Welfare Reform Committee

Meeting date: Tuesday, January 22, 2013

Official Report 520KB pdf

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Work Capability Assessment and Personal Independence Payment Assessment

Welcome back. Item 2 is evidence from a panel of witnesses for our follow-up to our visit to an Atos Healthcare assessment centre last year. As members and witnesses will appreciate, there are a couple of strands that we would like to hear about. Given that the strands might overlap, I invite all the witnesses to introduce themselves and make opening comments. After that, I will ask members to interrogate the issue further.

I am happy to kick off. I submit apologies from Derek Feeley, who is the chief executive of the NHS in Scotland. He is appearing before the Health and Sport Committee today. I am here on his behalf because my responsibilities as the director of health and social care integration include primary care services.

I read with genuine interest the report of the committee’s visit to the Atos centre that was given at the committee’s meeting on 11 December. On the back of that reading, I will make three brief preliminary points.

First, although welfare benefits are a reserved matter and it is no secret that Scottish ministers have a number of concerns about the underlying principles of the reform, the Scottish Government is nonetheless alert to any role that it might appropriately play to make the experience of service delivery as good as it can be, given that many thousands of Scottish citizens are affected.

My second point is more specific. I make it clear to the committee that the NHS in Scotland absolutely supports GPs’ role in contributing to the welfare assessment process and providing information. That support is demonstrated practically by some content in the contract that governs the operating environment for general practice in Scotland. I make it clear from the outset that information that the DWP or one of its agents requests of GPs is within the contract, so GPs are obliged to provide it for free. Only if an information request came from a source other than the DWP and went beyond the basic provision for initial assessment could the scope to charge exist. I am sure that the committee will wish to tease out that distinction.

Thirdly, I introduce my colleague Dr John Nugent, who is also from the Scottish Government. He is a senior medical adviser to the Scottish Government, but he also has many years’ experience as a practising GP, when he provided the kind of information in which the committee is interested. We hope that, between us, we can help the committee to explore this important topic.

I am the human resources director at NHS Lanarkshire and my colleague Mark Kennedy is the general manager of Salus, which is our mainstream NHS occupational health and safety service. The committee will be aware that Atos recently awarded Salus a contract to support the delivery of assessment and reassessment in relation to the DWP PIP aspects of welfare reform, which will commence in June in Scotland.

NHS Lanarkshire’s contract will be to provide those assessments and reassessments in the west of Scotland and Edinburgh city. Fairly recently, I gave a briefing on the issue to Lanarkshire MSPs, who include the convener. I suspect that we were invited to give evidence because of that briefing.

I think that you might have been likely to be invited to give evidence anyway, as we invited Atos to appear, and you have a contract with Atos. However, as I said on the morning of your briefing, I thought that it would be helpful for other committee members to hear the information that you gave to Lanarkshire MSPs.

I am representing the British Medical Association Scotland. I am a GP in Springburn, which is one of the most deprived areas, and I am a member of the deep-end steering group, which represents the 100 most-deprived practices in Scotland. In my opening statement, I would like to describe briefly the amount of work that has come about for practices, especially those in deprived areas, as a result of welfare reform. I agree with my colleague on my left, Angiolina Foster, about the funding, and I am obviously happy to answer any questions later.

As practices in deprived areas deal with patients who have high levels of medical certification and appeals, welfare reform has added disproportionately to our workload. Personally, 12 per cent of my consulting time is taken up with dealing with consultations with patients asking for letters. As I need to review the case notes after the consultation, each letter takes about 30 or 40 minutes to write, so the amount of work that is involved for general practices is by no means small.

That gives us a fairly clear introduction to the questions that we are considering, so thank you all very much for getting us into the issues so succinctly.

Given that Kenny Small mentioned that the deputy convener and I attended a meeting with Salus for Lanarkshire MSPs just after Salus was awarded the contract, it might be worth rehearsing some of the questions that I asked then so that we have them on the record. One issue is the need for clarity on the position of Salus in relation to NHS Lanarkshire. I accept that the way in which the media have written about the relationship has given rise to some misinterpretation, so can you confirm that Salus comes completely within the ambit of NHS Lanarkshire? Although Salus can make charges and raise funds, those are returned to NHS Lanarkshire. Is that correct?

Salus is fully an integral part of the mainstream NHS Lanarkshire service. Its core purpose is to provide occupational health and safety services to the staff of NHS Lanarkshire and to NHS Lanarkshire itself. Historically, over a number of years, because of its expertise Salus has developed what could be defined as a commercial interest. In other words, Salus sells services and bids for contracts to provide occupational health and safety services and other services to other aspects of the public service and to the private sector. Any additional income that is gained as a consequence of that activity is fully reinvested within NHS Lanarkshire. I can confirm that clearly.

