§ [Relevant documents: Third Report of the Social Security Committee, Session 1999–2000, on Medical Services, HC183, and the Government's response thereto, Cm 4780; and the Social Security Departmental Report: The Government's Expenditure Plans 2000–2001 to 2001–2002, Cm 4614.]
Motion made, and Question proposed,
That a further, revised sum, not exceeding £1,110,424,000 be granted to Her Majesty out of the Consolidated Fund to complete or defray the charges which will come in course of payment during the year ending on 31st March 2001 for expenditure by the Department of Social Security on administration, for agency payments, expenditure incurred as part of the Welfare to Work initiative, expenditure on behalf of the Department of Health, and for certain other services including grants to local authorities and voluntary organisations and other organisations—[Mr. Belts.]
§ Mr. Archy Kirkwood (Roxburgh and Berwickshire)
It is a pleasure and privilege to open this short debate under the estimates on the important subject of the provision of medical services to the Benefits Agency. I have felt for some time that Parliament does not take enough time to revisit some earlier policy decisions taken in primary legislation. If that is true of primary legislation, it is certainly true of secondary legislation and the administrative systems within the departmental structures of Government. We need to look at the way in which primary and secondary policy is implemented on the ground through the administrative procedures.
It is an appropriate subject for debate under the estimates because, as the House will know, each year, some £25,000 million is devoted to providing for those who have a disability or long-term sickness. That is a large part of the Department of Social Security budget. In 1998, a contract was entered into with Sema, a private sector company, to provide medical advice for decision makers within the Benefits Agency. The contract totals some £305 million. It is for five years, with a possible extension of two. Therefore, the subject raised on the estimates day is an appropriate one.
My colleagues on the Select Committee on Social Security are grateful to our colleagues on the Liaison Committee for allowing us to allocate time for that subject. It is raised on the basis of the Social Security Committee's third report of the current Session, which was published recently. It was occasioned by the concern that came through clearly to my colleagues on the Select Committee—from a variety of different sources, it must be said.
In October and November, the Under-Secretary of State for Social Security, the hon. Member for City of York (Mr. Bayley), bravely made himself available for two evening sittings and had an uncomfortable time from a lot of Members, who were visibly distressed by and angry about the treatment that some of their constituents were getting, so we had that evidence available to us. Other evidence came to the Committee through our contacts with pressure groups and disability groups—the National 478 Association of Citizens Advice Bureaux and the like—which registered real areas of discontent about the way in which medical services work was being done. The casework from colleagues, taken together, led us to conclude that we should look at the provision of medical services.
We were able to take what we believed was a relatively short time for what we believed would be a relatively quick report. After placing the usual advertisement soliciting evidence from interested parties, we soon realised that the report could not be a cursory one. We received a staggering volume of evidence, which was staggering also in the extent and depth of the difficulties that it revealed. There was very clearly great disquiet in all parts of the medical services and Benefits Agency service delivery systems. Therefore, in November 1999, the Committee agreed to produce a report, which has now been published.
The Government have published a response to our report. I acknowledge that the Under-Secretary has a very good track record on the subject—for which he is responsible. Although it may embarrass him to know this, when the Committee went to various parts of the territory to discuss the subject, people spoke highly of him. It was recognised that, before he became a Minister, on his own initiative, he worked with the National Association of Citizens Advice Bureaux in York on this very subject. We are lucky that we have such a Minister. The trouble is that Ministers who are good and expert on subjects often move on. We shall have to work on the worst case assumption that he will soon be a Cabinet Minister and that we will be dealing with someone else.
The general tone of the Government's response to our report is positive. I detect the Minister's fingerprints on some of that response, which is welcome. I shall deal with the Government's response in a bit more detail in a moment.
It is fair to say that the system was never perfect. There was much disquiet also about the old system—the Benefits Agency medical services system—which was operated in-house and entailed medical evidence being given by officers employed by the Department of Social Security. It is also fair to say that we are bound to have some difficulties and complaints with any system purporting to undertake 1 million medical examinations annually. It would be foolish to have any other expectation of such a system.
In fairness, it is also true to say that the contract has been running for a relatively short time. It was an ambitious contract, and one could argue that it has not really bedded down yet. Additionally, as some applicants for disability benefits who are rejected—because they do not meet the eligibility criteria established by the House—are disappointed, an element of disappointment and anxiety is built into the process. We have to take that into account, and to be careful in reaching judgments and comparing the system with the previous one.
In paragraph 100 of their response, the Government quite candidly admit that the benefits that they had hoped to achieve from contractorisation have not been realised. I am sure that the Minister would say that it is too soon to judge that and that the contract has another three years—with an additional two years, if necessary—to run. However, at least the Government have made that admission.
479 Nevertheless, I think that the House is right to consider carefully how the decision was taken to privatise the medical services decision-making process. In retrospect, I think that the Government were wrong to take the decision so quickly. The Minister will know that, a few short months after the new Labour Government took office, some additional requirements were added to the brief. Admittedly, that happened after the previous Government had examined the issue for some time and had well developed plans.
I really wonder, however, whether a root and branch review was conducted of the proposals before the decision was taken, particularly in relation to advice from pressure groups and those who were going to be part and parcel of the system's daily work. Although all the contracts looked fine, the lawyers had crawled over them and the work was done professionally, with the benefit of hindsight, I do not think that anyone who had ever advised someone applying for disability living allowance or incapacity benefit ever got anywhere near that process.
If I had been a Minister, I think that I would have delayed contractorisation until I was absolutely sure of the quality of the service being delivered. I do not think that such an assessment was ever made, and we are paying a price because of that omission. The contractorisation timetable was doubtful, and contractorisation was implemented too quickly.
Additionally, there was inadequate benchmarking. I should be glad to have information on any comparators from Northern Ireland, which has a different way of dealing with the process. As Sema was given all three areas—the north, the south-east and the south-west—all in one go, the competition element could not be tested. There was, therefore, no way of benchmarking performance by sharing out the contract geographically.
An issue running as a thread through the report—the British Medical Association raised it originally, but others also did so in their own ways—is that the contract process, including its details and funding, was too lean and that it may not have provided sufficient resources to do the job properly. Undoubtedly, the day will dawn when the National Audit Office has time to examine the issue. However, if we are going to increase contractorisation and use that contract as a model, I really should like a Government body or departmental expert to examine the process and to determine whether lessons can be learned about how the decision was taken and how the process was implemented.
I say quite candidly to the Minister—I was nice to him earlier, but there is always a "but" when one is nice to Ministers—that, although I am prepared to wait for the contract to expire, in my considered view, if the level of service to claimants does not improve, Ministers must prepare for the possibility that the contract will be awarded elsewhere. I do not say that lightly, but I think that it is true. The view that the House takes today will be important in that decision.
This debate gives hon. Members the opportunity to give their own constituents a voice. I could use the next three hours of the debate reading out, without repetition, complaints that we have received. Some of the complaints are difficult to comprehend, because of the daftness and natural injustice that seems to have been visited on some claimants. Of course, we have heard only one side of the 480 story. We were dealing with anonymous complaints, which we encouraged, and were therefore never able to hear a balanced view.
In their response, the Government have taken a bit of a potshot at the Committee for accepting anonymous evidence. Hand on heart, I say that only a fraction of the evidence that we took was anonymous. However, if Ministers really do not understand that people in this country and in this day and age are frightened to put their names to their complaints, they do not understand the extent of the problem. I therefore make no apology for taking evidence that was lodged anonymously.
Additionally, Select Committees are not equipped with the depth and range of services that we need really to examine this type of problem. Only Departments have the resources necessary to conduct such an inquiry. Therefore, I do not think that, in the production of our brief report, there was any other way of getting the flavour of the boiling anger and frustration felt by those who have had bad service.
I confess that I told my Committee members that I did not think it would be possible to get evidence from everyone. It is asking a lot to ask people who have suffered at the hands of the system to come and tell us their story. However, we went to Bristol for one evidence session, and the opportunity to speak to people directly was an absolute eye-opener.
One thing just did not compute. We spent the morning at one of the medical centres provided by the Sema group and by medical services. We spoke to people whom I considered to be dedicated professionals. They were impressive, caring people who thought that they were providing a service that was up to scratch. I thought that there must have been some mistake, as the written evidence did not relate to what we were being told by the medical professionals. However, we spent the afternoon session down the hill in Bristol, where it was a completely different story.
There is a disjunction between what the civil service and the medical professionals were arguing and what we were told that afternoon by people who had had terrible experiences involving life events that they will never forget. The question is to what extent the really difficult cases are typical. I have no way of knowing that, but the volume of the evidence suggests that there is a problem which needs to be addressed urgently. People out there are crying out for help and they need a response. This afternoon's debate provides an opportunity for that. I hope that right hon. and hon. Members will take the opportunity to give the House a flavour of some of the cases that they have struggled to ameliorate and deal with, so that we can decide where to go from here.
I am not looking for scapegoats, victims, resignations or any damn thing. However, we all have an interest in moving on and trying to improve the service. The Government's response to the Select Committee report gives me confidence that, with good will, we can do that.
The Select Committee report can be considered under four categories. The first is the recommendations that are designed to improve the medical quality of the examining medical practitioners' reports. There was a great deal of concern about that. Secondly, I shall briefly look at the recommendations that are designed to improve the service to claimants generally, and with particular reference to 481 claimants from ethnic minority groups, female claimants and claimants with mental health problems, whose cases were particularly poignant and difficult to deal with.
The third category comprises recommendations that are designed to remove the perverse financial incentive, of which the Government are aware, involving the relative financial gain of considering cases by desktop scrutiny rather than by medical examination. There is a potential incentive for the contractor to make more money by carrying out fewer examinations. Incidentally, that might result in benefits being made available to people who did not really deserve them. The fourth and final category comprises the recommendations that are designed to improve the terms of employment of the examining medical practitioners, and their pay and training, which caused some concern.
On the first category—the medical quality of reports—the Government's response at paragraph 7 is welcome. It is to set targets for a reduction in the proportion of "C grade"—or unacceptable—reports and for increased compliance with scrutiny guidelines for incapacity benefit cases. I hope that that course of action will be prosecuted with energy and vigour.
The Government state at paragraph 15 of their response:More rigorous recruitment criteria…have been introduced which should set a minimum level of medical experience for the doctors who are employed.I shall return to that in a moment as the British Medical Association has faxed me a response that causes me some concern.
At paragraph 20, the Government's response states that revised guidance has been issued to examining medical practitioners. I am particularly pleased that a medical skills database has been introduced. We should take advantage of the fact that companies such as Sema have expertise in these matters. If we can have available quality audits of doctors' work, details of their training and any remedial work that they may have undertaken, that must be valuable in terms of getting people trained and enabling the contractor to assess medical practitioners' success rates.
