HoC 85mm(Green).tif


Work and Pensions Committee

Oral evidence: Health assessments for benefits, HC 128

Wednesday 25 May 2022

Ordered by the House of Commons to be published on 25 May 2022.

Watch the meeting

Members present: Stephen Timms (Chair); Debbie Abrahams; Siobhan Baillie; Neil Coyle; Steve McCabe; Nigel Mills; Selaine Saxby; Sir Desmond Swayne.

Questions 276 - 386


I: Stuart Paterson, Client Executive Partner, Independent Assessment Services (Atos); Dr Barrie McKillop, Clinical Director, Independent Assessment Services (Atos); Antony King, Managing Director and Client Partner of Capita Health & Welfare, Capita; and Laura Erskine, Clinical Director, Capita.

II: Dr Paul Williams, UK Division President, Maximus; Emma-Jane Bannister, Customer Director, Maximus; and Suzie Frew, Lead Nurse and Head of Quality, Maximus.

Written evidence from witnesses:

Independent Assessment Services (IAS) (HAB0103)

Capita HAB0133

Maximus HAB0145

Examination of witnesses

Witnesses: Stuart Paterson, Dr Barrie McKillop, Antony King and Laura Erskine.

Q276       Chair: Welcome, everybody, to this evidence session for the Work and Pensions Select Committee’s inquiry into health assessments for benefits, and a particularly warm welcome to the four witnesses joining us for our first panel. I will start by asking each of you to tell us very briefly who you are.

Stuart Paterson: Good morning. I am the client executive partner for Independent Assessment Services. I have been leading the delivery of the PIP service in northern England, Scotland and southern England for the past two years and have been involved in the larger delivery for the past seven or eight.

Dr McKillop: Good morning, Chair and members of the Committee. I am the clinical director for Independent Assessment Services. I have been in my current post since 2014. I lead a team of 13 senior clinicians, and together we are responsible for the quality and performance of the health professionals within IAS.

Laura Erskine: I am an occupational therapist by clinical background, and I was appointed as clinical director for Capita Health & Welfare in 2020. I am responsible for providing clinical direction and leadership to our 1,000 health professionals who deliver PIP assessments on behalf of the Government.

Antony King: Good morning, Chair and Committee members. I am the managing director for Capita Health & Welfare, which includes the contracts that we have to deliver functional assessments for PIP in the midlands, Wales and Northern Ireland.

Q277       Chair: Thank you all very much for joining us. On behalf of each company, can somebody tell us the key changes you have made to assessment since this Committee reported on it in 2018? As you know, most people who appeal against a negative assessment are successful. What would it take to make assessments more accurate than they seem to be at the moment? Can I ask somebody to answer that on behalf of Independent Assessment Services?

Stuart Paterson: I will talk about the changes that we have made since the last Committee and then hand over to Dr McKillop to answer your second question.

First, recognising that at the last Committee there were a number of recommendations, we have also had the covid-19 pandemic since then, which has led to a number of changes that have been accelerated in that period. The first and most significant change that I would highlight is the move to a predominantly virtual assessment channel. Previously, in our service, we would first attempt to write a paper-based review for the majority of our claimants, where we could. We would try that with everybody, and the remainder of claimants would be seen face-to-face in one of our assessment centres. Clearly, as the pandemic started to take hold, we were not able to see people face-to-face and we moved to a predominantly telephone-based service.

That change is quite a significant one. We have been receiving lots of feedback and have done lots of research with our claimants and representative groups to understand the impact. It has predominantly been a positive and significant change for the service.

The second thing that I will highlight is audio recording, which was a strong recommendation from the Paul Gray review and previous Committees. We are able to offer audio recording for all our assessments that are face-to-face or by telephone. The PIPAGthe PIP assessment guide, which underpins the way we assess peoplehas also been changed to allow claimants to record an assessment themselves on any device and keep that recording for themselves. That is a significant step forward with audio recording.

The final point that I will raise for this Committee is the quality of our assessments during that period. While we continue to recognise that not all claimants are satisfied with the service and get the experience they desire, the quality of our assessments is measured by the Department in its independent audit function. Over 2021 in particular, we have seen a significant improvement in the quality of our assessments and we are now regularly meeting the Department’s target for us in the quality of our assessments overall.

Q278       Chair: What is that target?

Stuart Paterson: The target is that no more than 3% of our reports are considered unacceptable by the Department.

Dr McKillop: On the appeals question, it is absolutely our aim in Independent Assessment ServicesI am sure it is the same for colleagues in Capitato get the assessment and the outcome for a claimant right the first time. I think that the Committee has heard evidence in other sessions about how important two aspects of that are. First, there is further evidence from someone other than the claimant who provides background, medical information, functional information or just a slightly different picture on how the claimant will function day in, day out.

The second aspect, which has also been highlighted, is the importance of the deep and probing questioning that our health professionals aim to undertake during a PIP assessment. In a previous session the view was discussed that in appeals settings the questioning from appeals panel members had gone into real detail and asked the claimant to explain how their daily life was affected by their medical condition. I think the word “holistic” was used; we absolutely recognise that.

We are not assessing someone’s individual medical conditions; we are looking at their medical conditions as a whole and how they impact the person’s daily life. We hear feedback that taking the time to probe into a person’s daily life and ask them for the detailsnot just scratching the surface but looking at the light and shade, considering the good days, the not-so-good days and the variability in their conditionssometimes causes an appeal to be successful or causes someone to get a different outcome from the initial decision.

We absolutely train and expect our health professionals to go into that level of detail. Since the last Committee, a lot of work has been put in, in the IAS space, to train health professionals and support them to do exactly what I have just described, rather than scratch the surfaceto go into depth and have a detailed conversation. PIP very much focuses on that holistic approach, rather than on a medical condition or one particular piece of medical evidence or test result, for example. It is all about the rich picture of their daily lives. What I have described is exactly what our health professionals aim to do.

Antony King: There is a danger that we are going to repeat ourselves if we are not careful. We work very closely with the Department for Work and Pensions and IAS. Clearly, a lot of the changes that Stuart and Barrie have mentioned are ones that we have implemented as wellvirtual assessments, audio recording and so on.

I will pick up on some of what we are going to add to the changes that we have made. We bucketed them as assessments and training; safeguarding, which is really important; and comms and accessibility, which I think was a recommendation from the last Committee. We continue to run a number of pilots. With safeguarding issues, for instance, we now have clinical markers that are transferred between us and the Department to identify claimants who are at risk. We have employed mental health specialists so that we have dedicated mental health teams, and we have improved our training in that area.

In trying to gain further medical evidence, we now use the nhs.net email address. Previously, that was an issue: we would send requests to GPs for further evidence, but because they did not come from an NHS email address they would sometimes not be picked up. It is little things like that. We have completely revamped our website to make it much more accessible to people who are deaf or have visual impairments. When we send out invitations for appointments, there are now booklets that go out as well. We have beefed up the training for our assessors, particularly in areas relating to mental health conditions. I will let Laura add a bit more colour about some of these improvements.

On your question about what would reduce the number of appeals, as we understand it, a lot of the appeals present further evidence that we did not have access to. I think a general theme is how we could get more timely, better-quality evidence at an earlier stage to prevent the appeal process from kicking in. That could be a theme that we come back to during the session.