That is helpful. Another question that I posed at that meeting—the deputy convener might want to restate the questions that he posed—also sought further clarification. You have said that the work forms part of a commercial contract with a private agency, which in turn has a commercial contract with the DWP. Did NHS Scotland have any input into that contract? Did it know that the contract existed? Did it know that Salus was discussing a commercial contract with Atos? Did it have sight of the contract and approve the contract before you signed it off?

The answer to the first part of your question is that we gave a briefing to the Scottish Government health department prior to our entering into the contractual agreement. That briefing did not include a copy of the contract at that stage. My memory is that we did not have the contract at that stage.

Did lawyers at NHS Scotland eventually see the contract?

Yes. The central legal office had sight of the contract and commented on it and we had a conversation with Atos prior to the contract being signed.

That is helpful. Jamie Hepburn might want to restate his questions.

This is not really a question that I asked at the time of the briefing. As I recall—I am sure that you will correct me, Mr Small, if my interpretation is incorrect—at the briefing for Lanarkshire MSPs you set out your ambition to improve the perception of the process, which has come in for some criticism. I see that you are concurring, so I think that my interpretation is correct. How do you plan to do that?

If you will forgive me, Mark Kennedy and I might do a bit of a double act on that.

In becoming interested and then involved in this work, our overt intention is to seek to add the value that we believe an appropriately recruited and selected and then trained and supported NHS workforce can bring to the assessment and reassessment process for DWP PIP.

Based on our vast experience of recruiting and retaining experienced and highly productive professionals, we believe that we have the ability to make a positive difference to the assessment process experience. As I said, we are talking about a prospective arrangement, and we have not yet begun to deliver the process. At present, we are looking to recruit the appropriate numbers to deliver the assessments, but that is set against a moving feast on the numbers. We are responding to the DWP, through Atos, on the number of assessments that will take place in the area for which we have responsibility.

12:15

Our plan is to recruit people for the required roles on a number of fronts. One is through external advertisement of the opportunities but, as the work is relatively light but repetitive, we will use the opportunity to address issues of long-term sickness absence and as part of our response to our ageing workforce. We all know that the demands that are made on clinicians towards the end of their working life can present difficulties to the NHS and can, on occasion, result in long-term sickness absence.

Part of our response is to consider the opportunities that are presented. We will almost create a mixed economy in which we recruit from outside and use internal redeployment, secondment or rotation. We will also use the contract to address workforce pressures that we have experienced as a result of organisational change and the redeployment of staff. We will sometimes redeploy people and protect them by giving them roles in which they are paid the same amount as in their previous role but which are at a lower grade. I hope that the contract will give us an opportunity to address some of those issues.

The response is to have a mixed economy. For me, the two key issues are that the workforce will be in addition to the current workforce, so the contract will not be to the detriment of core services or the quality of clinical services in NHS Lanarkshire. Secondly, our response will be to recruit and retain as professional a workforce as the one that delivers our mainstream NHS services.

To return to the convener’s original question, in June, prior to the award of contract and before we even had a high-level submission with Atos, I was called to a meeting with the then Cabinet Secretary for Health, Wellbeing and Cities Strategy. At that point, I was directed to ensure that, if we were successful in winning the contract, we should deliver it within the culture, ethos and ethics of the NHS and provide a dignified and humane professional assessment. We intend to do that.

As Kenny Small explained, we have an experienced workforce. Salus has a great deal of experience of delivering functional and descriptor observational assessments through our occupational health work. Therefore, the assessments are a comfortable fit with us. The scale of the work in previous contracts has been across Scotland and in parts of England and Wales. We are of the stature, and we have the appropriate experience and quality and performance infrastructure, to deliver the assessments well on behalf of the people of Scotland.

You are doing the assessments on behalf of Atos, which is working on behalf of the DWP. How prescriptive are the arrangements that are set out in the contract? Is there leeway for you to come to your own arrangements or is the contract detailed and prescriptive on how the assessments are to be done?

The contract contains an appendix on the backbone or spine of the assessment. The committee has witnessed some of that, albeit in the context of work capability. I stress that the work that we will do will be different and will be about assessing levels of impairment rather than ability to work. The spine of the assessment will be prescribed. We will get a tool from the DWP, although it has not yet passed through the UK Parliament—I think that it will go through in February. However, I have seen drafts, which fit fairly closely with what we deliver anyway in the occupational health service and with how we function, so there is nothing too scary in that.

We have not seen the final document, but another part of the assessment will be observational and based on descriptors, with a degree of clinical examination if required. Again that fits comfortably with our bread-and-butter work in the NHS. However, I stress that we do not as yet have the final documentation on how the assessments will proceed.

There is a tendency with such contractual relationships for the detail in the contract to be deemed commercially sensitive and unavailable for public scrutiny. However, you have set out clearly that Salus is entirely part of NHS Lanarkshire. Will the public be able to see the documents that you described? Will the documents be confidential?

We are in the process of responding to freedom of information requests, which will go through the normal NHS procedure. We have had requests to see the documents. My understanding is that we are issuing the contract as part of the response to an FOI request, albeit that parts of the contract might be redacted because of commercial sensitivity.