I welcome the targets and the medical skills database and, in particular, the fact that in looking at the medical quality of reports, the Government recognise that their objectives have not yet been met and that work needs to be done.
§ Rev. Martin Smyth (Belfast, South)
The hon. Gentleman referred to a comparison being made with Northern Ireland. Was he referring to the situation generally, or specifically to the medical examiners? Quite frankly, there is great concern about that. In a number of cases, the standard of examination was deplorable and it was despicable that people who were genuinely in need were put under such pressure. I wondered whether the hon. Gentleman was referring to that, or to another area where he thought that things were better in Northern Ireland.
§ Mr. Kirkwood
Had I realised that the hon. Gentleman, who has expertise in this area, would raise the matter, perhaps I would not have strayed into an area that I do not know very much about. My point was that if 482 Sema are providing medical services in the northern area, the south-east and the south-west of Britain, the only opportunity for finding another system to act as a benchmark would be to look at the provision in Northern Ireland, but the hon. Gentleman may have taken away any hope of succour from that direction. If the situation is just as bad in Northern Ireland, it may not help us. However, I welcome his expertise and acknowledge his interest in the subject, and I hope that he manages to catch your eye, Mr. Deputy Speaker.
I now turn to the Government's response in respect of service to claimants. At paragraph 25 they state that training is being offered to examining medical practitioners in customer care, but accept that revised guidance, which provides more information, is welcome. They state at paragraph 27 that the Department is working with medical services to review all aspects of the treatment of claimants and that a taskforce has been set up to review all communications to claimants.
Less welcome, however, is the fact that at paragraph 36, the Government appear to reject the need for a review of the system's treatment of mental health problems. At paragraph 39, in respect of communications with patients from ethnic minority groups, they state that multilingual noticeswould not be consistent with current practice in other parts of the Benefits Agency.If that is a defence, I do not think much of it. Some members of the Select Committee who specialise in these matters helped us enormously by bringing to the fore some of the problems experienced in certain communities, so I hope that that is not the Government's last word on the issue.
At paragraph 40, the Government appear to complain that our comments were based on anonymous examples. I tried to deal with that point earlier. At paragraph 42, they state that new training will be provided in multicultural awareness.
Less welcome is the fact that at paragraph 45, the Government's response totally fails to address the difficulties of female claimants. They state that if a claimant requests a female doctor, attempts will be made to meet that request. That is not a sufficiently robust response.
Although the Government say that they understand the Select Committee's concerns about the complaints procedure, once again, they accuse us of using anonymous evidence to support our view that the complaints procedure is totally inadequate. Indeed, early in the inquiry, we were told that a customer satisfaction survey produced a satisfaction rating of 88 per cent. As I said earlier, there is clearly a disjunction with some of the evidence on the subject and that is deeply worrying.
On the question of service to customers, the Government are in danger of being complacent and defensive. I notice with interest that some 46 hon. Members signed early-day motion 826—which was unsponsored, honestly—congratulating the Committee on its report. Against that continuing level of concern, the Government's response leaves something to be desired.
I am content that the Government seem to have got the message about removing the financial incentive to deal with claimants by scrutiny rather than examination. The report says that the Government would view "with 483 unmitigated disapproval" any evidence that the fall in the number of examinations was driven by commercial gain. I am content with that response. It is a difficult issue and there may be good reasons for some of the trends in the figures. I hope that the Government continue to share the Committee's concern that that potential threat exists and I urge them to keep the matter robustly under review.
The Government state that within one year, all doctors will be trained in the assessment of people with mental health problems, the treatment of people with disabilities and the avoidance of distress for people with musculoskeletal conditions. That is welcome. The Government are also concerned about the failure of medical services to meet their contractual obligation in regard to training.
§ Mr. Desmond Swayne (New Forest, West)
Since the publication of the report, I have received representations from sessional doctors in my constituency who are being encouraged by Sema to take additional training, but are being required to do so without pay. When the training was provided by the Benefits Agency, the doctors were paid for doing it. The Government have said that they are renegotiating the terms, but what prospect is there of them bringing pressure to bear on Sema in that respect?
§ Mr. Kirkwood
As I would expect, knowing the hon. Gentleman as I do, that is a perceptive point and he anticipates my next comments. The Government sidestepped the issue of pay for training days by stating that it was a matter for medical services to address. Frankly, that will not do. I welcome the initiatives on training, but I remain concerned that by failing to specify the number of days of training to be delivered by medical services, the Government may allow the contractor to opt out entirely. I hope that that will not happen.
The BMA has raised several issues connected with the report. The parliamentary response arrived on my desk this morning, and the tone of it concerns me. The BMA is an interested party and tries to improve the pay and conditions of its members, just like any other trade association or professional body. However, it points out several issues that suggest to me that the relationships in the set-up are not yet right. For example, it points out that people who work as sessional doctors for Sema and medical services have received no pay increase for some eight years. During our inquiry earlier in the year, it was suggested that that situation was being addressed and would be fixed. I do not know the current situation and it would be helpful if the Minister could give details. I know that he will say that it is technically nothing to do with him under the contract, but Nestor Disability Analysts says the same, and medical services also seemed to say the same at one point. Everybody was passing the buck and that may be why no pay increase has been given in eight years. If that is true, it is unacceptable and will not assist in attracting the quality of medical practitioners required to perform that sensitive and skilled work.
I am also worried about the spirit of non-co-operation that appears to exist between the BMA and medical services. The BMA says that it last met medical services in September 1999. The proposed meeting in December was cancelled by medical services and a letter sent by the BMA to medical services on 25 November 1999 has not yet received a reply. I do not know any more and I do not 484 wish to enter into any dispute between the two bodies, but that does not suggest the spirit of co-operation necessary to achieve improvement.
The BMA also raised the issue of time for interviews. It says that medical services have informed doctors, in a letter sent on 22 September 1999, that they will have to report all instances in which fewer than five clients are seen per session. A session lasts three and a half hours. The BMA also alludes to the issues surrounding non-payment for training, mentioned by the hon. Member for New Forest, West (Mr. Swayne).
§ Mr. Gordon Marsden (Blackpool, South)
On the point about the BMA's concerns about the time spent on individual cases, I noted the Committee's comments in the report. I offer the hon. Gentleman an example from medical services. I wrote to the Preston office with concerns about a particular doctor and the amount of time that he spent on his investigations. The reply from a Miss Unwin, the client team co-ordinator, stated straightforwardly:From the perspective of Medical Services, a total of 45 minutes or so in a house would be regarded as sufficient in most cases. The majority of clinical examinations can be concluded in 10 minutes.Does not that underline some of the BMA's concerns?
§ Mr. Kirkwood
It does, and the hon. Gentleman makes his point eloquently. I hope that the Minister has taken due notice.
The BMA says that it is concerned that it does not know how many sessional doctors are employed by Nestor Disability Analysts. Although the Department was told that 2,482 doctors had agreed to the contract, with a further 659 continuing to provide a service but without signing a contract, information obtained by BMA members indicates that a significant proportion of the 3,000 or so doctors approved to work for medical services have stopped offering their services. The BMA also believes that even under the new, rigorous recruitment criteria, which are mentioned in the Government's response, ordinary general practitioners can start to work for Sema and medical services as soon as they qualify. That was not my understanding during our work on the report, but I may be wrong. The BMA also believes that the pay issue must be addressed.
The BMA drew my attention to some fresh concerns that are pertinent to the debate. The association is a not inconsiderable pressure group and its views should be taken into account. I hope that the Minister will be able to answer some of its questions.
I shall conclude by saying that, although saving 14 per cent. of a contract worth £305 million over five years will realise £62 million, I wonder whether that is not taking too much out of the system. Removing that money will put pressure on the most disadvantaged people—the claimants.
My anxiety about that is genuine. Today's debate should question whether the resources in the system are sufficient to achieve the standards that we all want. Speaking for myself, I think that the jury is out on medical services. The debate will allow hon. Members to speak for their constituents, but I believe that the Social Security Committee is likely to decide that, one way or another, it will in future monitor very carefully the progress of these matters, to which it reserves the right to return.
485 The Committee is also likely to take up the option of compiling a report at the end of the contract period. It is possible that that report will make a recommendation as to whether the Government are safe to continue with the present arrangements.
I hope that the debate will be informative, and that the Minister will be able to reassure the House. I hope too that hon. Members will feel that the Select Committee report has been of some assistance in securing better provision for our constituents.
§ Mr. Gareth Thomas (Clwyd, West)
I am grateful to my hon. Friend the Member for Roxburgh and Berwickshire (Mr. Kirkwood), who is Chairman of the Select Committee on Social Security, of which I am a member. He provided a comprehensive analysis of the inquiry conducted by the Committee.
An inquiry and report such as the one that we are debating today offers an admirable example of the good work that Select Committees can do. If the report serves to concentrate the Government's mind on the need to maintain a good quality service in this crucial area, it will have been justified.
I am heartened by the Government's generally positive response to the report. It is worth mentioning, as the Government are at some pains to do in the introduction to their response, that the history of medical services needs to be placed in context. There is reason to doubt the effectiveness of the present contractorised system—I am sure that some of the defects that came to light are only too familiar to hon. Members—but the fact remains that the old system was very far from perfect.
Delays were part of the culture of the old system, and there was a total lack of co-ordination in terms of standards and training. Contractorisation at least gives the Government some significant degree of leverage over how quality should be monitored and the system improved.
As my hon. Friend the Member for Roxburgh and Berwickshire said, the people seeking benefits under the system—which costs £25 billion a year—are the most vulnerable in our society. It is crucial to ensure that examinations for eligibility are conducted by doctors in a professional and fair manner, and claimants must believe that they are being dealt with fairly. I am sorry to say that it became apparent from our inquiry that in many instances that was not the case.
I acknowledge that an enormous bureaucracy is involved, given that a million medical examinations are held every year in relation to medical benefits. No system can be perfect, but there is certainly a need for improvement. I agree with what has been said already: if medical services do not improve significantly over the next year or so, there should be scope to reconsider the contract and take robust action—including the draconian step of withdrawing the contract from Sema.
Many hon. Members will want to inform the House about their experiences in this matter, so I shall confine my remarks to a few about some of the issues highlighted in the report. First, I want to deal fairly and squarely with the perception of fairness.
486 The perception exists that doctors do not spend enough time with claimants, that they examine them too quickly and do not do justice to their complaints. I agree with the Government's response that time spent with a claimant is not necessarily commensurate with quality. However, I am sure that the Minister agrees that it is essential for examining medical practitioners to devote sufficient time to listening carefully to claimants. Some claimants no doubt have difficulty in explaining themselves, but they must be left with the overall impression that they have been dealt with fairly.
I am dismayed that the Government are somewhat critical of the Committee's approach to what the Government describe as anonymous reports of instances of dissatisfaction. I echo the remarks of the hon. Member for Roxburgh and Berwickshire: it is unrealistic to expect vulnerable people, who may be afraid of the consequences of complaining too strongly, to be very forthcoming in giving their identities.