Laura Erskine: We have redeveloped our training three times since the last Committee, taking on board feedback from our stakeholders. Our stakeholder team meet regularly with stakeholder groups, many of which you have met in gathering oral evidence for this Committee. We have developed a more conversational approach to our assessment, which we have launched in the last six months. It takes the functional first approach that Paul Gray recommended and that we implemented, but it takes it to another level. Rather than going through the 12 activities, which claimant feedback often says are like a repeat of the claimant questionnaires, we are adopting a much more conversational approach with what we call conversation starters, so that we can get the rich, detailed functional picture that Barrie mentioned as being useful at the appeal stage and so that we can support right first time.

On appeals, as Antony mentioned, we often get feedback saying that further evidence was presented at the appeal stage, whether that is medical evidence or a richer picture of the individual’s functional impairment. We would welcome more insight into appeals and tribunals. We are fortunate that we are able to attend appeals. My colleagues have just informed me this morning that we are attending four appeals on Friday this week, so we are hoping to get some rich information to take back and feed into our quality improvement.

Department stats suggest that it takes about six months on average for the appeals process to happen. Feeding that back to an individual assessor may not be as useful, but we welcome that insight into the overarching trends to support right first time, which is what all of us are trying to achieve.

Q279       Chair: Are you getting that information?

Laura Erskine: We get some information.

Chair: Could you do with more?

Laura Erskine: We would like more. We are having quarterly meetings with the presenting officers, which is a great step. Covid put a little bit of a delay on that moving forward. It is a step forward, but we would prefer more.

Q280       Nigel Mills: Where, on a scale of one to 10, do you think you have got the performance of these assessments to?

Antony King: We aspire to deliver a compassionate, empathetic and quality service to all the claimantsall the people we see. Since we were last before the Committee, as Stuart said, there have been huge improvements.

The vast majority of claimants now have a good experience with us. That is supported by our data on claimant satisfaction—we do independent surveys of claimants after they have been through the process with Capita and Atos—and it is also supported by the level of complaints that we receive. I think that the majority of people have a good service. However, we are fully aware that there are individuals who slip through the net and we have problems with them. In those cases, we very much seek to take the learnings and improve on the back of them.

I am a bit loth to answer your question about numbers, but here we go: the last time we were before this Committee, it was maybe a four, and we are probably at around seven or eight now.

Stuart Paterson: From my perspective, it is a similar answer. We have put significant effort into some of the key measures across the service, such as claimant satisfaction and the quality of the reports, as measured by DWP’s independent audit, as well as some of the softer stuff, such as communications and our website. We are helping people to understand the process and feel less anxious about it. We have introduced things like welcome calls: a couple of days before somebody’s assessment, they will get a phone call from one of our representatives to help them to understand how the assessment will go and what information they need to bring, and to remind them that they can bring somebody to support them with the assessmentall those key things. I think we have made significant improvements, similar in scale to what Antony referred to.

Q281       Nigel Mills: To get that score any higher, is it just about having a continual improvement loop with slight tweaks here and there, or do we need a lot more money in the system to make any further leaps? Do you need to have a lot more time and employ even higher-skilled people, or do you think you can get up to a 10 with the current structure?

Stuart Paterson: It is a big, complex service, and there will always be some claimants and some people who go through our process and are not entirely satisfied with that process and the outcome that they get.

Some of the changes that have been identified through the Green Paper and previous reviews would help to move that service a step further on. There is mention of advocacy support in the Green Paper, and there is the move to functional assessment services in future, which brings the PIP delivery and the WCA/ESA delivery under one roof, essentially. It is not one assessment, but it will enable better sharing of information between those two areas and those two parts of the benefits process. Some of the changes that have been identified, and that are already being made and starting to take hold, will help to continually improve that service further.

Antony King: It is an interesting question, isn’t it? Within the constraints of the existing service, as Stuart alluded to, we have to acknowledge that we have 1,000 ex-NHS professionals delivering the service, and mistakes will happen. That is inevitable. We will do whatever we can to correct those mistakes and learn from them, but it is a human-based process. Therefore, there will never, ever be a straight 10 within existing constraints.

That said, I think some tweaks within the existing system would help to improve things. We have mentioned audio recording already; it would be really helpful if that were opt-out rather than an opt-in, because one of the key things that keeps coming back through all the reviews is nervousness about the actual assessment process. Things like having an opt-out audio recording system would be helpful. I know that the Department is looking at that as a potential option.

Better access to data for further evidence could be done within the system with not too much trouble, I think, but some of the wider things are much bigger—hence why the Green Paper was published, as Stuart said. Wider advocacy support and so on would mean investment.

To answer your question: yes, we can continually improve, but I think some bigger changes are needed.

Q282       Nigel Mills: I will move on to the points you have been making about access to medical evidence. A decade ago, I had this naive understanding that you did an assessment of the person in front of you, and the decision maker at DWP took your assessment and the other evidence and made a decision based on all that. It appears that what you are saying now is that you go through the additional medical evidence as part of writing up your assessment report. That is right, isn’t it?

Antony King: When we can get hold of the evidence. Sorry, I keep calling it “medical evidence”, but it is a bit wider than that: it is also from carers, personal statements and so on.

Q283       Nigel Mills: How much time do you give your assessors? From start to finish, when I go for my assessment, how long do they have to research me, assess me and write the report up?

Laura Erskine: We aim to give them about 120 minutes. That includes preparing for the assessment, having the consultation and then writing up the assessment. That also allows them some extra time in the day for continuing professional development and calling our advice support line, which they utilise a lot. We have had 45,000 calls to our support line, which they can call to gain insight and advice from a more senior clinician.

That is obviously an average. Sometimes we find that there are individual applicants with hundreds of pieces of evidence that they present with their case; obviously that takes a lot longer for the health professional to review. Equally, sometimes people do not provide any evidence at all. In the PIP assessment guide, which is the legislation, there is no requirement on the individual to prove with a diagnostic report that they have the condition that they are diagnosed with; they may even have a working diagnosis. It is a functional assessment. That is also why, when we are looking for evidence, we are looking for functional evidence.

I know you spoke to Dr Kieran Sharrock at an oral evidence session, and he was open about saying, “Are GPs the best people to provide this level of information?” Improving access to the people who could provide that information, such as occupational therapists, physiotherapists and carers, would help to inform that assessment process.

I do not know whether you want to add anything to that, Barrie.

Dr McKillop: I agree with what you have said, Laura. I will add that it is very much the same in the IAS space: each assessment and the preparation for that assessment will take as long as is required.

The most important thing to ensure a good-quality report and—on a point that we discussed a little earlier—a good-quality assessment and conversation with the claimant is for the health professional to be aware of what has been provided already. We know that the claimants can spend a lot of time completing the PIP2 claim form, telling us about the problems that they have. Happily, a lot of cases come to us from the Department at the point of referral, with lots of further evidence that the claimant has helpfully provided to us. We always encourage that when we meet customer representative groups, for example.

A lot of our claimants have complex medical conditions. It is not unusual for claimants to have multiple problems that affect many different aspects of their lives. Having an understanding of that further evidence before the assessment can really help the assessment to go as well as it can. It gives the claimant the reassurance and the trust that the health professional has taken the time to read the evidence and know something about their condition before the assessment takes place.

