inadequacy of the appeals system? Someone must be able to. Quite an important observation is being made here. It has implicit in it the fact that money is going to the wrong places or not going to the right places. It is lots of public money. If the professor has observed this, have you fed it into the system? If so, at what level have you fed it in? Professor Aylward: I fed it in at the highest level. I fed it in at the highest level in the Appeals Service. I have made my colleagues in DWP aware of it recently. It is not something which one concludes without some quite significant data research and evidence, so I have only recently reached this conclusion. Q98 Mr Williams: Mr Anderson, obviously the buck stops with you and there is no-one else to try to pass it to at the moment who can answer on this. I would not grin with too much comfort at the end; we may get to you eventually anyhow. Were you aware of this assessment? It has been put into the system at the top and I do not for a moment dispute what you say—you are a fellow Welshman so I would not dare. Are you aware that this judgment has been fed into the Appeals Service? Mr Anderson: I have not heard that directly from the Appeals Service, though I have heard it from Professor Aylward. Q99 Mr Williams: That is okay. I do not mind where you heard it from, so long as you heard it. Now you are not just the person who is sitting there, you are the person sitting there knowing this. Why has it happened?
Mr
Anderson:
This
is something we need to take up with the Appeals Service and try
to discuss with them how we can ensure that doctors who attend
appeals get a certain level of training and the same exposure as
doctors who work on the main cases. Part of the problem of
course is that doctors who work for Schlumberger see far more
activity in this area particularly employed doctors and
therefore the number of training days they can devote to it is
significantly greater. Finding a way of getting doctors who are
available to turn up and fulfil appeals, who can devote
sufficient time to being trained to the same level, is a real
challenge for the Appeals Service. Professor Aylward: I have not said that. I have not used the word "wrong". What I have said is that of a random sample of cases which were said to demonstrate underestimation of disability by the first tier doctor, of those I felt around half did not demonstrate an underestimation of disability. I disagreed with the doctor's opinion on the Appeals Service. Q101 Mr Williams: That is an important difference, is it not? We are talking of cases where, 57% in some instances, one in two of the appeals are successful. Therefore on that basis, if half of those are wrong, there must be massive sums of money going in the wrong direction. Professor Aylward: No. If you look at both Attendance Allowance and Incapacity Benefit, about one third are said to underestimate the disability. Q102 Mr Williams: Half of those. Professor Aylward: Half of those in my random sample. I did not look at all of them. Q103 Mr Williams: That still means one sixth and that is still a lot of people and a lot of money, is it not? You must know what these appeals are costing you in terms of extra payout. It would be interesting, if there were some way of doing this, if you could give us some sort of statistical analysis, based on the third being wrong, of what it might be costing you because the appeals tribunals inappropriately overturn the decision of the recommendation at the first stage. Then, if you can tell us how much in ballpark figures that might cost, or if NAO can help you do that—I do not care where it comes from—we can work out what sort of pot of money you may have in hand where you could make sure you get a higher trained quality of person at the appeal end and still possibly save money. Mr Anderson: I certainly think we could look at that. I should be cautious at taking the figure of one half of one third, that is one sixth, and saying that is potentially the cases at risk. Professor Aylward looked at a small random sample and that may produce a misleading result. That does not alter the general sense of the argument which says that this difference is significant and warrants investigation. We should try to get an accurate quantification of what is going wrong. Q104 Mr Williams: I would ask you and NAO to see what you can get.[4] I know that it is a matter of which information is collected and how it is analysed, but if the two of you could look at this to see. I think you would agree that if we can resolve something from this, there could be quite a substantial saving of money without depriving people who are genuinely in need. May I switch completely to paragraph 3.17? The point is made about decision-makers and people wanting to appeal and why things go wrong when they submit their claims. In the final sentence there it makes the point " . . . general practitioners may not be able to supply all the information required. Many people with disabilities or severe medical problems may be treated by one or more specialists and may rarely see their general practitioner, yet claim forms did not prompt claimants to provide consultants' reports". Surely that is extremely important. Back now to the Professor's point about quality. It is now not just a doctor who has a general field of work but