§ Mr. Gordon Marsden
Does my hon. Friend accept the close correlation between the cursory way in which some claimants are dealt with by examining medical practitioners and their subsequent reluctance to make a formal, or an identifiable, complaint? In my constituency, I have had several complaints against a particular EMP for giving a physical examination that lasted for only two to four minutes. When I pressed one or two of the claimants subsequently at advice surgeries—
§ Mr. Deputy Speaker (Mr. Michael J. Martin)
Order. I really must stop the hon. Gentleman. This is an intervention.
§ Mr. Thomas
My hon. Friend makes a valuable point. A few doctors keep cropping up, time and again. They are very powerful, or are seen to be powerful, which might account for the reluctance to complain. The complaints system is not particularly user-friendly. The rate of successful appeals has traditionally been very high, although I accept that that is not necessarily a reflection of poor medical evidence. However, the point is well made.
§ The Parliamentary Under-Secretary of State for Social Security (Mr. Hugh Bayley)
The pattern has been that about 4,000 people a year make a formal complaint. There has been a lot of debate about whether that is a reflection of the true number of people who are dissatisfied, or a small part of the true number. However, I caution my hon. Friend against creating the myth that something happens to people who complain. Has he any evidence of somebody being victimised as a result of using the complaints procedure? If so, the Committee should bring it forward; it has not done so to date.
§ Mr. Thomas
I do not have such evidence. I raise the issue—I do not want to dwell too long on it—simply to rebut the Government's suggestion that, because we could not provide a list of identities of individual complainers, that had somehow undermined our evidence.
It is imperative to have a programme of recruitment that ensures that doctors who really want to do this job, and have some pride in their work, are recruited. There is an urgent need to look at their remuneration. I, too, am concerned that there has been no increase in the salary of 487 EMPs for some time. Unfortunately, that suggests that this is a Cinderella service, with all the implications that that has for quality.
A more rigorous system of auditing performance is required. I am very pleased that the Government intend to take action to remove doctors who consistently under-perform. I am sure that that was always so, but it is nice to hear it. It will be welcome if medical services' efforts are redoubled.
Training in customer care is essential, as is dealing with poor performance. The Committee criticised the manner in which EMPs deal with claimants with mental health problems or from ethnic minority groups, and strong conclusions were reached on some doctors' cultural insensitivity. I am pleased that the Government accept that that matter must be rigorously addressed.
Two points should be made on appeals. First, a feedback procedure is necessary. When a pattern emerges of successful appeals involving a particular doctor, there should be some follow-through. Alarm bells should ring so that someone conducts inquiries and asks what is going wrong. It seemed to the Committee that that does not happen, and I should be grateful if the Minister would clarify the Government's approach.
Secondly, as a lawyer experienced in personal injury cases, I know that, in addition to the medical report for the case, one of the most valuable pieces of evidence for a court determining liability and quantum is a person's entire medical history—general practitioners' notes, hospital records and so on. If one is successfully to assess someone's eligibility for benefits, that is essential. I did not know until I heard it in Committee that there appears to be no systematic approach to ensuring that additional medical evidence is obtained. The procedure requires tightening.
I share concerns about financial pressures in the system, which give rise to suspicion that there is a disincentive to carrying out full examinations. There is evidence that the scrutiny procedure—examining the papers, not the patient—is increasing. The Government are concerned about that, and the figures are particularly worrying.
I emphasise the need for adequate training of doctors. The status of doctors who specialise in this area should also be enhanced. There is a strong case for encouraging doctors to have training, paid for by medical services or the Government, to improve their skills and obtain further qualifications, including a diploma in disability assessment medicine.
The Committee was right to ask whether the objective of contractorisation had been achieved. If improvements are not seen to be happening fairly quickly, the Government should bite the bullet and re-examine the contract.
§ 5.5 pm
§ Rev. Martin Smyth (Belfast, South)
I appreciate this opportunity to make a brief contribution to the debate. I join the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) in paying tribute to the Under-Secretary, the hon. Member for York (Mr. Bayley). I worked with him when he was a member of the Select Committee on Health. He is open and helpful on all issues.
I share the concerns that have been expressed, especially in relation to Northern Ireland. My first concern is that medical examiners should be directed not to look 488 just at the picture presented by the client at the moment of the examination. However, time and again, I discover that that is exactly what they do. They quickly tick the boxes, without listening to the patients who are trying—in sometimes limited vocabulary—to explain their problems.
I thought we had moved on from the situation that existed 15 years ago when I took up the case of an elderly woman. She was asked whether she could walk unaided and, because of her dignity, she replied that she could and showed the examiner how she did so. Mr. Deputy Speaker, you might know, from your Scottish background, that in our Ulster Scots parlance, we talk about doing the rounds of the kitchen. She moved from the table to the dresser, but held on to the furniture all the time; that was supposed to show that she could walk without help. The medical examiner put on the form that she could walk unaided.
One of our traditions in this place is that, during Prayers, we turn towards the Bench. Some people say that the tradition arose because it was easier to kneel on the seat. Not long ago, I was involved with the appeal in the case of one my constituents. The medical examiner had put on the form that the person could kneel unaided. Before the tribunal, I asked my constituent where the medical examiner had asked him to kneel. My constituent had been asked to kneel on a chair. I can kneel reasonably well on the floor, but it is far easier to do so on a chair. To pass that person as having mobility because he could kneel on a chair and could do certain things was ludicrous. That quality of examination does down the service.
One is left with some doubts, because, under the contractual arrangements, the examiners are paid by the hour and by the number of people with whom they deal. Surely, in health and social services, we should be concerned to put the patient first. However, there is some recent evidence that a person in at least one branch of the health profession put his office needs before the care of the patients in his area. That does down the care of people with disabilities. We should be more concerned about them.
I would have no difficulty in removing from the list those people who find a way around the system—who fill in the forms so as to give the impression that they are in a bad way. On the other hand, the job of the medical examiner should be to discover whether the case is genuine rather than to try to get people off benefit.
Only this morning, I spoke on the telephone to the constituent of one of my colleagues, whose case reflects some of the concerns felt by patients when they talk to doctors. She has a girl of 10, vaccine-damaged, and a young man, now 17 years of age, also vaccine-damaged. It transpired that even her own GP had not been given the proper notes from the hospital, and that he was unaware of certain treatment that one of those young people had received, but his guidance to her was that she had a case and should pursue it, either against the firm who supplied the vaccine or against him. She replied, "Doctor, I would not want to bring a case against you as my doctor."
That personal relationship is first and foremost: people trust doctors and are rarely ready to complain about them. I believe that that is one reason why, although the number of successful appeals regarding medical examiners has been growing, some people do not consider that they have a right to appeal, and therefore do not appeal. I believe that the authorities expect people to appeal if they are wrongly turned down, but I am not convinced that they will necessarily do so in many cases.
489 Therefore, we should start by raising the standard of medical examiners. I have not met any. I find it hard to decipher their signatures. They do not turn up to give evidence to support their case when we go to appeal. The matter is left to an adjudicating officer, who must take the decision in the light of the form that the medical officer has returned. That is one reason why I questioned the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) as to what difference he had discovered between Northern Ireland and the rest of the kingdom, but I now know what he intended.
I believe that perhaps in Northern Ireland we are still suffering, with the rest of the regions of the kingdom, because some medical examiners are not doing their job properly in the interests of the client or patient, but are more concerned to fulfil their contractual arrangements, which may be to get through as many examinations as possible in a given time. That is not a proper examination.
I sometimes tell folk, "If there is something wrong with you, you had better go to the vet." They ask, "Why do you say that?" I reply, "Well, when you go to the doctor, the first thing that he will say is, 'What's wrong with you?' whereas a vet has to find out for himself what is wrong with an animal." When I tell my medical friends that, they say, "If you go to a vet, the next thing that he will say is, 'Where's the shotgun?'" In a caring society, we cannot spend our time getting rid of people who may be an economic drain, but who have a right to the facilities and support of society.
§ Mrs. Maria Fyfe (Glasgow, Maryhill)
I congratulate the Select Committee on Social Security on the excellent work that it has done. I am especially glad because I believe that it will give heart to a number of my constituents who have begun to wonder whether there is anyone out there listening. I also welcome the Government's positive response.
However, I am grateful for the opportunity that the debate gives me to draw attention to a few issues. Earlier today, I spent half an hour having the three-yearly check-up that is offered to Members of Parliament, merely as a way of checking on one's general health. I have absolutely nothing wrong with me, yet it took half an hour simply to question me about various aspects that could be wrong with my health. It seems to me that, although it is fine for an examination to be concluded within 10 minutes if it is patently obvious that the person is so severely disabled or ill that there is no point in continuing an examination at length, if someone is likely to be denied either disability living allowance or incapacity benefit, a considerable amount of time should be spent before a person is denied that benefit and a considerable sum of money is taken from them.
Recently, a father in my constituency came to visit me to talk about two sons, both of whom have the same serious illness. Both applied for disability living allowance, and an odd thing happened: the son whose condition is less severe was awarded the higher component and the son whose case was far more severe was denied it. Mistakes can occur in any organisation that deals with so many cases, but there needs to be a quicker way of putting right an obvious anomaly when evidence is presented by a general practitioner and a hospital doctor.
490 I know that hon. Members can provide umpteen examples from their constituency case loads, but I will not weary the House with many of my own. However, a particularly atrocious example is that of a constituent who was denied incapacity benefit, but who two weeks later was in a hospice for those dying of cancer. That is how bad the errors can be.
At present in Glasgow, the waiting time for appeals has been reduced to 16 weeks. It had been as long as a year, so I am grateful for the fact that it has been reduced to a more reasonable level. However, people have to make do without their benefit while they wait all those weeks. Perhaps in other parts of the country people have to wait longer, so I suggest to my hon. Friend the Minister that it might be worth while considering the possibility of allowing people's benefit to be restored if they are forced to wait more than a few weeks. I know that the Department intended that people would do without the benefit because their cases would be heard soon. However, if a case is not heard for months, it is unfair to deprive them of their benefit.
In the report of the Social Security Committee, I found a surprising statistic that I want to place on the record. It says:In 1998–99, the Independent Tribunal Service (as it was then) received 324,067 appeals.That is a third of a million, and the figure relates only to those who appeal. Many other people should receive the benefits, but they are too sick, too tired or too dispirited to make an appeal. Many of the appeals made were successful. The reports points out that 41 per cent. of incapacity benefit and 49 per cent. of DLA appeals were successful. That certainly shows that there is much wrong with a system that decides that people are not worthy of receiving the benefit in the first place. Serious work has to be done on that.