As you said, we then submit a report that considers all of the evidence, but our understanding is that the Department’s case manager also reads all the evidence and comes to a decision on everything that is presented to them.

To take up a point that you made earlier, Stuart, we would absolutely welcome any sharing of evidence between benefits within the DWP space. At present, we do not routinely have access to evidence in the WCA space, but our understanding is that there is a suite of evidence available for many of our claimants that we just cannot see at present. That would be an improvement.

Q284       Nigel Mills: It all sounds good, obviously, but you can understand why people get a bit annoyed when they see the report and it says, “Mrs X seemed to walk in okay and seemed to answer questions quite well, therefore I think she is fine”I am slightly paraphrasing. Do you think that those sorts of informal observations or assessments are a sensible part of the process, or are you trying to move on from “Carried folder under arm fine”?

Dr McKillop: On the observations that you have described, it is a core part of our training and support for our health professionals to ensure that they always bear in mind that PIP is not a snapshot assessment. It does not, or should not, matter to a claimant what particular day they are assessed or when their appointment happens to fallwhether it is a day when they are functioning better than average, or not such a good day for them. PIP looks at a person’s function in the longer term, over a period of 12 months.

A key aspect is what are sometimes referred to as the STAR criteria, which are outlined in the PIP assessment guide. Those criteria make sure that when we are advising on each of the 12 activities, we assess and advise a descriptor based on whether someone can do something safely, in a timely manner, to an acceptable standard, and repeatedly, as often as may be reasonably required.

The sort of informal observation that you described really has to be taken in context as a snapshot of that person at that point. All evidence is potentially useful and helpful to us and must be considered in the wider context of the conversation. The health professionals would be expected, for example, to ask the question, “How are you walking today? Tell me about how you walk on most days, on a better or a worse day.”

Q285       Nigel Mills: Can I ask about video assessments? My understanding is that a lot of claimants quite like the video or telephone call, as it is less stressful for them. How do you decide who comes in person and who gets a video or a telephone call?

Antony King: You are absolutely right. We have introduced a virtual assessment: I think 85% of our assessments are currently done by telephone and a much smaller number by video, albeit that it is still at the pilot stage. I will let Laura explain the route in a bit more detail, but we look at the assessment. If we can do a paper-based assessment, if we have enough evidence, that is clearly a preferable option because it is much less stress for the claimant, as we do not have to speak to them at all. If that is not the case, we move to stage 2, which is either a face-to-face or a telephone assessment. As I say, at the moment the majority continue to be by telephone. Do you want to add anything, Laura?

Laura Erskine: I can talk about the decision-making process. When an individual applies for PIP, their case and the evidence presented is reviewed by a health professional. The training that we provide them is based on the PIP assessment guide, the legislation, section 1.3.6, which asks the individual, the health professional, to review the evidence; consider whether there is enough information to write a paper-based report at that stage; consider whether evidence is likely to be forthcoming that would enable a paper-based report; and then consider the individual and any risk to them that may be presented at that initial decision.

We have updated our guidance on this over the past couple of years. We are now able to invite people to a telephone assessment, whereas before they would potentially have had to have a clinic or home assessment. A clinic assessment can obviously present some quite significant anxiety for individuals.

Stuart Paterson: I can cover the process side from IAS. It is very much the same principle: writing a paper-based review is the first thing that we try to do. I will also note that at any point that the claimant is with us for our process, if we receive evidence or information from that claimant that allows us to write a paper-based review, we will carry out that paper-based review. That is our first priority for all those claimants.

As part of our initial review process, we also identify claimants who would require a face-to-face or telephone assessment based on some clinical information. Those cases would be routed for a manual booking into their appropriate channel. The remainder of our cases receive the next available appointment, whether that is a face-to-face or a telephone assessment. At the moment, the vast majority of those are still telephone assessments.

We also have a clear process in place that if a claimant is to call us on receiving their appointment, whether it is face-to-face, telephone or video, and they explain to us that that is not a suitable assessment channel for them and that they need to move to a different assessment channel, we will accommodate that. If somebody rings us and says, “Youve booked me in for a telephone assessment, but I can’t do that because of x, y and z, so please can I have a face-to-face?”, we will move that person to a face-to-face appointment, or any combination of those.

Q286       Nigel Mills: Do you get paid the same fee whichever route you use, so there is no incentive for you to do face-to-face assessments to get more money?

Stuart Paterson: There is no incentive for us to do them via any particular channelthat is right. It is all based on clinical evidence.

Chair: Thank you very much. We have lots of ground to cover this morning, so could I ask you to be as succinct as possible in your answers? Apologies, but we need to keep things moving quite quickly to make sure that we get through everything.

Q287       Steve McCabe: I have some questions about the recording of PIP assessments. I understand that the figures for people requesting that are quite low: 0.25% or 0.24%. Maybe I can start with Capita, because you have said that you think it is a good idea and that it helps build trust and promote transparency. Why do you think the figures for people requesting it are so low? Could you talk me through what exactly you do to inform people of that entitlement in advance? It says here that in the information sent before the appointment, they are advised of it. What exactly is that advice? Is it a line in a letter, or is it something more detailed?

Antony King: Yes, it is included in the letter.

Q288       Steve McCabe: Could we see a copy? I am wondering if people are overlooking it because they have a big, dense letter, or if it is something that really stands out so that you would notice the entitlement.

Antony King: We can get you a copy of the letter.

Q289       Steve McCabe: That would be useful. Why do you think the figure is so low?

Antony King: I wish I knew, because then we could try to address it a bit. IAS is a little further forward with this; I think it can offer it on the day of the appointment now. We are just starting to roll it out. Once it is completely rolled out, we will be able to say on the day of the appointment, “Would you like to audio record it?” I don’t know the reasons why. That is why it would be preferable to do it as opt-in by default, and then they would have to opt out.

Q290       Steve McCabe: The advice that we are getting is that the DWP has been advised that that may not be possible. You were saying that it should be opt-out earlier, and we have been told that might not happen. Anyway, you are planning to make sure that people are told on the day.

Can I check something with IAS that I do not quite understand? I have been reading about the associated consent process. What exactly is the associated consent process if you want a recording?

Dr McKillop: From a clinical point of view, we all have to recognise that claimant choice and informed consent to recording of what could potentially be some pretty sensitive clinical personal details discussed during the assessments is absolutely key.

As Capita colleagues have described, we welcome anything that will increase trust and transparency in the process and reduce anxiety, but it is important that we recognise that claimants with some health conditions may feel that a recording made by IAS on behalf of DWP is not the right option for them. They may choose to record on their own devices instead. As Stuart said, the PIP assessment guide has been updated recentlyin fact, just three months agoto say that.

Steve McCabe: To say that that is permissible.

Dr McKillop: That might be a better option for some people. I think that choice and informed consent are key. If we can explain to people what their options are for recording and they can make an informed choice, our aim is to make sure that their wishes are granted.

Q291       Steve McCabe: Thank you. What proportion of your assessments and reports are audited?

Laura Erskine: I can take this. Are you talking just about audio recording?

Steve McCabe: I am coming to recordings later, but I want to know the overall figure.

Laura Erskine: We tend to audit about 45%. Contractually and to support a positive claimant journey, we audit 100% of the assessments conducted by our assessors who are in their new starter training; we also observe a proportion of the assessments that they conduct. When they meet the quality criteria that we expect, which is quite a high expectation, they will move into more of a random or performance-related audit process.