now the consultant's opinion. I would have thought that would have been extremely relevant. Why is that not given top priority in the evidence you seek from people making applications? It would seem obvious to the layman that this should be so. Mr Anderson: We are improving the process to make sure that the decision-makers have access to all reports and the forms are being changed. Q105 Mr Williams: As we speak, the form is being changed. Will it emphasise the role of consultants? Can you assure us of that, or will it from now anyhow? Professor Aylward: When there is a question of diagnosis, then it is important that we seek the advice of someone who is a specialist in making this diagnosis. In that case we do seek the views and opinion of consultants. However, most of the disability benefits are not related to the exact diagnosis of a disorder somebody suffers from, but the effects of that. In that regard we look towards the new speciality of disability assessment medicine. There the consultant and the general practitioners admitted themselves that they are not the experts in assessing the effects of disabilities. Where we need the expertise of a consultant we would seek it and we would probably seek that more with the new forms. When we need to look at the effects, it is far better to get that information to people who are qualified in disability assessment medicine. Q106 Mr Bacon: Mr Anderson, in Mr Williams' request for more information on the chart on page 23, Figure 12, could you include, in addition to anything you are going to do for Mr Williams, just a little table which has for each month the actual number of sub-standard medical reports? That will only be about 44 rows long and two or three columns wide, I hope. It would just be interesting to know the gross figures for each month. Mr Anderson: Yes.[5] Q107 Mr Bacon: Mr Chipperfield, how much do you pay a doctor to do an assessment? Mr Chipperfield: It depends on the assessment. Q108 Mr Bacon: Incapacity Benefit. Mr Chipperfield: It depends whether they are a permanent employed doctor, or whether they are doctors we pay per case. Q109 Mr Bacon: For example. Can you give me an example? Mr Chipperfield: I do not know. Q110 Mr Bacon: A permanently employed doctor to do Incapacity Benefit. Mr Chipperfield: It depends; it varies. The range would be around £50k to £70k per annum. Q111 Mr Bacon: If they are not a permanently employed doctor, then how much would you pay them, if they are coming in just to do that? Mr Chipperfield: I do not know the figure off the top of my head. Q112 Mr Bacon: If you could send a note that would be great.[6] How much do you get from the Department for each assessment? Mr Chipperfield: I am not so sure that I am at liberty to disclose that information as I believe it is confidential. Q113 Mr Bacon: You get £80 million altogether. Mr Chipperfield: Yes. Mr Bacon: I want to know how much assessments cost. Q114 Chairman: I think you could answer that. Why should you not answer that? Mr Chipperfield: I do not know whether I am able to answer that or not. Q115 Chairman: Are you saying you will not answer or you do not want to or you cannot? Mr Chipperfield: I am not sure— Q116 Mr Bacon: It is taxpayers' money. We look at how taxpayers' money is spent. Mr Chipperfield: I am not sure whether I can answer it. I do not actually have the figures. Q117 Chairman: Give us a note then. Mr Chipperfield: I am happy to do that.[7] Q118 Mr Bacon: Do you think you lose money on assessing Disability Living Allowance? Mr Chipperfield: I am not in a position to comment on the commercial aspects of the contract. Q119 Mr Bacon: We have witnesses from private sector companies constantly and they often comment on the commercial aspects of contracts. We are a financial committee. Do you think you lost money on assessing Disability Living Allowance? Mr Chipperfield: I do not know whether I can answer that question
Q120 Chairman: Why do you not know whether you can answer it? Are you refusing to answer or do you not know the answer, or what? Mr Chipperfield: It is not that I am refusing to answer. It is that I am not clear on the extent to which I am permitted under the nature of the contract to reveal the commercial arrangements of the contract. I need to take advice from the Department on these questions, if you do not mind. Mr Anderson: I was going to suggest that we came back to you in the form of a note. One of the issues is that presently we are in the process of early re-tendering for this contract and there are several bidders involved in that process and therefore publicising some detailed numbers at this point might prejudice that process. Q121 Mr Bacon: Perhaps you could give us a confidential note.