Finally, I refer to a point that I was not going to make until my hon. Friend the Minister intervened on my hon. Friend the Member for Clwyd, West (Mr. Thomas). I hope that no one with a sense of responsibility would want to create fear among people. However people may not provide their names when they make a complaint, because they fear that it will rebound badly on them. My hon. Friend the Minister was right to ask for evidence of that, but those people's life experiences might have taught them that they should not provide their names. They need reassuring that other people have won their appeals and suffered no adverse consequences. To people in that position I say, "Take courage, make an appeal, give your name and address and don't be afraid." However, people must be shown that they should do that.
I know that my hon. Friend the Minister is deeply concerned about this issue. As someone else has said, the Government's response has his fingerprints on it. I welcome that response, but we need reform and we need it quickly. Bad decisions are being taken and, I am sorry to say, they are affecting the Government's reputation. People are becoming worried about how fair this Government are, and I do not want a Labour Government to suffer from such a reputation. I want us to make sure that people can say that the Government are fair to people because they deny benefit to con men, but provide it to those who deserve it.
§ Mr. Desmond Swayne (New Forest, West)
It is always a pleasure to follow the hon. Member for Glasgow, Maryhill (Mrs. Fyfe) and I shall endeavour to be as brief as she has been. As a member of the Committee, I feel that I have had my say on the report and I am interested to hear what other Members have to say about it. The hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) gave a lucid exposition of the report and an analysis of the Government's response, so there is not more that I wish to add.
I wish to draw attention to one point, however. The evidence presented to the Committee was powerful in respect of the suggestion that Sema had made too lean a bid for the contract. To be fair, Sema inherited many of the difficulties that it now faces. After all, we have been told that there has been no increase in remuneration for eight years. Sema's problems did not arise suddenly but its low bid for the contract none the less gave it little scope to manoeuvre and address problems such as recruitment, pressures on doctors to accomplish examinations quickly, remuneration and particular difficulties with training. I wonder if the Minister can do anything to open up those issues before the contract comes up for renewal? I doubt it, but I hope that the hon. Gentleman will consider the matter seriously.
I wish to draw attention to one other matter. The sessional doctors of whom we are often so critical are the self-same doctors to whom other people go for surgery consultations to get prescriptions to make them better. They are not different people. One may find an examination by one's own GP cursory, painful or uncomfortable, but that will not have the same psychological effect—in terms of humiliation and so on—as it does when one finds the sessional doctor insensitive or when he generates pain or discomfort or makes a cursory examination.
Why are people prepared to accept that from their own GP but not from a sessional doctor? There is a psychological difference. People go to their doctor to be examined and given a cure for a problem, whereas a sessional doctor comes to see someone to examine whether they qualify for a benefit or—to put it bluntly—to make sure they are not malingering. Overcoming that barrier and psychological difference requires the sessional doctor to be much more sensitive than a GP has to be. That demands additional training which of course requires additional resources, which brings us full circle to the fact that Sema made too lean a bid for the contract.
§ Mr. Andrew Dismore (Hendon)
I agree with the final point made by the hon. Member for New Forest, West (Mr. Swayne) and hope to return to that later.
This is an opportune time to debate the issue. The report of the Select Committee on Social Security, together with the outcomes of the two seminars held by the Department of Social Security with Sema's officials at the end of last year, operated as a wake-up call for the Department by bringing to the fore criticisms of the Department's medical services, both when they were in-house and now that they have been contracted out. I welcome the Government's largely positive response to the report. I shall highlight areas in which, perhaps, there may be differences between the Select Committee and the 492 Government, but I hope that that will not be taken as detracting from the overall thrust of my remarks, which welcome the Government's response.
I shall start with one or two points about the contract, especially the ratio of scrutiny to examination, which has been mentioned and which sounds very technical. The Committee was concerned that there may be other than logical reasons behind the falling ratio. The Government accept that our concern needs to be examined, and have identified several possibilities. When we considered the matter, the suspicion was put in our minds that the way in which the contract is formulated means that Sema can make money out of doing examinations not by seeing people but simply by going through the paperwork. If it does that and passes someone for benefit that person will not complain about receiving benefit—for obvious reasons. People who may not be entitled to benefit are potentially getting it, and the cost of that is passed on to a different part of the DSS budget. However, Sema is paid the same whether or not it does a full examination or an examination on paper, thus potentially finding a way of making profit out of the contract, which may not have been anticipated.
I am pleased that the Government said in their response that they would view that with unmitigated disapproval and take decisive regulatory action if it were the case. I am pleased that they have given such a strong response to the suspicion expressed by the Select Committee and that they are studying the issue in more detail. If the falling ratio turns out not to have more valid causes, that is a serious matter that needs to be addressed.
I am pleased also that the Government indicate that the contract with Sema allows the Department to share any financial savings if the ratio is found to have fallen for genuine reasons. I make a plea that, if those savings are identified, Sema and the Government should think about transferring the money to the wages of the doctors who, however one views the matter, are not getting a fair crack of the whip, for the reasons given by the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) when he opened the debate.
The issue of complaints has loomed large in the debate. It is a bit rich for the Government to protest that the Select Committee worked on the basis of anonymous complaints. I listened carefully to my hon. Friend the Under-Secretary's intervention on my hon. Friend the Member for Clwyd, West (Mr. Thomas) on that point. The issue is that raised by the hon. Member for New Forest, West, and it is not that people are being victimised because they complain; there is no evidence of that and I have no reason to suppose that it is the case.
We must, however, understand the power balance, or lack of balance, between the claimant, for whom the doctor's decision can mean the difference between living in poverty and being a little, or a lot, better off, and the doctor, to whom the claimant is just one of a dozen that he may be seeing that week. That power relationship inevitably affects the way in which the doctor and the claimant view each other, so even though there is no threat and, as far as I can see, no evidence of victimisation, claimants may perceive that, given the power that the doctor and the Department have over them, it is best to complain anonymously.
I shall turn later to the issue of cultural insensitivity, on which we are again criticised for putting forward anecdotal examples. However, I submitted one of those 493 examples from my constituency case load, and I wrote to the Department about it 18 months ago, so the Department has chapter and verse on that case at least.
We have to make it much easier for people to understand how they can make a complaint, and we have to work to overcome the fear that arises from the imbalance of power in the doctor-claimant relationship. I am pleased that the Government are considering ways of making claimants more aware of the complaints procedure, particularly for those who are examined in their own homes and who, at present, have no direct access to a complaints form.
There is ground to be made up. The National Association of Citizens Advice Bureaux, which wrote to me about this matter the other day, said that it was not surprising that clients found it difficult to get copies of the complaints leaflet because itwas not even listed in the Benefits Agency's most recent catalogue, issued in May 2000.If that is the case, the matter needs to be addressed.
We heard earlier of the 88 per cent. satisfaction rate, but that gives rise to the question of when clients are asked whether they are satisfied with the examination. They have no way of knowing whether what they have told the doctor has been accurately recorded. I accept that if the record is later found to be inaccurate, that can give rise to an appeal, but there has to be a way of dealing with a complaint from a client who genuinely believes that what they have said has not been accurately recorded. At the moment, there is a lacuna in the procedure.
My hon. Friend the Member for Clwyd, West pointed out the need for an accurate medical history. The Department rarely asks for medical records and notes from GPs and consultants. I fully accept the point made by the Department in its response, which is that in those circumstances doctors are primarily concerned with diagnosis, prognosis and treatment. However, like my hon. Friend, I was a personal injury lawyer. I practised in personal injury law for almost 20 years. I cannot recall a case in recent years in which the doctor preparing a report for use in court did not first ask to see the medical records.
The supposition in the Government's response is that issues relating to disability and function might not be dealt with in such records, but, in fact, they are. I have looked at many dozens, if not hundreds, of records while preparing cases over the years, and they often contain that information. The questions that doctors in personal injury cases have to address in court not only involve prognosis, but are rooted in the need to deal with functional disability because that represents the lion's share of any assessment of compensation.
Those doctors are asked to decide exactly the same questions with which Sema doctors deal, sometimes in medical examinations that last only a few minutes. They can do so because they get the history from medical records. It is important to get the history from the medical records when determining whether any pre-existing medical condition is relevant to the case because, with the best will in the world, I have found that many clients are not very good at giving a full account of their medical history. Such information is more easily and quickly obtained from their medical notes.
494 The kernel of all the complaints and submissions that we have received—and, indeed, all the discussions that we have had with hon. Members on both sides of the House during the Department's seminars and during the inquiry—is the way in which the Department treats people. I am concerned that the Department has not followed up our recommendations on claimants with mental health problems.
A separate review of how claimants with mental illness and mental health problems are treated is necessary, because they are special and the doctors involved need special training, especially in considering the degree of functionality. I fully accept that additional training is being given and that the emphasis is being placed on a much more empathic, active listening approach, but such a review is needed.
We criticised the services offered to members of ethnic communities in two main ways, the first of which relates to interpretation services. I am concerned that, as the hon. Member for Roxburgh and Berwickshire mentioned, the Government have not taken up our suggestion that there should be a multilingual notice. The reason given is that it is not consistent with the agency's practice. Perhaps that suggests that there is a question mark over the agency's practice, rather than over the recommendation.
Coincidentally, the Select Committee paid an informal visit to my constituency this morning as part of our pensioner poverty inquiry. Some of this morning's discussions were with ethnic community groups from the Asian and Afro-Caribbean communities in my constituency. We considered take-up, claims and so on, and they made the point that a much more simple claims procedure and face-to-face explanations are needed so that people understand what is happening.
We were given copies of the questionnaires that people must complete. The questionnaire that claimants must fill in is some 20 pages long. It is difficult to imagine people filling in those forms if English is not their first language. Completing the form would be bad enough if English was their first language. People may need interpreters because they do not speak English or have difficulty with it. That fundamental problem must be addressed. Similarly, the medical report form that doctors have to complete runs to 24 pages of questions.
Without an adequate interpretation procedure, and even with interpretation, there is enormous scope for misunderstanding between doctors and claimants for whom English is a second language, or those who try to answer the doctor's questions through an interpreter. Many of the complaints that we have had from ethnic minority communities and those who advise them on such matters arise out of misunderstandings caused, as much as anything, simply by the complexity of those forms.
I am disappointed to see from the Government's response that the Commission for Racial Equality has so far not been involved. From what is said there, that seems to be as much a problem of the CRE as of the agency. I hope that it can be much more involved in trying to deal with some of the problems, but we must not see those examples as merely anecdotal. I return to the fact that there is so much anecdotal evidence that it cannot be disregarded.
NACAB wrote to me yesterday with a batch of other examples. First, a young Somali woman with chronic back pain was examined, although none of the physical 495 descriptors for incapacity benefit were mentioned. She was simply asked to hold out each arm. The doctor remarked that her English was very good "for a Somali". Secondly, a black woman lost benefit after a medical examination when, in a stage whisper, the doctor asked a colleague whether he thought that the client was "faking it".