Q292       Steve McCabe: 45% of assessments and reports are audited. What proportion of those have been recorded?

Antony King: As a proportion of the ones that we record, 25%, but given that, as you pointed out, the recording rates are less than 1%, that is a pretty small number overall.

Q293       Steve McCabe: Are all requests for recordings accepted by you?

Antony King: To the best of my knowledge. Laura?

Laura Erskine: We do as much as we can to facilitate the audio recording. Antony mentioned that there was the PIPAG change in January, and we are now trying to support people to be able to record on the day. Sometimes if an individual does not want to wait to be matched with an assessor with the facility to audio-record, they have opted not to audio-record.

Q294       Steve McCabe: I ask that because I asked my office to check on constituency cases in preparation for this session. One constituent was very concerned when the decision came back with a number of errors and mistakes, and she asked for the recording that she had requested; she was told that the recording had not been made. I then immediately came across another one, for a 16-year-old boy: when the request was made via his mother, she was told that the recording had not been made.

In the first case, my office asked Capita what went wrong, because it so happened that the woman had made a recording, which is now permissible, as you say. Capita informed us that she had made a covert recordingan interesting choice of words. What do you think was happening there?

Antony King: Prior to January, of course, it was not in the guide.

Steve McCabe: Was that a covert recording? Is that how you would describe someone taking a recording when you had failed to record one that she had requested?

Antony King: It is not the best choice of words. It is difficult to comment on individual cases, but I am more than happy, Mr McCabe, to look at it outside the meeting.

Steve McCabe: I am happy to give you the details of that case, because I must admit that I was a bit shocked.

Antony King: Please do, yes.

Laura Erskine: Yes, please. We will look into that, Mr McCabe. The PIP assessment guide actually uses the term “covert recording”, so that is where that terminology has come from.

Steve McCabe: Say that again, sorry?

Laura Erskine: The PIP assessment guide, the legislation, uses that terminology. That is where that terminology—

Q295       Steve McCabe: Let me just get this right: if the assessor fails to make the recording that they are asked to make, but the individual makes a recording, that is classed as a covert recording?

Laura Erskine: It is a permissible recording.

Q296       Steve McCabe: Thank you. I have to say I am a bit surprised by that, but there we go. Tell me: is there anything in your guidelines for assessors, like a checklist, that would ensure that they could not inadvertently fail to make a recording that has been requested? Do you have a checklist so that the assessor says, “Oh yes, I see Mrs So-and-so is requesting a recording”?

Antony King: We do have guidance and instructions for our health professionals on how to carry out that recording.

Q297       Steve McCabe: Then these two cases must just have been human error, where they overlooked them?

Antony King: Without knowing the cases it is hard to comment, but I am more than happy to look into them.

Q298       Steve McCabe: I am grateful for that, but I am trying to establish the position. You would think that if there were a checklist, it would be followed—that is normally the purpose of one. I wonder how people could overlook that.

Let me ask you something different. The Committee recommended that all claimants should receive a copy of their report with the decision. Does that happen?

Antony King: That is really a question to ask the Department because they send the decisions out. As I understand it, they request a copy of their report; it does not get sent by default. Genuinely, that is a question that you would have to ask—

Q299       Steve McCabe: Is that because you regard the report as the Department’s report, not really the claimant’s report?

Antony King: As I say, you would have to ask the Department.

Q300       Steve McCabe: I will. I am just trying to understand—you are getting paid to do this, and I am just trying to understand how it works.

Antony King: From our perspective, we send the report to the Department to make the decision and then they notify the claimant with the decision. We have no problems at all with that level of transparency.

Q301       Steve McCabe: I do not want to put words in your mouth, but are you saying that you would be happy for the report to go with the decision and that that is how it should be?

Antony King: I cannot stress enough that we want this process to be as stress-free, acceptable and transparent as it can possibly be. We support anything that promotes that.

Q302       Steve McCabe: Is that the same for IAS?

Stuart Paterson: It is the same from our perspective.

Steve McCabe: Thank you very much.

Dr McKillop: I think the important thing to recognise about that report is that it is only part of the evidence that the case manager uses. The case manager may make a different determination on the award from the report that is given. At that point—we spoke earlier about your desire to look at improving appeals and statistics on getting decisions right the first timeif a claimant has access to the report and knows the evidence that was used to come to that initial decision, that helps them in the mandatory reconsideration stage, because they can point to that.

Q303       Steve McCabe: If you are the claimant, the only evidence you are likely to have is the recording, assuming that it has been done; the report; and the comparison between the report and the recording. That is fair, isn’t it?

Dr McKillop: They will have access to any information that they have supplied and the assessment report but, yes, we would be supportive of the claimant having access to that, so that if a mistake has been made and some evidence has been recorded that they do not think is correct, they can raise that and hopefully get it dealt with at the mandatory reconsideration stage before an appeal is necessary.

Q304       Selaine Saxby: Good morning. My question is about the backlogs, because we understand that during the pandemic there have been backlogs and people have been waiting a long time for their health assessments. The data that we have seen suggests that in October 2016 there were 88,500 people waiting, but by December 2021 there were 312,000. What is causing the delays? Has the size of the queue gone down now?

Stuart Paterson: From our perspective, we can probably only talk about the numbers that fall into our space. We only cover the middle part of the process, which is the assessment. There is the beginning part of the process, around registering claims, and the end of the process, around decision making. The numbers will include everything in the end-to-end process.

We absolutely recognise the increasing time it has taken to process claims. A number of things have led to that position in the last two years. The onset of the pandemic was certainly one of those challenges. At the end of March 2020, as lockdowns started to appear across the country, we stopped face-to-face assessments altogether. We were still receiving referrals to our organisation, but we were unable to carry out any face-to-face assessments.

We carried on doing paper-based reviews, but face-to-face stopped while we worked with the Department and our Capita colleagues to stand up telephone assessments at the scale needed to continue delivering the service. We did that period of standing up telephone assessments carefully between our organisations to make sure that the assessments were of the right quality and were delivering the right outcomes for claimants at the end. That stand-up period was six to 12 weeks. It was a growing period of capacity.

Throughout covid-19, we saw an increase in the number of health professionals who wanted to leave our service and work on the frontline in the covid response. We also saw a reduction in the number of people who wanted to leave the frontline and join our organisation to deliver assessments.

We have since made significant improvements in our capacity through various changes that we have made in our recruitment, onboarding and training strategies. We are seeing the capacity of our service grow significantly: it has grown by about 35% in the last 12 months in the number of assessments that we can deliver. At the end of 2020, we had somewhere in the region of 173,000 referrals in our space to deal with. That had increased to 188,000 by the end of 2021, but we have seen it start to come down now as our capacity is bedding in: we are down to 167,000 cases.

We recognise the challenges for the service and we are delivering the capacity that the Department expects of us at present, but the final element that we are starting to see, which is having an impact on the turnaround of cases, is that demand on the service has increased quite significantly in the last 12 months. The number of referrals or new claims has increased by approximately 20%. That is what the Department is feeding back to us at this stage.

Selaine Saxby: Do you have anything to add?