[8] Mr Chipperfield: I am not refusing; it is merely that I am looking for guidance from my customer as to what I am able to say. Q122 Mr Bacon: I understand. Mr Chipperfield, would you say that overall the contract is profitable? Mr Chipperfield: It is just about profitable. Q123 Mr Bacon: Is it correct that the only way you can make any profit is to avoid ordering Incapacity Benefit assessments? Mr Chipperfield: That would be totally incorrect. Q124 Mr Bacon: That would be totally incorrect. Do you have an informal target, where you expect that roughly 50% of the applicants would be deemed unfit for work at the medical scrutiny stage so that they do not end up having an assessment which costs you money? Mr Chipperfield: No. Q125 Mr Bacon: You have no informal target, no covert target. Mr Chipperfield: No, we work to scrutiny guidelines. The calling rate, to which you are referring, which is the rate at which the doctor makes the decision whether someone qualifies at the scrutiny stage or whether it is necessary to call for exam, fluctuates all of the time. Currently it fluctuates between the early 50%s and into the early 60%s. It varies from centre to centre. It is not a rate that we manage in any way, shape or form. It is totally the decision of the doctor using the scrutiny guidelines as laid down by the Chief Medical Advisor. Q126 Mr Bacon: Mr Anderson, you are spending £18 billion of taxpayers' money. 1% of that would be £180 million. You are only giving Mr Chipperfield £80 million. Do you honestly think that you are spending enough money on checking whether the people who are getting this £18,000 million of taxpayers' money all deserve it? Mr Anderson: Yes, I believe that the processes we have in place for making the decisions are fit for purpose. Q127 Mr Bacon: A national charity will boast if its administration costs are 2% to 4% and that 95% gets through to the good cause. You are spending less than half of 1% on making sure that this £18,000 million ends up in the right place. Mr Anderson: I do not believe that is correct. Q128 Mr Bacon: It says £18,000 million. Mr Chipperfield gets £80 million and, doing the maths in my head, 10% is £1.8 billion, 1% is £180 million, divide that by two gives you £90 million which would be 0.5%, so half of 1% would be £90 million and you are giving him £80 million, you are giving him less than half of 1%. Mr Anderson: Mr Chipperfield's company does not fulfil the whole of the process in administering the £18 billion of benefit. Quite clearly there is a terrific amount of activity which takes place inside DWP to administer that benefit which is not included in that £80 million. Q129 Mr Bacon: Could you give us a note on how much the value of that activity is? Mr Anderson: I do not believe that information is currently available. Since the merger of the Benefits Agency and the old Employment Service, we have not yet implemented a new unit costing system. Q130 Mr Bacon: So you cannot say how much money you are spending on checking this £18 billion. Mr Anderson: No. That information ought to become available as that system is developed during the course of next year. Q131 Chairman: Reference was made there to the next contract. How do you think it will deliver more innovation and service quality improvements? Mr Anderson: Obviously we have learned during the course of this contract and we would like to put that experience into the tendering process. A number of firms have asked to be included in the process and they have been asked to make their own suggestions as to how the service delivery could be improved as part of the tendering process. We have five years' worth of experience of operating the contract that we did not have last time we let it and we would hope that we could improve it as a result. It is fair to say that since the extension to the contract, significant new targets were included for Schlumberger which have produced some of the improvements which are shown in this Report. Chairman: That is a complete non answer to the question I asked you. When you have had a chance to look at the transcript, you may be able to give us more information in a note.[9] Q132 Jon Cruddas: One brief question. Can you quantify the number of appeals proportionately where your doctors, DWP doctors, sit on compared with Appeals Service doctors? Professor Aylward: How many appeals doctors who work for SchlumbergerSema sit on appeals? Q133 Jon Cruddas: Yes. Professor Aylward: I cannot give you that figure, but I can provide it.[10] Q134 Jon Cruddas: Could you provide it? A lot of questions have revolved around the difference between the different doctors, so that would be useful. Mr Chipperfield: If I may answer, I do not know the exact figure, but I believe it is quite small, no more than 10 to 20. Jon Cruddas: It is only because I received a letter from a disability information advice line and their main source of criticism was the number of doctors sitting on appeals who had sat on initial cases; not necessarily the same cases but as part of the same pool. Therefore they were questioning the actual relative independence of the appeals systems themselves. It would be useful to know what the proportions are. Mr Bacon: May I just say that I think it is a matter of severe concern that the Department cannot say how much money is spent scrutinising this process? I very much hope that our report will reflect that. Chairman: Thank you very much, Mr Bacon. Thank you, gentlemen, for coming to see us this afternoon. Clearly progress has been made since our last report and no doubt we shall be looking in our report as to how further progress can be made and another £50 million saved with a bit of luck. Thank you very much.
Retour à Infogérance et dérégulation des services publics : Pas vu pas pris, pris pendu!" 25 octobre 2006 Les fiches de poste: des cartes non similaires aux territoires 12 décembre 2006
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