Thirdly, a Muslim woman felt unable to disclose details of her incontinence to a male Asian doctor. The client felt insulted. The doctor asked whether she was married. When she responded that she was single, she was asked whether she had any children.
Fourthly—we have stressed the need for women doctors—a woman client was visited at home by an examining medical practitioner on a Saturday. The doctor made remarks about the clienthaving a child out of wedlockand fell asleep on her sofa.
Fifthly, a woman client was alone when a doctor called. The doctor asked the woman to go upstairs to the bedroom for a medical examination. The client declined and said that she was on her own, but would be examined on the sofa. The doctor did not want to do that and dismissed her symptoms and complaints.
§ Mr. Bayley
My hon. Friend makes a powerful point to the House, but I am concerned that the Committee has neither investigated the allegations put to it nor asked the Department to do so. The allegations need to be investigated. As a Minister, I asked the Clerk of the Committee to provide the information on who those people are so that we can learn lessons from what happened, and I ask my hon. Friend to ask NACAB to provide the information, which it is often reluctant to supply or cannot substantiate. If it can provide that information, every case will be investigated because we want to get to the bottom of the problem.
§ Mr. Dismore
I am grateful to my hon. Friend and, in those circumstances, I shall not cite the last case, which is perhaps the most appalling of all. I shall tell him about it afterwards. [HON. MEMBERS: "Go on!"] Oh, all right then, since I am being pressed. A woman client of Chinese origin was visited at home by an examining medical practitioner. The doctor asked the client a number of questions about how she came to England and how she "got her children in". The doctor pulled up the client's skirt, revealing her underwear. Unsurprisingly, the client was made to feel uncomfortable. Such behaviour is unacceptable and I am grateful to my hon. Friend for taking a firm view on that.
I referred a constituent's complaint to the Department, with a full explanation. An Irish gentleman had fallen off a roof, suffering a badly fractured leg. When he went to be examined, he was asked whether he was drunk at the time. Assumptions are made about Irish people. I see the hon. Member for Belfast, South (Rev. Martin Smyth) nodding.
§ Mr. Dismore
The hon. Gentleman makes his point from a sedentary position, and my constituent made exactly the same one, because he is teetotal and felt grossly insulted by the question. Stereotyping is the problem. In that respect, I am grateful to the Government 496 for saying that they adopt a serious approach. We must get to grips with these issues and we can do that by spending a little money on ensuring that proper interpretation facilities are available and that people can understand both the claims forms and what is expected of them during an examination. Above all, we must make the system a lot simpler.
§ Mr. Andrew George (St. Ives)
I congratulate the Select Committee on a first-class report and my hon. Friend the Member for Roxburgh and Berwickshire (Mr. Kirkwood) on his introduction to a constructive debate that has highlighted the fact that there is a degree of consensus across the Chamber. If Parliament is responsible for scrutinising the Government, we all have a responsibility to point out that the public out there—our constituents—are receiving a service that is clearly failing in a number of significant areas. We must put that right. That is why we are all present in the Chamber, and we should follow up the debate and ensure that the service is improved.
I hope that the Select Committee will continue to press the Government. I agree with my hon. Friend the Member for Roxburgh and Berwickshire that the Government's response was helpful, but it contained a number of commitments for which there were neither targets nor timetables. I hope that the Select Committee will make sure that those commitments are met. One of the failings that has been highlighted in the debate is the uncertainty surrounding issues such as complaints, audit, pay and training. We need a firmer basis on which to assess the progress that the Government are making.
I shall not repeat unnecessarily points that have already been raised, but I shall try to set the debate in a wider context—the need to ensure that disabled and sick people who want to get back into the job market are enabled to do so. The system should be designed not to stop disabled and sick people receiving benefits, but to focus on their abilities and to smooth their path from sickness and disability into gainful employment. That seems to be what the Government are proposing through personal capability assessments. At present the path is not clear and smooth; for many, it is a precipice, and the process becomes understandably stressful.
I was one of the new intake of Members of Parliament, although we are not new any more. We all recognise that we do not have people queueing up at our casework surgeries to congratulate the Government on not taking their benefit away. They come to our constituency surgeries to complain when that happens.
In comparison with the Child Support Agency, the medical services are not doing too badly—[Interruption.]—but as hon. Members say from a sedentary position, that is to damn with faint praise. The CSA is a rather poor benchmark against which to judge the performance of the medical services. Many hon. Members find that after the CSA, one of the most prevalent issues with which they have to deal involves the former all-work test, the problems with the medical services and the difficulties that people experience in comprehending how the system is supposed to work, even when their disability is clearly demonstrated by their evidence to their Member of Parliament.
The number of appeals that we know about, and the proportion of cases in which appeals are upheld and benefits restored, show that the system is not working. 497 It is not working in a number of ways. If the Government intend to reduce to 10 per cent. the failure rate of the medical services to meet professional standards, they are setting the rate too high. Poor quality reports result in poor decisions. Although arrears will ultimately be reimbursed to those whose benefits are wrongly withdrawn, the process still results in trauma and poverty.
In addition, to mount an appeal a claimant must obtain additional medical evidence, which may be costly. For example, Carol Simons, a Leicester resident who successfully challenged a decision to refuse her claim to incapacity benefit, had to pay £40 for additional medical evidence to support her appeal. A Leicester city council report reveals that charging for medical reports is widespread, with charges ranging from £11.50 to £60, with some doctors charging more than £100 an hour. Not only does withdrawal of benefit mean trauma and poverty, but an appeal to have it reinstated costs money. The disabled person is clearly not at fault, but he must still pay, and no one will reimburse him. Clearly, the system is failing there.
From the disabled person's point of view, the system is self-policing. As has been pointed out, its approach to mental health is inadequate. The hon. Member for Hendon (Mr. Dismore) articulately described cases showing that ethnic minorities and others with language problems have also had to face prejudice and difficulties from the service.
The British Medical Association has requested a meeting with the Minister and medical services, but has yet to receive a reply. As has been pointed out, the fact that doctors have not had a pay increase for eight years is clearly a matter of deep concern. The fact that the Government intend to apply valid measures of professional services, but have not worked with the BMA in devising them, is also a matter of concern. Free training for doctors has been dealt with inadequately, as a number of hon. Members have said.
In September 1998, in a letter to my hon. Friend the Member for Bath (Mr. Foster), the Under-Secretary, the hon. Member for Wallasey (Angela Eagle) said:the intention is that a new fee structure will be introduced which will be linked to the quality and effectiveness of the work.The BMA informs me that it still awaits a new fee structure. Apparently, medical services offered a pay increase of 3 per cent. in February 1999, which the BMA rejected. We need to be clear about the status of those negotiations and what the Government intend to do to move them on. Clearly, doctors are unhappy about their pay, and one can understand why.
In delving into the subject, I was concerned about whether the system could adequately pick up some of the less common illnesses suffered by those on incapacity or other benefits, and I looked up Guillain-Barré syndrome. I also looked up ankylosing spondylitis in the disability handbook published by the Department of Social Security. Its purpose is as follows:The handbook is intended primarily to help adjudicating authorities to assess the medical evidence presented to them.Ankylosing spondylitis is a condition that I have. I am sure that my intellectual handicaps are obvious to all, but my physical ones may not be apparent. I have only a mild form of ankylosing spondylitis and I did not recognise the 498 extent to which some people are crippled by it. It affects their legs and hips and they are unable to walk. That is not identified in the handbook.
I contacted Professor Richard Hughes, who is head of the division of clinical neurosciences, about the Guillain-Barreé syndrome. I asked him to read the guidance that is provided in the disability handbook with regard to it. In his response, he stated:The section on 15.6 is so seriously inaccurate that I have been unable to revise it in any simple way.He offered an alternative text book for consideration. As I have said, Professor Hughes is the head of the division of clinical neurosciences of Guy's, King's and St. Thomas' school of medicine. It is clear from the two texts that the handbook attempts to diminish the potential impacts of Guillain-Barré and the way that it affects the patient. If that is the case with Guillain-Barré, to what extent is the rest of the handbook adequate in providing an accurate assessment for adjudication authorities when considering the evidence that is presented to them?
I suspect that the Minister may comment on the fact that the Government are introducing personal capability assessments in one pilot area. To what extent has the Minister learned from these assessments and when will they be trialled or moved into other areas? Is there evidence that is helpful to the debate?
We take the same view as the Government. We talked about personal capacity tests, while the Government call them personal capability assessments. However, we are considering the capability of a client rather than his or her incapacity. While we may argue about something being half full or half empty, we wish the Government to take a different approach. If we are to encourage and enable people who are disabled or sick to have work trials and to move back into the employment market, we need to support that with a social security system that allows them a smooth passage back into the world of work.
§ Mr. Eric Pickles (Brentwood and Ongar)
The hon. Gentleman's points about personal capacity are interesting. Will he confirm that the medical test for the personal capacity assessment is identical to the one for the all-work test?
§ Mr. George
The hon. Gentleman has asked me a question that I am about to ask the Minister. As far as I am aware—
§ Mr. George
I am grateful for that clarification. Perhaps the Minister will comment on the relevance of personal capacity assessments and the effect on our debate in his winding-up speech.
The report provides a picture of a service that is driven by profit, and not necessarily by quality. From the report, medical services appear to provide the minimum that they can get away with and to maximise their use of the scrutiny rather than the examination method. Many doctors are poorly paid; many of our constituents have been treated brusquely and impatiently, and some have, sadly, suffered rudeness, insensitivity and racism. The system operates without a proper, independent complaints procedure or independent audit.
499 As I said earlier, the Government should reconsider their response to the Select Committee report and provide clearer targets and timetables to deal with the important issues that have been raised.
§ Valerie Davey (Bristol, West)
I welcome the debate, and I know that constituents who have visited my surgery because they have suffered traumatic experiences as claimants also welcome it. I stress at the outset that my hon. Friend the Minister has always responded with understanding to the individual cases that I brought to his attention. He has looked into them, and I respect his concern for the subject that we are considering.
If only a handful of cases existed, perhaps they could be tackled individually. However, through talking to other hon. Members, especially in the Bristol area, I have begun to perceive a pattern of anxiety. I therefore welcome the Select Committee's report, especially as its members visited Bristol and were able to take direct evidence. I welcome the reference by the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) to that experience.
Wide experience has been gained by the Avon and Bristol law centre, to which many people have brought their cases. I want to draw on that experience in presenting four main points. The importance of communication is paramount. When the hon. Member for Roxburgh and Berwickshire mentioned his Bristol experience, he talked about the way in which dedicated professionals and people bringing complaints showed completely different sides of one coin. That is worrying, and I am glad that the hon. Gentleman brought it to light. As has also been said, if English is not a person's first language, the disparity and the scope for misunderstanding is even greater.