I can confirm that we have received a number of FOI requests and that a slightly redacted version of the contract was issued last week in response to an FOI request.

If you do not mind my asking, what type of information was redacted?

It was mainly around costs.

You will appreciate that we will be interested in costs, but we will be particularly interested in the assessment process. Will that be available?

Yes.

Mark Kennedy’s point is important, because we have not yet received the formal assessment process. As you will appreciate, it is being developed by the DWP. We had an opportunity at an earlier stage to contribute to and influence the development of the document in what I hope was a positive way. Ultimately, however, it will be issued to us, as a deliverer, to enact.

I have a question for the Scottish Government officials. I was heartened to hear that the contractual arrangements are such that when information is requested by the DWP, it should be provided for free. However, that information did not seem to tally with what we were told in our earlier evidence session, during which you were in the public gallery. What happens if a GP charges when they should not do so?

First, if a GP charges when they should not, there are well-established mechanisms at health board level for managing the performance of the practice or practitioner. The issue would need to be raised formally in order for it to be addressed. However, my guess is that the instances of charging that advice colleagues have experienced are more likely to have arisen because the source of a request was other than the DWP, or because the request required a more intensive level of GP engagement in the context of an appeal, for example, which would be likely to fall outwith the terms of contractually obliged input from the GP. However, my GP colleagues might want to give a first-hand explanation of where the cut-off comes in that regard.

Absolutely. The contract is quite clear in that, if the request comes from a DWP official, a medical officer, or someone acting on their behalf, the GP provides information for employment and support allowance purposes. All such requests are free. A small number of other requests from the DWP incur a fee, but the requests that I described are included in the contract and there is no additional fee.

As Angiolina Foster said, if requests come from outwith a DWP source, they are essentially private work, which is not covered by the contract. In such cases, GPs are at liberty to provide the information or not and to charge for their advice and for what they do. Colleagues have mentioned that range. It is not for me to defend why GPs charge or do not charge, or how much they charge.

What if it is a body acting on behalf of the DWP? Is that still covered by the terms of the contract?

Could you define what body?

Atos or Salus.

Yes.

So that would still be covered. Okay. Are we confident that the arrangements are effective? We are talking about vulnerable individuals who probably do not have a lot of money. We heard about them being asked to pay £96. That seems an extortionate amount to request. Are the current arrangements sufficient?

I clarify that GPs are asked for reports in two different ways. The first way is through the DWP and, as already discussed, that is not chargeable.

The second way, of which we are seeing an increasing amount, is a direct request from the patient, a solicitor who acts for the patient or advice services—welfare or housing advice services—that act for them. That is additional information that is not necessary or essential but which is requested by patients, their carers or workers because patients are intensely worried and scared that their benefits will be stopped.

The number and level of those requests is escalating. A solicitor may write to us, tell us that a patient is appealing their benefit assessment and ask us to provide them with information. Usually, that information is about one to two pages in length. There is a charge for that, which the solicitor would usually claim back through legal aid. We never charge the patient; the fee is for the solicitor.

On the description that was mentioned, I could not explain the situation because I am not sure who requested that charge—whether it came from a solicitor or an advice agency.

It is important to add that the DWP is generating a lot of work for GPs. Somebody has to do it, but GPs do not have the elastic ability to absorb everything that is thrown at them especially when, in some areas—such as mine—they can do two reports a day. That is an extra hour and a half on top of time that is already incredibly tight. There must be some recognition that that work is not core. It is additional to what the DWP requires.

I have some questions for Salus, because I was not at the briefing that was mentioned.

I was pleased to hear that Salus is keen to work within the culture and ethos of the NHS, as insisted upon by Ms Sturgeon. We have heard much bad publicity about Atos. We heard again this morning about the lack of transparency within the DWP. How can Salus square the culture and ethos of the NHS with that?

I presume that Salus is accountable to the NHS Lanarkshire board as part of NHS Lanarkshire. As it is wholly owned by NHS Lanarkshire, to whom is it responsible for the operation of the contract?

It is a commercial contract, so we report entirely via Atos.

I note that the assessment document is awaited. I presume that it will come along with guidance.

It will be an IT system rather than a document.

Oh, right. Okay.

The assessment process is IT based. It replaces the current system, which is paper based and remote. The assessments will be done face to face from June onwards.

Thank you for that clarification. I had missed that point.

Whether the assessment process is IT based or otherwise, guidance about its operation will come along with it. If you get to a point at which what you are asked to do is not within the ethos and culture of the NHS, is there a way of coming out of the arrangement? Is there a break point within the contract? Is there an assessment point at which the board will be able to consider the work that is done and determine whether it is within the ethos of NHS Lanarkshire?

12:30

Mark Kennedy might contradict me, but my understanding is that the answer is no. We are committed to a four-year contract with Atos to deliver the service.