Antony King: Just to reiterate the root cause of this: a 20% increase in new claims. Like IAS, we are recruiting more staff to deal with the increase in new claims, but there is a turning circle on that. There are a finite number of healthcare professionals available, and they are obviously in high demand across the NHS as well. We are successfully recruiting, but the turning circle, plus the increase in new claims, means that backlogs are there, as you say.

Q305       Selaine Saxby: Can somebody explain why we are seeing a 20% increase in new claims?

Antony King: We can give you some indications. It sounds a bit soft, but I think that that is really a question for the Department, because it has lots of clever statisticians who look at all this. We are seeing long covid, there is definitely an increase in mental health conditions, and thenas I think the Green Paper highlightsthere is an ageing population, and there seems to be a drift upwards in new PIP claims. The question that we cannot answer at the moment is to what extent that is linked to the current cost of living crisis, as people are looking for further ways to augment their income.

Stuart Paterson: We continue to work with the Department to better understand, first, why that increase is there and, secondly, what the likely projections of future demand are on the service so that we can resource properly to deal with that. As Antony says, it requires significant planning ahead. Onboarding health professionals is challenging. It takes quite a period of time to bring a health professional into the business, train them and get them to the level that we expect so that they can complete assessments successfully. We do not know the reasons for the increase, but we are working with the Department to understand those reasons and understand the future projections.

Q306       Selaine Saxby: Our understanding is that you, as organisations, are paid per assessment. It is important that we try to understand whether you are able to provide the same service for the increased number of claimants as we try to clear the backlog. Also, do you think that you are providing a good level of service to claimants and to the taxpayer in general?

Antony King: We have to be a bit careful about what we talk about on the commercials, but we are no longer paid per claim. That is not the case any longer.

On the second part of your question, as Stuart said, we process what the Department is telling us it is going to send us. If it sends us more than that, we have problems, because we then have to recruit and so on.

Whether we are providing good value is a variation on the question asked at the beginning about whether we are providing a good service. If you look across the range of metrics that are measuring our service, they suggest that we are, but that is not to say that we cannot improve or that there are not individual cases, as Mr McCabe highlighted, where we have problems.

Dr McKillop: From the IAS perspective, the response is very similar. We touched on quality earlier; we are now meeting the expectations on us for quality, and we have been doing so for the period of 2021 and the year to date in 2022. The quality of the assessmentsgetting the assessments right the first time and getting the assessors trained to give every claimant a good service—is absolutely at the forefront of what we do. We are trying to grow the service and we are bringing on more people to deal with the capacity, but it is never at the expense of quality.

Q307       Selaine Saxby: Can we look at the timing? We are talking about a backlog of over 100,000 people. How long are people actually waiting? How long will it take to clear the backlog so that people are not waiting so long?

Stuart Paterson: The current position is that the end-to-end time for a claimant to move through the PIP process is 22 weeks, including all the DWP elements of the process. The middle bit, which is the time spent with us as a provider, is 17 weeks.

We continually work with the Department to update our forecasts for the future. The big unknown for us is what the demand on the service will be over the coming months. That makes it very difficult for me to say that by a certain date or within a certain timeframe, the backlogs will have passed.

Antony King: It is a similar story for us. Our target in the contract, for the bit that we are in charge of, is 35 days. This is probably data that DWP will need to validate, but as a snapshot in time, I think we are at 48 days at the moment, so we are obviously beyond the 35.

On bringing it down, I would say with my hand on my heart that if the number of claims keeps rising, that is a difficult thing to predict. We are predicting it to be fairly static through the rest of this year, but that is obviously not bringing it down. As we keep saying, we need to recruit, which takes time. Then, once you have numbers in your backlog, as it is called, you have to clear them while still processing the rising new claims.

Q308       Debbie Abrahams: Good morning, everyone. I would like to start with Ms Erskine and Mr King, if I may, specifically to consider the death of Pip Day, who, as most people will be aware, took her own life in October 2019. In the inquest into her death, the coroner found both you and the Department culpable for multiple failings that contributed to her death, and issued a prevention of future deaths report to you and to the Government. Did you have a safeguarding policy?

Laura Erskine: Absolutely. We have always had a safeguarding policy.

Q309       Debbie Abrahams: Why did it fail?

Laura Erskine: If we go back to the prevention of future deaths report and Mr Clow’s inquest report, it was around the initial review decision-making process, which is where improvements have been made. The decision to invite Philippa to a clinic assessment is where the error was made, and then not being able to consider the verbal further evidence given by her community psychiatric nurse on the phone, which then meant that we continued to try to invite her for a clinic assessment.

From a safeguarding perspective, it was more around that initial review decision-making process, where we made the error. We have, however, since made further improvements in our safeguarding processes. As we mentioned earlier, we now have a flag on claimants’ claims where there is an indication that they could be vulnerable, such as expressing suicidal ideation, engaging in deliberate self-harm or talking about self-harm. We do our absolute utmost to conduct a paper-based report where possible, so that that individual is not invited to a clinic assessment. A clinic assessment would be the last option for an individual like Philippa.

Antony King: Can I add to that? We have said it before but we again, in public, apologise to the Day family for the errors that Capita made that contributed to her death.

Q310       Debbie Abrahams: Thank you for that. Can I understand what you consider a vulnerable person? Do you consider, for example, that the process involved in assessing whether somebody will ultimately receive support for their illness or disability makes them vulnerable?

Laura Erskine: We look at the individual and do not really consider, necessarily, whether they have support or not. For example, obviously in the case of Philippa Day she had a CPN who was clearly advocating on her behalf, as well as her father who was advocating on her behalf. We would take the individual’s circumstances and decide whether they were vulnerable; we have a very low threshold when deciding if someone is vulnerable. Someone could just call our inquiry centre once themselves and be quite distressed and upset on the telephone call, and regardless of asking whether they have additional support we would consider them a vulnerable claimant.

Q311       Debbie Abrahams: Therefore, vulnerability just by virtue of having an illness, having a disability or condition does not necessarily alter your approach to them.

This question is open to the Atos representatives as well, Dr McKillop and Mr Paterson. We know from evidence from the Department that approximately 60 people a month die within six months of being found unfit for support with the personal independence payment; that goes back to a written question from my former colleague Madeleine Moon. Does it suggest that something is completely and utterly flawed in the process if this is happening?

Dr McKillop: It is always very distressing to those of us involved in delivering the PIP service when we hear of the death of someone who has used our service. We always aim to get the assessment right, to conduct a compassionate assessment with minimum distress and stress for claimants, but obviously in not every situation will we get that right the first time, even though it is our aim.

With PIP, we are seeing people with chronic, often severe medical conditions who are passing through our service, making a claim with lots of illnesses. With the assessment itself, our assessors can only base an assessment on the information that they have available to them at that time, not necessarily on anything that may happen in the future. We are looking at function, how someone lives their daily life and the effect of their illnesses on their functioning, rather than looking to make a diagnosis or treat.

If there are any concerning symptoms that an individual tells us about during the assessment, or if we identify anything that we think the GP should know about—that can be a symptom relating to their physical health that they have not told anyone about before, or it can be thoughts of mental distress, suicide or self-harm—we have a process in place whereby we alert the GP using an unexpected findings form, as in the PIP assessment guide, to make sure that the GP is aware of those symptoms.

Q312       Debbie Abrahams: I am sorry to interrupt you; I am just conscious that the Chair will remind me about the time. When did you introduce that?