The first point that the Avon and Bristol law centre emphasised to me was the importance of the Select Committee's recommendation that all claimants should be clearly told in initial correspondence with medical services that they have the right to request the presence of an interpreter. Like some hon. Members, the Avon and Bristol law centre was dismayed by the Government's response. It would like interpretation services to be expanded throughout the Benefits Agency rather than pulled back. It asks the Department to investigate further the cost and benefit of a policy that would mean greater use of interpreters. From my experience of constituents who have come to my surgery, I fully endorse the law centre's first point.
Secondly, the Avon and Bristol law centre would welcome greater recognition by the Government that there are a small proportion of appalling reports and a larger proportion of substandard reports. It requests that other organisations—advice agencies and the BMA—monitor the reports.
The Avon and Bristol law centre's third point is about racism. Based on its experience, it believes that the Government have been too dismissive of the Committee's findings. It supports greater participation by the Commission for Racial Equality in training doctors. It was felt that the Government should make a real commitment to the investigation, and to rooting out racism. 500 The fourth issue was that of complaints, to which many others have referred. The Avon and Bristol law centre feels that the whole procedure needs to be overhauled. It says thatConsultation…with organisations such as the Law Centres Federation and the Federation of Independent Advice Centres, as well as NACABwould be welcome.
The Bristol centre commented specifically that there had not been a single admission of fault, and that there had been no apology. Given the complexity of the organisation and the number of people involved, the failure to admit to a single mistake is inhuman. It is a reflection on the system that no one was prepared to make an apology, or to admit to a mistake.
Nevertheless, I want to end on a positive note. I welcome the report and, indeed, the Government's response, which is positive on the whole and which—in the hands of the Minister—will, I trust, be explored and developed fully. Similarly, the Avon and Bristol law centre welcomed the commitment to a diploma course, which was seen as an important step. It also made special reference to the training that is now being recommended for those who must deal with people suffering from mental health problems. It said that mentally ill patients had specific requirements in terms of those dealing with them. I am sure that the provision of more training would be welcomed by all concerned.
This is an important debate for many of the most vulnerable people in my constituency and those of my hon. Friends. I trust that the Select Committee's admirable report, which has done a remarkable job in a difficult sphere, will be taken on board by the Minister, the Department and the Government, and that the points made by the Avon and Bristol law centre will be considered.
§ 6.2 pm
§ Ms Linda Perham (Ilford, North)
I, too, congratulate the Committee on its report, and welcome the Government's response. I also thank the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) for letting me know—as a person who signed the early-day motion—the timing of the debate. As I am sure many hon. Members know, on Thursday afternoons, the calls of the constituency are sometimes greater than those of the Chamber.
The great majority of cases concerning problems with disability living allowance or incapacity benefit that come to me concern assessment by Sema, on behalf of Benefits Agency medical services. People who have been unable to walk a few steps from their doors to my surgery have been assessed as "fit for work". In those cases, there have clearly been shortcomings in the conduct of medical examinations, especially with regard to the time that they have taken. Others have mentioned that.
In some cases, a doctor has been present for only 10 or 20 minutes, and a report has subsequently stated that the person concerned was able to engage in an activity for much longer. On at least one occasion that I remember, an assessment included comments on a person's appearance. For instance, someone was described as an "obese lady". That person was very upset when she saw the report.
A woman who lives near me in north Ilford has been unable to work for nearly 20 years because of her spinal problems. Over the years, when examined by doctors at 501 our local practice, at local hospitals and by those whom she describes as "Government doctors", she has been told many times that her condition can only worsen. According to a letter that I have from her, the examining doctor said that she could not sit comfortably for more than two hours. She says that she cannot sit comfortably for more than 10 minutes. No points! The doctor said that she had no problem with rising after sitting down; she says that she cannot get up without holding on to something—"usually my husband". Again, no points The doctor says that she cannot walk more than 800 m without stopping or severe discomfort. She says that she cannot walk more than 200 m without stopping or severe discomfort—again, no points on that assessment.
Looking through the report's recommendations and the Government reply, I can say on behalf of my constituents that a good number of their concerns have been addressed. They include the time spent with claimants, which my hon. Friend the Member for Clwyd, West (Mr. Thomas) covered in some detail; the quality of reports; the recruitment, training and monitoring of doctors, which is important, and how poor performance is dealt with; and communication difficulties and providing interpretation services, which my hon. Friends the Members for Bristol, West (Valerie Davey) and for Hendon (Mr. Dismore) highlighted. He also touched on the availability of female doctors to examine women, especially those whose religious or cultural background precludes contact with males outside the family circle.
The complaints procedure was another concern. From looking at the report, Sema is conducting a review, but it is disturbing that so many claimants are appealing, rather than complaining. That is dealt with in the Government's response.
All in all, it is a thorough and much needed report. I look forward to improvements in service for a lot of anxious and deserving people, who are already facing lives full of frustration and pain.
§ 6.6 pm
§ Dr. Peter Brand (Isle of Wight)
I welcome the report. I have practised as a general practitioner for 25 years and have had to go through the agony of some of my patients' contact with the Benefits Agency in its medical manifestations. Not much has changed to date. In fact, matters got a lot worse during the dreadful benefit integrity project, when there seemed to be a witch hunt.
The thing that concerns me most is that we are asking doctors who work for the Benefits Agency—they did so in the past directly, but now do so through Sema—to do their job wearing a blindfold, or blinkers at best. As the hon. Member for Clwyd, West (Mr. Thomas) pointed out, history is important when making an assessment, but so is examination and having access to the result of investigations. We do not have an integrated system where relevant knowledge is made available.
We are not just talking about disbursing £25 billion of public money, although it is right that we should take that seriously and target it at the right people. Decisions by the Benefits Agency can have a dramatic impact on people's clinical outcomes. For the Benefits Agency to say, "Go back to your doctor and get another certificate," adding in brackets—it is never stated—"Make sure that it is for a 502 different condition, so that we can restart your claim," is nonsense. A doctor can write a further certificate, but that does not reinstate the benefit for that patient, unless we are being particularly clever about something.
One sometimes sees the real effect. We get these amazing decisions by the examining doctors who will not accept the history given by the patient and who will not take steps to ensure that investigation results are available to them. That means that the appeal mechanism gets triggered, if the patient is well advised. However, many patients do not have that level of advice.
The internal system that BAMS used to have, and which still exists, involves having an assessor. Those decision makers are not competent either. I do not think that they are empowered to ask for more information so that a reasonable decision can be made.
I urge the Minister really to examine the contractual relationship between the Department of Social Security and the Department of Health, so that the Benefits Agency can buy more relevant information from the national health service. I realise that that information is not a free good and takes time to produce. Although I take the point made by my hon. Friend the Member for St. Ives (Mr. George), doctors are busy people and are expensive. Their time will be paid for either by the national health service, as part of their contract, or by a fee of some sort. I think that it would be helpful if the fee were a bit more up-front than it is now. The routine bits of paper that doctors are asked to fill out are of so little value that they really are not designed to give the Benefits Agency the information that it should have.
As I said, we are debating not only the disbursal of £25 billion, but a clinical matter. In the past few years, I have had a couple of cases that are perhaps relevant to this debate, one of which involved a relatively young man with unstable angina. He was trained to be a builder's labourer. He was not a very bright chap. He was assessed under the all-work test and was told that he was fit to go to work. However, he was not competent to do anything except heavy physical work—no other job was available to him.
The man was driven back into work, until I stopped him by telling him that he would drop dead. I am very glad to say that, soon after, he had his heart surgery. Now, he is much more stable and is even back at doing some good physical work. However, he is doing that within his own limitations.
In the letter that I wrote for the man—incidentally, I did not charge for it—I asked the Benefits Agency who would represent it at the coroner's court should he drop dead after returning to work. I did not receive an answer from the agency, but it reinstated his benefit. It really is appalling that one has to go to such lengths to achieve the right result.
Another case involved a man who was a gas fitter—which involves lots of crawling around little holes and turning one's head upside down—and had an unstable spine. He had very clear neurological signs, down his legs and his arms, of an unstable cervical spine and was awaiting surgery for it. Again, a clever person said that he was fit to go to work. If that man had continued in his job, he could have become a tetraplegic. Again, it was necessary for one to make that point so clearly, although any clinician worth his salt would have worked it out.
503 The Government acknowledge that there is an extraordinarily high rate of success in appeals. I must congratulate my constituent, Dr. Ralph Gasson, who is a doctor of divinity and devotes his life to representing people at appeals. He does lots of them, and has a better than 90 per cent. success rate. There really is something wrong with a system that allows that to happen.
In response to the Select Committee, the Government said:A successful appeal does not necessarily indicate that the medical report was substandard.I think that that is nonsense. A successful appeal may not indicate that the medical examiner was substandard, but it does indicate that the methodology for acquiring the medical information required for the report was extremely substandard.
People should not have to have an appeal before receiving what they need. Let us face it, benefits are just as much part of the health package as any direct medication, physiotherapy or occupational therapy.
My final plea—I do not think that this issue was addressed by the Committee—is that we should have not only a better and smoother way into work, with better therapeutic earnings allowances and tax credits, but a way of dipping into work and coming out of it again if it does not work out. Many people are reluctant to take that step because they know that their mortgage interest payments, for example, will not be reinstated until quite a long time after they have discovered that they cannot cope. That is particularly important in respect of mental health, but it also applies to other areas.
Generally, people are keen to make a contribution, but the present system seems either to goad them with very crude pushes or to put up barriers. I hope that the excellent report by the Select Committee will goad the Government into taking positive action.
§ Mr. Eric Pickles (Brentwood and Ongar)
It is a great pleasure to follow the hon. Member for Isle of Wight (Dr. Brand). He was looking rather ashen-faced when we were discussing doctors' remuneration, but we are grateful that he stayed. I found his final point about people coming off benefit most interesting. Last year, the Minister and I served on the Standing Committee considering the Welfare Reform Bill, which made certain changes to protect the benefit claimed by disabled people. That was a welcome step and it might also be appropriate in respect of incapacity benefit.
I, too, would like to congratulate the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) on an outstanding report. I know that we always thank the chairmen of Select Committees and say that they have produced thorough reports that we are pleased to debate, but this is an excellent report. Since I have been a Front-Bench spokesman on these issues—and it has been two years now—I have been fortunate enough to consider a series of really good reports at a time of quite rapid change in social security. I am most grateful to the hon. Gentleman and the Select Committee.
I do not want to cause the Minister any embarrassment or discomfort by saying that the Government's response to the report is well rounded and most welcome. It is sensible in its general approach, with one exception, to which I shall turn in a few moments.
504 The report deals with a service that is undergoing an enormous transformation. After all, it is only a relatively short time since the Government took the sensible decision to privatise the service, and it is fair to say that it is a good idea to monitor the great changes that are under way.