I should add that NHS Lanarkshire’s responsibility is to conduct assessments in a professional manner, as Mark Kennedy said. The outcome of an assessment is submitted to the DWP, and the decision is made by the DWP, not by Salus or Atos. The process is owned and ultimately managed by the DWP. Our intention is to ensure that we fully understand the assessment process and fully train the staff who will deliver assessments, prior to the launch date in June. In our project plan, we have, in effect, set aside May to deliver intensive training, which is designed to deliver quality.

As you would expect, there is a governance infrastructure behind the work that we are doing, which reports to the NHS Lanarkshire corporate management team, of which I am part; to Lanarkshire NHS Board; to the Scottish Government, because the cabinet secretary has asked to be informed about where we have got to at stage points; and to Atos, because Atos has stage points in its implementation plan and will want reassurance from us that we have established locations and the appropriate staffing infrastructure. We will work with Atos on staff training and so on.

There is a range of inputs. You asked about the guarantee; for us, the guarantee will come from appropriate and professional preparation, the support that we give staff and real-time monitoring of quality and output. Ultimately, however, the decision making is not ours.

As Mark Kennedy said, you are assessing level of impairment rather than capability for work. Is there anything in the contract that means that you could be given additional responsibility during its four-year term? For example, a year down the line could you be told to assess capability for work, too?

There is nothing in the contract that would add that element. However, I am aware of the DWP’s framework for procuring contracts; Atos is a prime contractor, and prime contractors are increasingly looking for supply chains, to deliver. What you suggested has not been discussed and we are not looking for that conversation.

Thank you.

Under the contract, will you be paid a fixed amount over the four years or will you be paid per assessment by Salus?

The agreement is that we will be paid per report that is submitted by Salus. There is an element in the contract that provides that the volumes that the DWP has put forward are subject to change, so it is appropriate that we are paid on output.

Have you agreed how much you will be paid per assessment?

Yes.

However, you said that the formal assessment has not been agreed by the DWP.

We have seen drafts of what we expect to deliver. We will not see the final draft, which will be in IT format, as Kenny Small said, until February.

I would be a little concerned that the draft might grow arms and legs. If you are paid per assessment, you might end up not breaking even. What guarantee do you have that that will not happen?

I have no guarantee, but we have had sight of and conversations about the structure that the assessment will take—there will be a functional element and a descriptive element. As I said, we comfortably deliver such assessments in our mainstream work. I do not see any risk of the assessment criteria changing in the near future. I saw the latest draft of its format at the end of November.

As I think I mentioned at the NHS Lanarkshire briefing for MSPs, our intention is that, rather than finding ourselves pressurised by a time limit versus a rate for the assessment, we have engaged with Atos to ask for the introduction of an added value in the interaction with the individual as part of the assessment, which the NHS mainstream can bring to the process. That means that, if our clinicians feel that it would be helpful to signpost the individual who is with them on that occasion to mainstream NHS or third sector service, they would do that, as a beneficial piece of added value.

Does that added value have a cost to other patients in NHS Lanarkshire?

No, because the staff who are doing that work are paid for out of the contract—it is separate from the arrangements for our mainstream staffing in NHS Lanarkshire.

You have already explained that any profit from the contract will go back to NHS Lanarkshire. How much profit do you reckon that Salus is going to make for NHS Lanarkshire in the next four years of the contract?

Because of the commercially sensitive nature of the contract, it would not be prudent of me to announce that, if you do not mind. It is—

Can I stop you there? You gentlemen have already stated that any profits will go back into NHS Lanarkshire at the end of the day. That will obviously be a matter of public record because it concerns the finances of NHS Lanarkshire. I do not think that there is, therefore, any commercial sensitivity around my asking how much profit will be ploughed back into NHS Lanarkshire from the contract.

My concern is that I cannot give you an accurate figure. It is not so much—

I do not expect an accurate figure, but I think that you could probably give an assessment—

Kevin, I think that you could let Mr Kennedy answer the question before you jump in and berate him.

As I have explained, we have a cost-per-report financial model. The numbers that we have been told to expect by the DWP have already changed on two separate occasions. Our profit margin is linked to the volume that we deal with over the four-year period. I can say that we are hoping for a surplus level of somewhere between £1 million and £2 million.

Over the four-year period?

Yes.

And that will go back into NHS Lanarkshire.

Yes. However, I stress that that is totally dependent on volume flow, which we do not control.

Are you able to subcontract to other organisations any part of the subcontract that you have with Atos to deliver the services?

We are allowed to do so with Atos’s permission, but we have no intention of doing so.

Dr Brown, you said that you would never charge a patient for information that you thought was—I think that this is the terminology that you used—necessary or essential, but you said that you would charge solicitors if they wanted to access information for any appeals. Has the BMA offered its members any guidance on charging? What do you think of your colleagues who directly charge patients for the information that you do not charge for, which patients often think that they need in order to win an appeal?