Dr McKillop: The unexpected findings process has been in place since the beginning of PIP; it has always been in the PIP assessment guide. Our health professionals see someone or assess someone on one occasion only, so it is important that we have a route by which we can alert their GP to anything that causes our health professional concern that we want—

Q313       Debbie Abrahams: How many deaths have you been made aware of?

Dr McKillop: I am not able to give you an actual number. I can say that we work with the Department and colleagues in Capita on the internal process review. If, as you describe, someone who has passed through our service later passes away, we would be involved in the investigation of that. We would look at the report and any actions that were taken on that case, and we would work with the Department and the other provider to see if any mistakes were made that we can learn from.

Q314       Debbie Abrahams: Thank you. Ms Erskine and Mr King, how many deaths have you been made aware of in the IPR process?

Laura Erskine: We have been made aware of a very small number. We would welcome some more transparency around claimants who sadly die either during or after the PIP process so that we can fully investigate from our side and work with the Department and IAS colleagues to understand if there are any further lessons that could be learned.

Q315       Debbie Abrahams: I have to say that I am surprised that neither of you have this information. Can I tell you that between July 2019 and July 2021 there were 97 IPR reports into deaths? I am pretty sure that there will be people who have gone through your process who will have died subsequently and that that will have been investigated. That will not be all the people who have died, but their cases will be investigated for flaws in the system.

Antony King: Ms Abrahams, not all of those will come to us. Ours are a small number.

Q316       Debbie Abrahams: So Atos or IAS will get details and will be involved, but Capita will not?

Antony King: No, we do get IPR reports, but it may not be that all the ones that the DWP deals with are referred to us for further investigation.

Debbie Abrahams: That is interesting.

Dr McKillop: It is a DWP-owned and led process. They will typically reach out to us with a specific request from the people who are investigating a case for us to look at any aspect of our dealings with that case. We do that investigation and send the information back to them.

Q317       Debbie Abrahams: You are not part of that process, but you may have information on some of the cases. We have established that the DWP does not necessarily provide you with all the information. Do you also let other authorities know about your concerns? You mentioned GPs. What about social services and others? Do the DWP and other agencies let you know when they are concerned about the health of—

Antony King: Yes to all of those, but Laura might want to give a bit more detail.

Laura Erskine: Just briefly, they will identify via the “additional support needs” flag. They have also made some changes to their system: there is an “advanced customer support” flag where details can be given if they have had to contact anyone themselves to share information. We can see that on their system. As Barrie mentioned, we will also contact GPs, and we have called 999. We contact multi-agency safeguarding hubs and LADOslocal authority designated officersfor safeguarding concerns. We do that regularly. We have seen a marked increase in concerns from our health professionals and our inquiry centre agents over the past 18 months in our onward referrals to health professionals and internal concerns raised about individuals.

Dr McKillop: We have a similar process to what Laura has just described for safeguarding. We have a safeguarding policy; all our health professionals are trained in safeguarding.

Debbie Abrahams: All of them?

Dr McKillop: They all have access to the policy. We have area and designated safeguarding leads who are trained and certified appropriately so that any concerns that do not fall within the unexpected findings processclinical concerns that a GP is probably best at dealing withcan be passed on to social services or another agency.

Q318       Steve McCabe: All your staff have medical backgrounds, is that right? Can you give me a rough idea of the types of medical background they have?

Dr McKillop: We have about 2,000 health professionals in the IAS team, including those directly employed by ourselves and some from our partners. The majority of our health professionals—around 67%—are registered general nurses by background. Within that group, there is a wide range of clinical experience and background. Of our health professionals, 17% are either registered mental health nurses or registered learning disability nurses, and roughly 15% are occupational therapists, physiotherapists or paramedics, in roughly equal proportion. We also have three doctors working in the service.

Q319       Steve McCabe: I am curious about this. I was reading the information we were sent from the National Audit Office about the targets that the Department has set for staffing. Do all your staff continue to practise? Are they retired, or do they work for you part time? Are all of them still in medical practice?

Dr McKillop: The majority of health professionals, as Capita colleagues have described, come to us from NHS backgrounds. They have a really wide range of age and experience. We have young people who are perhaps two or three years into their career. We also have people who have considerable experience—25 years’ experience in the NHS is not unusual—and they bring all that clinical experience to us.

Most health professionals work for us relatively full timefour or five days per week. Only a few, we understand, work for us at some times and continue to practise in an NHS setting. But it is important to point out that all our health professionals are fully registered with their governing bodies and are all subject to the revalidation process, so they must all keep up to date and make sure that their registration is kept up to date, just as they would in any other clinical setting.

Q320       Steve McCabe: So they are all fully active“live”, if that is the right term.

Dr McKillop: Yes.

Q321       Steve McCabe: Okay. I just wonder about numbers. I was looking at this thing that came from the Department back in 2015, which recommended an 84% increase in the staff you would take on to keep up with the numbers. Mr King, you were talking about the increase in numbers. IAS has just over 2,000 staff. How many does Capita have?

Antony King: As a snapshot, about 1,000.

Q322       Steve McCabe: Back in 2015, the Department estimated that providers would need to increase the number of healthcare professionals by 84% from 2,200 in May 2015 to 4,050 in November 2016. I am not surprised that you are struggling to meet that target, but since it is now 2022, that would mean, by some calculations, that we should be talking about nearly 11,000. How are you coping with such low numbers? That is the question I have to ask.

Antony King: I do not recognise the data, and without knowing the data it is a bit difficult to comment, but I think—

Q323       Steve McCabe: Do you think you have adequate staff?

Antony King: No, not at the moment. We think 1,200 is about where we need to be. I do not recognise the numbers that you have cited there; they seem very high.

Stuart Paterson: I echo that. 2015 was quite early in the delivery of PIP, and the service was growing quite significantly back then. PIP really only started at the end of 2013 and into 2014.

Q324       Steve McCabe: The numbers I am citing are from the 2016 National Audit Office report, “Contracted-out health and disability assessments”. The National Audit Office says that the figures come from the Department for Work and Pensions. You have never come across themI accept that.

Antony King: Let me look at them, and I will be quite happy to write back to you and comment.

Q325       Steve McCabe: That would be helpful, because obviously it would appear that the Department has much greater expectations than you are able to meet in staffing numbers.

Antony King: I do not think that that is the case, at the moment anyway. That is why I think those figures are outdated. I will take that one away.

Q326       Steve McCabe: Fair enough. If you are in a position to comment, that would be helpful.

How many of your staff do you find have to be retrained or indeed dismissed annually because you have found their work unacceptable?

Antony King: We have some statistics on that, which we have prepared for this session. As Laura said, we audit about 40% to 45%. If we detect any staff who are struggling, or if they have a complaint raised against them or are subject to various other measures, we will start monitoring them more closely. The primary thing we do is give them lots of support to try to improve. To answer your question in a succinct way, about 9% to 10% of our staff leave for what we call performance-related issues over the course of a year.

Stuart Paterson: From our perspective, I do not have the percentage, but I have the actual number: 61 health professionals left our business in 2021 because of those issues we talked about. Similarly, we want to bring in health professionals and give them a successful career in our organisation. Most of the 61 we are talking about are people who have come into the organisation, and through the first six months, when they are learning and understanding the job, we are auditing their reports and keeping an eye on what they do. We find that some health professionals are just not suited to the role, and we part ways with those health professionals.