At times during the debate, we rather lost sight of what the Government were seeking to achieve, which is set out on page 1 of their response:The Government chose the option of contracting-out because it believes that the public is entitled to good quality public services. What matters is what works.A couple of weeks ago, a Labour Member reminded me about a quotation from Deng Xiaoping, who I think is very new Labour in his general approach to most matters. He said that it did not matter whether the cat was black or white, so long as it caught mice. I feel that the report enshrines that general principle. We stand by the Government's privatisation programme and hope to see more.
There have been considerable changes during the inquiry and since the report. We know that, generally, better accommodation has been available in which to carry out examinations; there has been a shorter waiting list; waiting times have been reduced and there have been some improvements to the audit system. However, the Select Committee was quite right to identify problems with regard to quality, timing and, most crucially, training.
The hon. Member for Roxburgh and Berwickshire talked about benchmarks and said that it would have been better to have had some idea of how bad the system was before the process started. The hon. Member for Belfast, South (Rev. Martin Smyth) gave us an idea as to what the system was like before the changeover, and how it operates in his constituency. There was also a problem in respect of the specifications of the contract that was sent out. That is a common difficulty in central and local government.
It is a common problem that people become anxious about matters that are not in the contract. The Committee's report mentions structural problems, and there is always some tension about omissions from contracts. When I was on a Select Committee, we had discussions about specifications for railways and we had an interesting witness appear before us. I asked him why problems were experienced in meeting the specifications and he said, "As a general rule, meeting specifications within a contract is a bit like walking on water. It is easy to do if both are frozen." In this case, items missing from the contracts have created much of the problem.
It is indicative that the contracts contained no medical quality targets, only medical standards. My hon. Friend the Member for New Forest, West (Mr. Swayne) mentioned the problem of lack of pay for training, but much of the training requirement was additional to the contract. Of course, Sema bid on a tight basis for the contract and has ended up funding things that were not part of the contract price. In the process of re-examination of the contracts, we should perhaps ensure that quality targets are included in matters that are put out to tender.
My experience of such matters goes back eight or nine years and I believe that things are getting better. Hon. Members have described the current problems, and dreadful cases still arise to which hon. Members will wish 505 to alert the Minister, but there is a general feeling of improvement. Much of the frustration that revolved around the old all-work test was really about assessment, because, before the changes were made, there was no real way to judge matters.
I have some points to make that may be unfashionable and go against the general tenor of the debate with regard to desk-top scrutiny. I accept what the hon. Member for Hendon (Mr. Dismore) said about the risks, but there is a risk the other way. It would be worse if, in order to prove that everything was above board, we forced people to go through medical examinations when it was obvious from the medical documentation and case history that there was no need for them to do so. I cannot see the point of putting people through the anxiety of a medical examination when it is obvious that they will not pass it. The hon. Gentleman is right about the need for proper scrutiny, but it would be wrong to force people into medical examinations, thereby increasing the waiting list, for reasons of financial control, when their illness is evident.
I said that the report was excellent. However, the response on mental illness was rather smug. There was something of the Mr. Nicely-nicely about it that I found unacceptable. The Committee's recommendation (h) is thatthe Chief Medical Adviser instigates a review of Medical Services' treatment of claimants with mental health problems.That is a good recommendation that will improve the whole process.
Paragraph 33 states:Recently as part of the Personal Capability Assessment (PCA), development and thorough evaluation of methods assessing effects of mental health problems on ability to work, have gone some way to meeting that challenge.I think that that is wildly optimistic, and that the changes have gone only a little way in that direction. Baroness Hollis said last year:There are 200 advisers in the field who have gone through an average of 200 hours of training—and in some cases 300 or 400 hours—working towards established qualifications such as NVQ3.—[Official Report, House of Lords, 13 July 1999; Vol. 304, c. 214.]That gives an idea of the logistical problems facing Sema in getting training in place.
The briefing that all hon. Members have received states that Sema is putting doctors through a three-day induction course, which will deal with cultural awareness, mental illness, post-traumatic stress, disability discrimination and chronic fatigue syndrome. That is all very sensible, but the nature of people receiving incapacity benefit is changing. Twenty-odd years ago, 9 per cent. of people had a mental illness; 10 years later, in 1988, the proportion was 16 per cent., and last year the figure was nearly 30 per cent.
We cannot say that significant changes have been made in the process of benefit payments when forms such as the one displayed a little while ago by the hon. Member for Hendon place so much emphasis on physical condition. The forms for incapacity benefit and disability living allowance are difficult for people with a mental illness or disability to complete and thereby make a claim.
Hazel Ruane of the National Schizophrenia Fellowship wrote a letter on 14 June to my hon. Friend the Member for West Chelmsford (Mr. Burns). It was passed to me by 506 my constituent Mrs. Murphy, on whom I rely for up-to-date information on the care of schizophrenia. The letter states:In fact, the plight of persons who are currently unemployed for reasons of mental ill-health is being made far worse by the present, growing trend of summarily stopping the payment of disability allowance for sufferers of schizophrenia, manic depression and other serious disorders. This may be an attempt to improve the statistics leading to the next election when, no doubt, there will be some self congratulation from the government regarding supposed achievement of manifesto targets… So, far from improving the implementation of care in the community, this haphazard termination of disability allowances is bound to damage it entirely.A similar letter was sent to the Secretary of State.
There needs to be a balance to ensure that people with a mental illness or disability are not excluded from employment. We do not suggest that such people should be excluded from getting work, but the balance must be considered very carefully, and with sensitivity.
I have a couple of illustrations. I recall seeing the Minister and some Labour Members a couple of days ago at an Alzheimer's Disease Society reception. I talked to a lady there who had been through the assessment process. She had been asked whether her husband could walk a particular distance. Of course he could—her worry was whether he could find his way back home if he wandered off while he was walking that distance. That was not taken into account during the scrutiny of the case. She had to fight very hard to get that idea across.
As for schizophrenia, there was a difficult case at my advice surgery involving a constituent who had gone through the process. Her son was asked how high he could raise his arm above his head, but my constituent was more concerned about his ability to organise his affairs.
Someone who suffers from manic depression may give a false impression of their state of health. If manic depressives are asked how they feel, they say, "Life is wonderful, I feel great. I can do anything; I'll apply for anything. I really want to go out to work." Then, with just a click of the fingers, everything changes. That is not catered for in the forms and the way in which the assessment is made.
We have come a long way in the way that people with a mental disability are treated. However, we are a long way from achieving the sensitivity that is necessary for the various medical assessments. Life is pretty much stacked against people who are mentally ill or suffer from a mental disability. We must deal with them sensibly, and the tests that we apply should reflect that.
We all received briefing documents today from MIND, which supports the report of the Select Committee on Social Security. Given the narrow nature of our objection to this report, which by and large we endorse, I ask the Minister to look again at that recommendation and see whether he can change the Government's mind with regard to reassessing the process, from the form onwards. If he succeeds in doing so, that would be the icing on the cake for this excellent report.
§ The Parliamentary Under-Secretary of State for Social Security (Mr. Hugh Bayley)
I start by echoing the sentiment expressed by many right hon. and hon. Members in thanking the Select Committee on Social Security for producing this report. The Chairman and 507 members of the Committee have provided a service to the House in throwing a spotlight on an area of public policy that needs to be improved. The Government are strongly committed to improving both the administrative efficiency of the way in which medical reports relating to benefits are conducted, and the medical quality of those reports.
Let me start with the quality of the service that we inherited from our predecessors when we came to power three years ago. Our view was that the previous in-house service—the Benefits Agency medical services, or BAMS—was not performing satisfactorily in the areas of administration or medical quality. One of the first tasks in which the Government engaged after the election was to consider ways of changing the culture within the medical service and improving standards of service to the public.
We decided that we would be more likely to achieve the changes that were necessary by making a fresh start with a new organisation. That was fundamental to the decision to go ahead with putting the work out to contract. That was based on many years of experience of running an in-house service.
Contracting out the service meant that standards of performance had to be defined, which had never happened before. They had to be put on paper so that people knew what was expected of them and performance could be measured. That was done in the contract, and data are collected monthly to compare performance in medical services against the standards set out.
Some of the standards are administrative. For example, there is a requirement that 95 per cent. of incapacity benefit examinations should be conducted within 50 days. In September 1998, when Sema took over the contract, achievement of that standard was 75 per cent. Now, the target has been hit in all three areas of the Sema contract. By April 1999, it had been achieved in the south-western area; by June 1999, it had been achieved in the north; and, by November 1999, it had been achieved in the south-east.
A second administrative requirement is that 95 per cent. of disability living allowance examinations should be conducted within 20 days of being requested. In September 1998, when Sema took over the contract, only 62.5 per cent. of examinations were made within 20 days. That was the standard of performance inherited from BAMS. Now, 95 per cent. has been achieved in two of the three areas. The target was hit in the north-west last October, and in the south-west in November. The target is still not met in the south-east, however, where 87 per cent. of DLA examinations were conducted within 20 days in May. Improvements remain to be made. None the less, there have been major, measurable and demonstrable improvements in the administrative efficiency with which Sema provides a service.
Other standards in the contract relate to the quality of medical work conducted by doctors. For example, the proportion of reports graded A, B or C is measured. As the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) said, a C report is not fit for purpose, a B report is fit for purpose but not perfect, and an A report fully meets all requirements under the contract.
A further example of medical quality standards is the proportion of doctors who complete required training. As I told the Committee some months ago, we have not yet seen a demonstrable improvement in the medical quality of the work being carried out. There has been no deterioration, but no improvement either. I am concerned 508 about that. Our principal aim in contracting out the service—we had many aims, but this was the main one—was to improve the medical quality of reports written by doctors. Sema shares our concern, and we—in the shape of the Government's chief medical officer—will work closely with the company to improve the medical quality of reports and the quality of customer service provided by doctors.
I shall say a little about standards of customer service. Sema employs more than 3,000 doctors, most of whose work fully conforms with the standards set out in the contract. Good practice in terms both of medical quality and customer service is the norm, but there are still too many cases—a small minority, but too many—of bad practice. All complaints are investigated, and we find some are justified and others not. In some cases, where there is a conflict of report between the benefit claimant who has complained and the doctor who conducted the report, it is simply impossible to tell where the truth lies. We must address that matter.
The Select Committee's discovery that there was a problem over the public perception of Sema and its predecessor, BAMS, was not new. Before the Committee instigated its inquiry, I had called two meetings for Members in the House—as the hon. Member for Roxburgh and Berwickshire acknowledged—so that they could give me case studies that demonstrated their concerns. I wanted to collect and learn from such examples in order to discuss the problems with colleagues. I also wanted to explain the improvements that we are undertaking: in recruitment standards; postgraduate medical education; in-service training; the base for professional standards—the new diploma in disability assessment medicine; and in the quality of clinical advice to doctors.