The DWP requests information that it feels is necessary so that the patient can go to the meeting. In addition, patients ask for lengthy reports. Most of the time, that request is driven by anxiety. They want a full list of their medical complaints over the past 10 years, what treatment they have had and who they have been referred to. It is as if they will feel more confident if they go in with a big pile of documents that they can show people.

Although the DWP does not see that information as essential, patients still come in and ask for it. There is no ceiling on that; you can have one person or five people coming in. That is not seen as core work and the BMA has guidance on charges for what it sees as private work—in other words, work that is not covered in the core general medical services contract. I do not have that guidance with me, but we can provide it to the committee.

That would be useful.

You suggest that your practice and the practices you represent mainly cover Scotland’s most socially deprived areas. Would the folks involved in deep-end GP practices stick to the BMA’s guidance on charging or might some of your colleagues in those deprived areas not do so?

I cannot speak on behalf of everyone but I reiterate the important point that GPs do not charge for the essential work that is covered in their contract and which has been requested by the DWP. That just does not happen. If a GP makes a charge, it will be for additional information that has not been requested by the DWP and which is not seen as being essential. That is seen as an additional service.

There is a split, in that some deep-end practices have stopped doing letters altogether because they simply do not have the resources. Of the six practices in the health centre that I work in, three of us do letters and the other three have had to stop because they cannot manage. It comes back to the lack of ability to be elastic and absorb absolutely everything that is being thrown at you. If you are spending two hours a day on reports, that is two hours less for something else. There has to be a cut-off somewhere. Some practices stick to ensuring that essential information is returned in a timely fashion, whereas other practices will spend extra time on additional letters.

That said, however, we will go on a case-by-case basis. We accept that a number of patients are vulnerable, cannot advocate for themselves and are simply not capable of putting across their problems and opinions and explaining to someone they do not know exactly what is wrong with them. If it is someone you know well and who you know will probably not get through the medical unless you supply certain information, you will do the work even though it will take a long time. However, even though we take these things on a case-by-case basis, a lot of it comes down to good will. The work is not covered in the contract; it is additional work that is carried out in our own time.

With regard to the essential information requested by the DWP or those acting on its behalf—Atos, in particular—I note that, according to the committee members who visited Atos, the organisation itself said that it was still waiting on approximately 50 per cent of the information that it had requested from GPs—I see the convener nodding at that. In other words, it is saying that half the time it is not getting essential information from GPs. Can you comment on that?

I am glad to. I have to say that that was news to us and we are quite keen to see the data and the number of patients involved. When I discussed the issue with the deep-end group before this meeting, they said that it was not something that they have seen. It is important to find out whether Atos was talking about a particular snapshot of one area, one practice and one process instead of something wider.

There are a number of issues with essential information. First of all, the requests do not come with a date telling us when the patient’s appointment is. Depending on the type of appeal, the letters come in either by post or through an information technology system. It might arrive on a particular day, but there is no push-pull mechanism to tell us that it is there; we have to go looking for it and when we find it, it does not say, “This patient’s appeal or medical will be in 10 days’ time. Can you please send back the report?”

12:45

The other issue with the forms is that we cannot populate them with medical information. We cannot pull data from a patient’s case record into a form, we cannot spell-check forms and we have to manually enter all the information by reviewing all the case notes. We cannot populate forms with information on repeat or acute prescriptions; we have to list and write all that down.

In addition, at least twice a week I get letters about people who are not my patients—in other words, letters that have been sent to the wrong GP. Some colleagues have described receiving late requests, whereby they have been phoned and told, “We’re faxing through a copy now. Could you send the information back to us because the patient has their appointment in a couple of days’ time?” I do not want to sound as if I am fobbing you off with excuses, but the situation is not as cut and dried as the suggestion that 50 per cent of doctors do not send back information.

The other important point is that the information that we are asked to send back covers a number of disciplines. It covers the diagnosis, which is already known about, because it is listed when we are written to. It covers prescriptions—information on which we have to fill in—and whether we feel that the patient’s condition is moderate, severe or mild. It also asks us for information on what we feel that the patient can do. That is information that is obtained from a history. I cannot understand why Atos would find it any more difficult to ask a patient whether they can put on their own socks than a GP would.

If Atos is saying that the reason why the successful appeal rate is so high is our not sending information in, I would respond that a lot of the information on the forms is taken from a history and, as we have heard, the history that is taken when patients attend an assessment is far more thorough than the information that we send back. I think that we need greater clarity on the situation, but I would probably not agree that patients do not get through the process because GPs do not send in the information. I think that there are too many variables that suggest that that is not the case.

You are describing a situation in which there is a lack of communication from Atos or whoever telling you the dates on which patients will be seen.

Atos does not tell us the dates.