Q327       Steve McCabe: Do you set performance targets for all your staff?

Antony King: Quality targets primarily, yes.

Stuart Paterson: Obviously we have a quality target. Effectively, we would like every report that our health professionals write to be of the desired and correct quality.

On targets for volume of assessments, we take the approach of scheduling a number of appointments daily for each health professional. We schedule three appointments a day for a health professional at the moment, but we find that on some days they cannot complete all three because they come across a case that takes longer. That is okay, and we will make arrangements for the other appointment to be dealt with by somebody else on that day, potentially. Ultimately, we are scheduling three cases a day, which is based on feedback from our health professionals on how long they need to carry out each individual assessment.

Q328       Steve McCabe: I am really just seeking an opinion on this. In the past, people have told the Committee that it would have been better if they had had an assessor who clearly understood their condition. I guess the argument is that the claimant should be able to select someone they can have some confidence will understand their condition. Is that operationally possible for you orgiven what we have said about staffing numbers and so onis it an impossibility?

Antony King: I think that there is a question to ask before that, which is “Is it the right thing to do?”, as opposed to “Is it operationally possible?” Laura can comment in a bit more detail, but a number, if not most of the claimantspeople who go through the processhave multiple conditions. Having a specialist in one particular area may not be that advantageous.

Would it be operationally possible? Everything is possible, but it would be more difficult, obviously. I think the key question is “Is it desirable?” I am not sure that that is the case.

Stuart Paterson: From our perspective, the operational challenge would be real. We already recognise the challenges on the service. There are many reasons. I know that special assessors have been discussed by this panel; I think that from our perspective the only way to understand whether it is the right thing to do is to test that. We would be open to testing it.

Dr McKillop: As Stuart says, we have discussed the make-up of our health professional team. We obviously have people in it with considerable specialist experience—people who are community psychiatric nurses or who have worked in neurology, for example. We do not know of any research to date that has looked at any potential benefits of matching a clinical assessor with someone who has that particular clinical condition.

To go back to a point that we discussed at the beginning, we should absolutely take the opportunity to look at anything that can be done to increase trust and transparency in the service. We recognise that it is natural for a claimant to want to have confidence that the assessor understands their medical condition, while balancing that against the fact that PIP is a functional assessment.

I think the key is communication skills and the ability to focus on that person’s daily life, because no two people with the same medical condition will have the same daily impacts. Much of the way PIP works in getting the assessment right the first time will depend on having a detailed functional conversation, looking at a person’s life rather than at medical conditions in isolation.

Q329       Siobhan Baillie: Thank you for coming in. In 2018, the then Select Committee’s report on performance targets said: “The Department’s quality standards for PIP and ESA set a low bar for what are considered acceptable reports. The definition of ‘acceptable’ leaves ample room for reports to be riddled with obvious errors and omissions. Despite this, all three contractors have failed to meet key performance targets in any given period.” That was in 2018. What is your current performance against the contract performance measures? You have just mentioned quality targets; have the performance measures changed since they were last reported?

Antony King: We touched on this before: I think IAS has mentioned that it is consistently meeting its quality targets, as is Capita, which is a big improvement since 2018. We have a range of measures in the contract and, aside from the 35 days versus 48 days that was raised earlier, we are largely meeting all of them regularly.

We are also in dialogue with the Department about whether they are the right measures. Since 2018, for example, again on the back of the Philippa Day case, we now have targets around making sure that the initial review decisions are correct, which I think is a step forward. To answer your question: yes, we are meeting the targets and it has improved since 2018.

Q330       Siobhan Baillie: My understanding is that there is nothing in the public domain about how contracts were changed and modified, particularly in the pandemic. Is that correct? Do you think it would be better to have more information in the public domain?

Stuart Paterson: From our perspective, the changes made to the contracts during the pandemic followed the Cabinet Office guidance that was issued on how to change and how to deal with those contracts during that time. Do I think more transparency or more visibility of those contracts would help in this space? I think the honest answer to that question is “I am not sure.” It is probably worth discussing with the DWP.

Siobhan Baillie: Do you agree with that position?

Antony King: I hesitate to disagree with Stuart, but I go back to the fact that we are comfortable with transparency. I believe that the Department is looking at publishing more data in this area. Again, if it can build confidence in the process, all to the good.

Q331       Siobhan Baillie: With the extensions of the contracts during the pandemic, did you agree vastly different terms? What was the profit that was created for your companies during that period?

Antony King: I am going to hide behind the commercial confidentiality piece here. I think we actually made less profit during the pandemic. The commercial model did change a bit, but if the intent of your question is “Did we profiteer from it?”, absolutely not.

Q332       Siobhan Baillie: Were there quite different terms, or was it an extension of the existing—

Antony King: It was a variation to the terms along Cabinet Office guidelines.

Stuart Paterson: We had the same outcome. I am happy to share the actual profits and various things of that nature with the Committee, but I would need to check with the Department that it is something that I can do. It is a live procurement at the moment for this service, so I do not want to put that under any challenge. But we followed Cabinet Office guidance and we kept the same measures for the quality of our service and outputs of our service for consistency.

Q333       Siobhan Baillie: Moving on very quickly, because I am conscious of time, what involvement have you had with the health transformation programme? Are any of you bidding for the new functional assessment contracts that are going to run to 2028?

Stuart Paterson: The health transformation programme is obviously something that we are aware of. Our involvement—and this was pre-pandemic—is that we have done a number of sessions with the Department where we have shared our learning from delivering the personal independence payment over the last 10 years. We have taken them through not only our journey in the last 10 yearswhat we have learned, what we have done well and what has not worked wellbut our current process and how we work through this end to end.

On the future servicesthe functional assessment services, which are currently being procuredI believe that that opportunity is currently at the qualification stage and is something that we are looking at.

Antony King: On the second part of the question, the Department asked us beforehand not to comment on whether we are bidding or not, so no comment.

Q334       Siobhan Baillie: Have you been involved in submitting information

Antony King: Probably not quite as much as IAS, but we have a little bit. We have also been involved in training some of the DWP staff for PIP assessment. Yes, they are keeping us informed, but we have not had a huge amount of involvement.

Q335       Chair: I am aware from your written evidence that you have referred to two performance targets. One is that no more than 3% of the reports submitted to the Department are deemed unacceptableI think you both said that you are achieving that one—and another is about claimant satisfaction targets of 90%. But from what you said there is a whole suite of other targets. Can you tell us what they are?

Antony King: To be honest, I could trot a load out. Do you want me to write to you separately?

Chair: Yes, that would be helpful, just to know what the measures are.

Stuart Paterson: Our measures will be similar, but we will also commit to that.

Chair: That will be interesting and helpful. Thank you.

That concludes our questions to all of you. Thank you very much for being willing to answer our questions today, and for the very helpful answers that you have given. Thank you also for offering to provide some further information in writing subsequently; we will be delighted to hear from both of you.

Examination of witnesses

Witnesses: Dr Paul Williams, Emma-Jane Bannister and Suzie Frew.

Q336       Chair: I ask the second panel to tell us who you are, starting with Suzie Frew.

Suzie Frew: Hello, Chair and members of the Committee. I have been a registered nurse for 30 years, and for the last 10 years I have been the lead nurse for CHDA or Maximus. I head up professional standards and quality.