I held two meetings because there was such a large response from hon. Members who wanted to express concern; so many wanted to attend the meeting that they could not reasonably be accommodated in Committee Room 14. Those meetings may have been one of the many factors that prompted the Select Committee to investigate the matter.
To follow up those discussions with colleagues, I convened—with the help of the National Association of Citizens Advice Bureaux—a series of regional meetings throughout the UK, so that welfare rights advisers from CABs, local authorities and other bodies could share with us their experience of problems with the service. That was extremely useful. As a result of those meetings, Sema is revising its complaints procedures, as we recorded in our response to the Committee's report; that action was welcomed by many hon. Members.
I shall outline my priorities, as the responsible Minister, for the year ahead. Above all, I want to achieve significant improvements in medical quality. I took advice from the Department's chief medical adviser on which of the indicators that we use regularly to collect data under the contract best showed medical quality. In our response to the Select Committee, my right hon. Friend the Secretary of State set out challenging targets for Sema on four specific matters.
The first was that, within one year, the percentage of C grade reports, across the whole spectrum of benefits, should be reduced to less than 5 per cent. I point out to the hon. Member for St. Ives (Mr. George) that we do not 509 want a reduction to 10 per cent. In the first six months, we want the proportion reduced by 10 per cent., with a reduction to 5 per cent. overall. The figure of 5 per cent. is higher than I would like, but is nevertheless a challenging target to meet in a year. Sema will have to work extremely hard to hit that target. We believe that it is achievable—as does Sema—but it will not be easy. If we achieve that target, we shall consider how we can do even better in the years to come.
Secondly, within one year, we require Sema to improve its compliance with the scrutiny guidelines for incapacity benefit claims so that the proportion of non-compliant reports falls below 5 per cent.
The third target is that, within one year, we require Sema to deliver training for all doctors in three categories. We have decided to set outcomes as a target—the fact that doctors complete the training courses, rather than that they undergo a specific number of days of training.
We, jointly with Sema, have selected three categories. First, there is to be a course on assessment of people with mental health problems, which is an issue that several hon. Members have raised. Secondly, there is to be disability awareness training. Thirdly, Sema has developed a new training package on how to avoid creating distress among people with musculo-skeletal problems—the biggest single group of people claiming incapacity benefit—by using what I would describe in lay terms as a hands-off examination process so that, where there is an alternative, people are not manipulated and do not have their joints moved by the doctor. Of course, on occasions, manipulation will be necessary, but the package covers alternatives to that.
Our fourth target is to improve customer satisfaction rates by 90 per cent. within two years.
After setting those targets, not before, the Government discussed them with Sema. Therefore, they were not targets set by a process of bargaining or negotiation; they were targets set by the Government because we believe that they are attainable, and we believe that they will make a significant difference or reflect a significant improvement in medical quality. We have since discussed them with Sema. It agrees with us that they will be extremely challenging, but it also agrees with us that they can be met.
I shall now respond to the contributions that hon. Members have made to the debate.
§ Mr. Kirkwood
Those are very helpful confirmations. Do I understand the Minister to be saying that those performance improvements are being required of the contractor without any compensating financial allowances?
§ Mr. Bayley
Yes; that is exactly what I am saying, and those targets are targets which the contract itself requires a contractor to meet, so it is not a matter of requiring a contractor to do anything other than what the contract already states. We set the contract in order to drive up medical standards. We have not seen that reflected in the monthly reports. We want to see it reflected. Sema, too, wants to see it reflected. That is our approach.
Perhaps I should comment on a point raised by many hon. Members, including my hon. Friend the Member for Clwyd, West (Mr. Thomas) and the hon. Member for 510 Roxburgh and Berwickshire, who were unhappy with the concern expressed by the Government that no attempt had been made to check the reports of fault with medicals that had been brought to the Committee's attention by citizens advice bureaux and quite a wide range of voluntary bodies. I am not in any sense, and nor are the Government, complaining that the Committee should not collect that sort of evidence.
As I explained in an intervention in the speech by my hon. Friend the Member for Hendon (Mr. Dismore), the reason that I became worried was that I wanted to investigate some of the complaints to find out what had happened. Perhaps I can explain my concern to the House by focusing on one group of complaints—the group of complaints about racism or cultural insensitivity. In the report, the Committee cited five identifiable but anonymous cases. The Committee, because it had received information about those cases anonymously, could not give us information—even confidentially—to allow us to identify those cases.
We have been able to identify two of the cases from the circumstances described by the Committee, and in both cases the Committee's description of the circumstances accurately reflects what happened. In both cases, the doctor concerned, who had behaved quite inappropriately, was suspended and retrained. Both doctors are now back at work. Obviously, their work is being monitored in the way that one would expect after such an occurrence, and no further complaints have been received.
I simply put it to the House that the complaint has been made, and that inappropriate behaviour has occurred in a very few cases, quite reprehensibly and quite wrongly, but that in response the Government have done exactly what the Committee and the House would expect us to do—to suspend the doctor, to address the issue through training and then to monitor the change in the performance of the doctor that occurs after training. My hon. Friend the Member for Hendon cited several other cases, and I hope that he can persuade his informants to release the facts about them, so that we can examine them closely.
The hon. Member for Roxburgh and Berwickshire made an interesting and important point about benchmarking. Had the contracts gone to three different companies, we would have been able to benchmark one company against another. I am considering the issue further, but we can, to some extent, benchmark between the different areas. In relation to administrative efficiency, I said that we were able to compare the performance of each of the three areas. That is useful, but we may be able to consider other ways of benchmarking. I need to inquire into that further.
The hon. Gentleman, like my hon. Friend the Member for Hendon and the hon. Member for New Forest, West (Mr. Swayne), asked whether enough money was in the contract to deliver it. We expect Sema to deliver a 4 per cent. saving each year, which is broadly what would have been required of BAMS if it had remained an in-house contract. I confirm that Sema expects to make a profit on the contract, although it expects to make less of one than it would on an information technology contract in the sector in which it has been working for a long time.
When one contracts out a service for the first time, it is difficult for us as a Government, and for those bidding for the work, to get costs right. We had an open-book 511 policy and bidders were able to examine the way in which we conducted the work, to examine our expenditure and to look for ways to make management savings. However, when a private firm bids for a contract, it hopes to make a profit and it also accepts risk. That risk justifies the profit, and it would be intolerable if the Government were expected to remove all risk and to contribute large profits to companies when they bid high and obtain the work. Some Members on the Opposition Benchers are nodding agreement, and if a company bids low, it must accept the risk attached to that. Nevertheless, we believe that the cost of the contract is broadly comparable to what the service would have cost in-house and that it is perfectly achievable. Sema also takes that view.
My hon. Friend the Member for Hendon raised an interesting point when he asked why we did not negotiate to get some money back because of a fall in the scrutiny ratio, and then redistribute it in the form of remuneration to doctors. In a roundabout way, that is what we are doing. I told the Committee that, each year, we have an annual negotiation over the cost of the contract with the contractor. We make various bids for the return of moneys when, for example, there is a fall in the scrutiny-to-examination ratio, and the contractors make bids for additional costs that are not covered in the contract.
This year a six or seven-figure sum has been returned to the Department in relation to costs that have not been incurred by the company, and those include the costs not incurred in scrutiny cases. We have also decided to pay a similar sum—albeit not such a large one—to the company in respect of additional work principally for the introduction of a personal capability assessment. Although the incapacity element of the personal capability assessment test is exactly the same as for the incapacity and the all-work test, an additional part of the test examines personal capacity. Therefore, in a roundabout way, the Government are saving money on scrutiny and it is being recycled to the contractor to pay for more extended medicals in the form of personal capability assessments. That will be reflected in the expenditure that the company makes on doctors and doctor's time.
I return to the point about multilingual notices. Perhaps I should start by saying by saying that, on reflection, I do not defend the statement in the Government's response which says that as we do not have multilingual notices in the form suggested by the Select Committee in other parts of the Benefits Agency, that is a jolly good reason for not having them in BAMS. I agree with hon. Members on both sides that that is not a good argument. One should look at the merits of the case, and I give the House an undertaking that I shall do so.
Incidentally, it is not true that we do not have multilingual notices. The Service First unit in the Cabinet Office produced a report on the attitudes of people from minority ethnic groups to Government services. People were asked whether they were aware of the fact that services provided by various Departments, such as leaflets, audio and video tapes and interpreters, were available in their own languages, and whether they found that useful. I am not wholly satisfied, but I am pleased to say that the Benefits Agency came second on that list, 512 after GPS, but above 31 other Government services, including NHS hospitals, local councils, libraries, primary schools, citizens advice bureaux, council house services, and so on. Twenty-six per cent. of people from minority ethnic groups were aware of the provision of services in their own languages and 17 per cent. said that that was useful.
§ Mr. Pickles
The hon. Gentleman should be complimented on his straightforwardness. Will he tell the House which of his ministerial colleagues approved the text of the Government's response?
§ Mr. Bayley
The responsibility was mine. I shall be frank with the House, as I recall putting a red line through a certain sentence, but I failed to see that through to the end. I do not defend the statement, which I believe to be wrong. We shall continue to investigate whether we could improve our language and translation services.
A wide range of matters were raised by hon. Members, some relating to training and the payment of GPs for undertaking training to do DSS work. Under their NHS contract, GPs are required to spend the equivalent of five days a year on training and, as independent contractors, they are not paid for that. The training regime operated in BAMS is broadly the same. The training is provided free, and doctors do not have to pay for the courses, but have to attend in their own time. Most of our training will give doctors credit against their GP training requirement—which they would have to do anyway—which will help to deal with the problem of their reluctance to undertake training because they are not paid for the training sessions. If the training is of a medical nature, such as mental health assessment or looking at medical conditions, that counts against the GP training requirement. However, it will not count if it is to do with the way in which the benefits system works.
My hon. Friend the Member for Clwyd, West urged the Government to try and capture feedback from appeals. As the hon. Member for Roxburgh and Berwickshire knows, five years ago, I raised that issue as a constituency Member of Parliament with the Benefits Agency. We do not think that simply collecting the results of appeals would give a good indication of whether the doctor's report was good, as many other factors are involved, such as whether the reports of the GP, specialist and decision maker are good reports. Judge Harris, who runs the tribunal service, has given me a commitment that he will look at whether we could investigate if, for instance, a chairman of an appeal believes that a particularly poor medical report has been provided. The chairman could draw that to the attention of our chief medical adviser and we could investigate.
Time moves on, so I shall summarise. The Government are clearly demonstrating commitment to improving the medical quality of our reports, and customer care, by setting four challenging new standards. The goal, of course, is to improve the quality of the service to the public, and the Government and Sema will work together closely to see that that is achieved.
§ It being Seven o'clock, MR. DEPUTY SPEAKER proceeded, pursuant to Order [25 October 1999], to put the Questions necessary to dispose of proceedings.