From memory, at the meeting that Kevin Stewart and I were at, Atos said to us that in some circumstances, a person would not necessarily be called in for an assessment on the basis of the information that the GP had provided. It was a lack of information from GPs that led Atos to bring people in. Atos indicated to us that an appointment would not be made for a client if it was waiting for information from the GP to determine whether they needed to be called in.

Mr Nugent wants to come in on that.

Like Georgina Brown, I was quite surprised about the percentage that was quoted and about the level of ignorance in the health system when we made inquiries about whether people knew about this. We have since learned that the DWP in Scotland is not convinced that it is an issue and that, if it were, it or Atos would be willing to work with us and boards to address it.

In a search for some information, I read Professor Harrington’s first three annual reviews. The only mention that I could find of the issue was in the first review, so the information might be slightly dated—the statistics might have changed slightly. On page 28 of his year 1 review, he says that 60 per cent of ESA claimants were called in for a medical. GP information was asked for in the 13 per cent of cases in which it was thought that a claimant might be in the support group, and such information was received two thirds of the time. I am not defending the lack of information in 5 per cent of cases, but the percentage of cases in which information was missing seems very small, so I am not sure that a lack of initial information from GPs would explain the high appeal rate or the successful appeal rate.

When I read Professor Harrington’s reports, I was also concerned about the perceived lack of value given to the information that was obtained from medical sources. His first report mentioned the views of healthcare professionals in Atos, some of whom wished for more medical information, while others felt that they did not want any more information because what they got was not helpful, as it did not match the descriptors that they used for a functional assessment. Therefore, I find it a bit disturbing that a lack of medical information early on is being blamed for a lot of the process issues further on.

Although I would not defend the lack of information that is covered by the contract, I wonder whether there is a case to be made for more pertinent, precise information early in the process. That would avoid requests to sources outwith the process, which incur costs for, and take time from, GPs and patients.

I will stick to that subject and dig a little deeper. I was one of the three members who attended the Atos assessment. The situation that has been described is exactly as I understand it. However, we have not covered the key issue that we were told about, which was that Atos did not call everybody in for assessment. The decision whether it called in an individual for assessment depended on two criteria: the information on the application form, which often came from the applicant; and the information that was received from the GP. In instances where the applicant’s form was poorly filled in or the GP’s information was absent, that meant that it was highly likely that an assessment would be required. I am talking about early in the process, before a decision was made as to whether an assessment was necessary. I think that that is where the 50 per cent figure came from. In 50 per cent of cases, the decision to call someone in for assessment was based on the fact that Atos had not received a response from the GP. I do not know whether my colleagues would agree with my assessment.

That is my recollection of what Atos told us.

Yes, I agree.

Having seen the 50 per cent figure in the Official Report of your December meeting, we did some very focused checking, in preparation for this session, with Scotland’s two biggest health boards, NHS Greater Glasgow and Clyde and NHS Lothian, to see whether they had any communication from Atos about the problem. In other words, we asked what the operational evidence was to support the slightly more anecdotal information that you appear to have received on your visit. Neither health board had been approached about the non-completion of the initial information.

We also checked with the DWP—the main client, so to speak—whether there was an issue in Scotland. It had not received anything formal.

In terms of practical next steps, there is a need to go back to Atos to ask it for more robust evidence that can be taken to boards and worked through the performance management system as appropriate.

That is really helpful. Quite clearly, the issue comes down to communication, which is why you are here. The evidence is really helpful because we were concerned about misinformation. There appears to be huge misconception about the whole process, including around the roles of Atos and GPs. It is being steered by the DWP, which seems to be using everyone else as a human shield. I am particularly concerned that all the problems seem to stem from the DWP. Perhaps Salus is getting a bit nervous about getting involved now that it has heard about all the problems.

People are being traumatised by the whole process, and if that comes down to miscommunication we need to get to the bottom of it.

I was going to ask about that, but the issue has been covered, so I will follow up on Georgina Brown’s evidence.

You describe a benefits system that includes an appeals procedure—it has to, because of human rights—within which claimants have to get additional information. I think that you are saying that some GPs are arbitrarily deciding that they will not provide that information, in which case they are actively taking claimants’ rights away.

Responses are not even consistent. Depending on which practice a claimant goes to within a health centre, they either will or will not get a letter, and they might have to pay for it. Are you comfortable with that situation?

I am not comfortable with it at all. I am not comfortable that so many people have to go to appeal because they have been found to be fit to work when clearly they are not. When claimants come back to us to ask us for letters, I am happy to support them.

However, that is not the only thing that we do. We have a large remit to cover and we have to stop doing something in order to do something else. Practices that have decided to not write formal letters for appeals when requested to by patients have done so because they just do not have the capacity and resource to do that. We need to look at that.

You have explained the pressures on GPs and why they might feel the need to say to patients, “We’re not going to provide this letter.” Nonetheless, should they not, as professionals, try to address the issue in order to make it possible for patients to access what are, after all, their rights under the system? I do not know whether that comes down to resource being provided or a change being made. My understanding of deep-end GPs is that part of their work involves dealing with their patients’ issues with benefits and access to food, heating and rent so that those GPs can deal with their patients’ medical problems. Here we are, however, with GPs saying, “No, I’m not going to do that. I’m sorry but that means you won’t get an appeal.” That seems very abrupt.

It is probably quite blasé to say that GPs are saying, “No, I’m just not doing it”—

Sorry, but that was your evidence. I must admit that I was surprised by it.

GPs do not do it in a blasé way. I am trying to put across that GPs who work in deprived areas will be more affected by the changes than GPs who work anywhere else because there are more patients going for appeals, more patients on benefits, more multimorbid patients, more patients with alcohol and mental health problems—the list goes on.

In addition, the number of GPs across the piece is fairly flat. There is not an excessive number of GPs in deprived areas compared with affluent areas. We are all working with the same number of staff but GPs in deprived areas are already stretched. We are talking about an additional workload that is far greater for them than it is for GPs elsewhere. Some of them simply cannot cope with the amount of work that needs to be done.

Some GPs have a standard letter and will write down a list of diagnoses. You would be hard pushed to find a GP who would say, “I’m not writing anything for you”, but a GP might give the patient a summary sheet. However, patients want to take something with them to an appeal that explains what they are going through, how they feel, why they cannot get out of bed in the morning and why they cannot get to work. That takes time, and time has to come from somewhere.

I agree that there needs to be a solution. I do not know whether, as a profession, we are able to find that solution without the resource to support us. I would not like it to come across that GPs in deprived areas do not care; deep-end GPs certainly do care. That is why they give up their time free of charge to meet and petition for change—they have done so for years. However, there has to be a point at which they put their own health first and get home before eight o’clock at night.

I do not think any of us doubt that GPs are under significantly more pressure in areas of deprivation. In fact, I have argued that, on the basis of deep-end work, the distribution of GPs in Scotland should be changed to provide more GPs per head in deprived areas.

Nonetheless, the fundamental point is that there are vulnerable people whose pathway to an appeal in the benefits system is being closed. Somebody ought to address that. The medical profession is at the sharp end and sees the impact. Rather than simply saying, “We won’t undertake that work,” could the medical profession try to do something to ensure that the situation is addressed? Maybe the NHS in Scotland could look at the issue as one that needs to be addressed. Whose fault it is does not seem to be the most important thing here.

Although the question is not whose fault it is, I would be keen to ensure that the root cause is addressed. I might be a little cautious, on behalf of the NHS, about appearing to put extra resource into dealing with a symptom if the root cause is a degree of dysfunction in another part of the public services. I would want to be extremely careful and clear headed in ensuring that we understand what the drivers are and that we address the correct policy and resource response to the root cause, so to speak.

13:00

Before Annabelle Ewing comes back in, Jamie Hepburn has a supplementary question.

It has largely been covered. However, I suppose that what Ms Foster has just said raises a question. Is that work on-going? Given what we have heard today, can we get an assurance that people are looking at the matter and considering whether there is a different way of doing things? Dr Brown pointed out that solicitors will get Scottish Legal Aid Board money that then goes to doctors so that they can provide information. Are we looking at this in the wrong way? It is all public money. Should funds—whether legal aid money or money from elsewhere—go more directly to support and facilitate GPs to do the work without people having to go to a lawyer? Will the issue be looked at? It is a straightforward question.

To a certain extent, some of the solution lies in the processes that we have, if we use them more effectively within the DWP, Atos and the contract. We have a contract that says that GPs will provide information, and they should do that. We have explained that it is news to us that a proportion are alleged not to have done so, and there is a mechanism to address that. That is one way in which to address the lack of information, but—

I am sorry but, with respect, we are also concerned about information that is not covered contractually. Clearly, people feel that they need that information to be able to take forward appeals and so on. Is that area being looked at as well? I am aware that that might require you to look at the contract.

The point that I was hoping to make is that providing more appropriate early information and making better use of it might reduce the subsequent need for information that is much more complex and demanding in terms of time.

My understanding from Professor Harrington’s report is that the vast majority of claimants are called for an assessment without a request to the GP for information. There is potential there to gather more information if that is required. It is still the case that information is required in the minority of cases. If we had more information earlier in the process, we might subvert the need for complex appeals later on. That is all that I am saying.

I am not denying that we can look at the appeals process as well, but it seems to me that there is a fundamental flaw with the information and how it is used, with Professor Harrington’s report reflecting great disparity in the value of the information. Even when it is provided and used, it is not used to its full potential—because it does not match the descriptors, for example. There are huge flaws in the system. Before we fix the back end, we could more sensibly go to the front end and look there.

I agree with John Nugent. We should not throw money at chipping away the top of the iceberg. We need to be at the base. We need to look at why 40 per cent of appeals are successful. What is going wrong? We should not be flooding the top with money and saying, “We need more detailed letters from GPs to really explain what is wrong with patients, because all these appeals are happening.” We should be looking at the very beginning and asking what is going wrong and why patients who are clearly not fit to work are being passed as being fit to work, then going to an appeal and being successful. What is happening there? That is what we should be looking at, and that is where the investment should be made.

We have been asking that question as well. We are going to go back to Atos, I think, to get some more information on a Scotland-wide basis.

I will be brief as it is approaching lunch time and I am sure that some people have other business soon.

Are you hungry, Annabelle?

No, I am fine. I can last out.

We have arrived at the focus of my question. The quality of the initial decisions is clearly subject to a lot of questions. We only need to see that a system’s appeal rate is significantly high to know that something is not working further up the stream. It also raises many other questions. If we have a UK Government policy whereby, for example, disability benefit has to be cut across the board by 20 per cent, we are looking at some very perverse decisions that have been made in the initial stages, even before people go to appeal.

I want to ask Salus what room for manoeuvre it has—if any—to do something slightly different and more sensible in its reference up to the DWP, which of course makes the decision rather than Salus. Do you have any room for manoeuvre to do anything different? Or do you just implement the Atos approach 100 per cent?

We work in the terms of the contract that has been let, which relies heavily on the IT assessment tool. Our room for manoeuvre, whereby we believe that we can add value in a way that another contractor or organisation might not, is in the quality of training that we give to staff who enact the assessment. I listened carefully to the earlier debate and, for me, the crucial driver is the quality of the assessment. That is one of the reasons why we believe that the NHS in Scotland can make the initial assessment process a much better driver in terms of outcome. We have not done it yet, and time will tell, but as you would expect there are milestones in our conversations with Atos, as there will no doubt be in Atos’s conversations with the DWP. Indeed, there will be conversations between the management of Salus and the staff who will deliver about the assessment of the assessments, if you like, regarding the quality, outputs and outcomes from the assessments, which will be an on-going part of our quality control and hope for improvement.

To me, though, the crucial issue, whether we are talking about PIP or any other aspect of welfare reform, is getting the right people with the right technique. Disability assessment at the moment is a paper tool that is given to an individual to complete, with or without support, and which then goes into the process. The new process, which we were attracted to become involved in, immediately introduces at the first stage a qualified, trained, skilled and experienced clinician. Our confident opinion is that that must bring the potential for added value.

That is very interesting. Of course, we all hope that that proves to be the case.

As do we.

We will watch that very closely.

My other question is for the medical profession, about the BMA and its policy work. I posed this question in an evidence session some months ago, at which we heard powerful evidence from witnesses. What is the BMA doing vis-à-vis representations to the UK Government in a general sense, in terms of principle? What the UK Government is doing, in effect, is turning medical orthodoxy on its head. For example, people who clearly have Asperger’s or are blind, as we heard in the earlier evidence session, will remain so. That is what the medical profession considers to be the case for such conditions. How is it possible, then, that some bureaucrats in a Government department can insist that there should be a different outcome?

I think that you are getting my drift. What is the BMA doing about that? It is a serious situation. It is a real threat to the trust that everybody places in the medical profession when people see extremely perverse decisions being made.

The BMA has been vocal on a similar thread to what I have said. I cannot give you information about what the BMA has been doing at UK level, but I can get that for you.

It would be helpful to hear a comment from NHS Scotland, because the situation affects everybody who works in the health service. At the end of the day, it is their reputations that are on the line.

For the Scottish Government, I think that it is a matter of reputational risk by association, you might say. I acknowledge the point, which is about something that must be carefully monitored as the process develops.

Thank you. The way to avoid the reputational risk—the boorach that is the system imposed by the DWP—is of course to take control over welfare ourselves and come up with a much better, more workable and fair system in our country.

Okay. I do not know whether that was necessary, but there we are.

It is true, though.

Predictable.

Coming back to the matters confronting us at the moment, I think that there appear to be some communication issues, so we will need to go back to Atos to verify and clarify some of the information that we were given. The more that we have looked at this issue, the more we have seen misconceptions and apprehensions based on those misconceptions. We want to try to cut through all that.

Before we finish off, I want to get on the record one point that we have alluded to and commented on but that needs to be verified. First, Atos went to great lengths to point out to us that the new computer system that it is operating was devised and provided by the DWP. Secondly, Atos was at pains to point out to us that the decisions are made not by Atos but by the decision makers within the DWP, who take the information from that system and then make the decisions. Is that exactly the process that Salus will be engaged in? Will you collect the information on a system that is provided to you, and will the decisions ultimately be made by representatives of the DWP?

Yes, that is exactly the position.

That is one thing that we have clarified this morning, which is useful.

As I said, we may need to keep an eye on those issues and bring you back at some point in the future. I hope that this morning has not been too traumatic for you and that you will want to come back. Your evidence has been very helpful. Thank you very much for your time.

Meeting closed at 13:11.