Dr Williams: As my title probably suggests, I am a medical practitioner specialising in occupational health medicine. I joined Maximus at the start of the service seven years ago as chief medical officer; I now oversee all Maximus’s services in the UK.

Emma-Jane Bannister: I am the customer director for CHDA. My team oversees the customer journey and customer experience; we refer to clients as customers within the Maximus business. I also have responsibility for our call centres and our customer relations, customer feedback and complaints.

Q337       Chair: Thank you, and a warm welcome. What areas do you identify where you think improvements could be made to the service that you are providing to claimants and the Department? Can you tell us how the roll-out of universal credit is affecting the service that you are providing at the moment?

Dr Williams: I am sure that Committee members, being well versed, know that we assess for a number of benefits. The major benefit that we assess for is the work capability assessment. It has always felt to me, as an occupational physician, that that is probably part of a wider policy of trying to support people with disabilities into work where appropriate, and provide support where that is not appropriate.

While it would be extremely difficult to do, I think that anything that created more linkages would be very successful in delivering the desired outcomes. Like colleagues who were here earlier, I think that there should be greater information sharing, even across the systems as they currently stand. I have family and friends applying for benefits; they often say to me, “Why have I got to submit my information again?” I think that is difficult for people, so any systems that led to improvements there would be very welcome.

The Committee was asking earlier about recording of assessments. I do not want to jump into future questions, but I think that to increase trust and transparency, making recording more readily available and accessible would certainly be an improvement. We often come across the question, “My GP says I am unfit for work—why is this different?” There needs to be more public information generally about what the assessments are for.

Chair: On universal credit?

Dr Williams: Yes, sorry. You will be aware, I am sure, that the part of the overall process that we look after is clinical assessment. For universal credit customers, the clinical assessment has some very subtle differences, but essentially it is exactly the same process. We are aware that more may be happening administratively before we receive the referrals. Universal credit, as I am sure everybody is aware, is intended to be a digital type of application; when our service was created, it was primarily focused on paper application forms, so some workarounds happen before cases reach our service, but once a case is with us it makes very little impact.

Q338       Nigel Mills: There has been a chequered history with these assessments. If I think back a decade, there were real problems before you took over. What sort of standard do you think you have got them to now, compared with where you could get them? On a scale of one to 10, what would you say?

Dr Williams: I heard your question earlier, so I was thinking about that. I as an individual, and probably we as an organisation, tend to focus on the areas of improvement rather than on what is going well. To justify my score before I give you a number out of 10, when we started a little over seven years ago, the waiting time for an assessment or the process of getting an outcome was 32 weeks. Immediately prior to the pandemic, it was down to nine weeks. It is currently up at 12 weeks as we recover from the pandemic’s impact, but we will have it back down to nine weeks shortly. We are currently meeting all of our 14 quality targets. We have customer satisfaction scores in the 97% to 98% range.

Taking those numbers, trying to be objective, I would give us a nine, but I continually focus on the one. We are dealing with vulnerable peopleI am sure we will come on to that—and people with multiple challenges in their lives. It is a worrying time, if they are unable to work. I think that there are still things that we need to work hard to improve.

Q339       Nigel Mills: Basically, you think you have got these assessments about as good as they can be, other than with a small tweak; if you wanted to change them dramatically, that would mean more money or a different structure. Is it your view that it is about as good as it can be, in the structure that you operate in?

Dr Williams: Yes. Let us just say that we are in the territory of continuous improvement. We are always trying to learn; you will know that we have a customer representative group of more than 50 charitable bodies, representing a wide range of interests that we work with in seeking to improve. I think a radical difference would require considerable investment in technology or a fundamental change to some of the underpinning legislation and guidance.

Q340       Nigel Mills: Where are you on telephone and video assessments? I think I came to Derby and saw you doing lots of telephone and video, so I am guessing that, like the previous witnesses, you are predominantly doing it that way now rather than face to face. Are you?

Dr Williams: We are at the moment, yes. One of the changes during the pandemic was to telephone and video; the majority of our assessments are done that way now. It is probably an important caveat that, in contrast to PIP, the proportion of cases that we can advise on, with initial paper scrutiny, is far higher. Typically, on paper, we are able to advise on one in four, but from that process onwards telephone and video is more likely. Emma-Jane probably has more detail on the channel mix, if you want to explore it further.

Emma-Jane Bannister: We have a very regular survey that is undertaken by an independent research agency, which phones over 1,000 customers every quarter. The feedback has been incredibly favourable towards telephone assessments. As you heard earlier, not having to navigate travelling into a centre has made having an assessment from the comfort of their own home a preference for many customers.

Q341       Nigel Mills: What proportion is by telephone? We were told earlier that it was 85%. Is it similar for you?

Emma-Jane Bannister: It is a bit less. It is roughly 70% on WCA.

Q342       Nigel Mills: So one in four is paper-based, and then—

Emma-Jane Bannister: That is rightthat is after the paper stage. Every claim is reviewed on paper by a clinician first. Any customer claim that can cleared will be cleared at that point. After that, any other customer will be called for an assessment. Roughly 70% of those are by telephone at the moment.

Q343       Nigel Mills: Do you get paid the same regardless? Do you just get paid to do a report on an individual?

Dr Williams: We have never been paid per assessment—that is not how our contract works. We agree with the Department the number of assessments that we will provide and there has always been a series of incentives and penalties if we do not hit those numbers, but we have never had a payment-per-assessment model.

Our contract is available on Contracts Finder, and you can see it. To support that, we have an open book accounting arrangement with the Department, and you can see in real time exactly what is happening with the assessments, our costs, the staff we employ and where everything goes. It is a very open and transparent system.

Q344       Nigel Mills: What proportion of your assessments are recorded? Are people wanting to record them, or is that not a big deal?

Dr Williams: The percentage recorded is quite low, but if we flip that around to the number of people asking, we certainly endeavour to be able to record every assessment that people ask us to record.

We occasionally get problems at the last minutepartly because, as I mentioned, our assessment has been going for a while and we use cassette recording technology. As anybody who had a cassette recorder back in the day knows, they sometimes play up at the last minute. When that happens, we ask people, “Do you still want to go ahead, bearing in mind that the machine is not working today?” Sometimes people are completely content to go ahead—they would sooner deal with the situation, perhaps if they have brought an advocate or somebody with them. At other times, we try to reschedule them as soon as we can. There is a very small number of cases where that happens.

Q345       Nigel Mills: That is strange, because almost everybody you ring these days has an automated message that tells you that they might record the call. If you are doing so many of these assessments by telephone, is it not quite easy to do a recording?

Dr Williams: I am not a technical expert, but I guess that recording would take up a certain amount of memory and there would need to be safeguards around data protection and access issues. But if your question is “If the technology were available, would we be in favour of recording assessments either by default or very widely?”, the answer is “Yes, we would.

Q346       Nigel Mills: It is quite hard for me to record a phone call. I can record what I am saying, I suppose, but it is a bit hard to record the other side.

Dr Williams: Elsewhere in our business we operate contact centres as part of the services that we offer, so the technology certainly exists. It would require a level of investment to bring it to this environment, but both sides of the recording can be made.

Emma-Jane Bannister: That is right. Our call centre calls are recorded—we have call centre technology that recordsbut the practitioners are using landlines and mobile phones provided for telephone assessments. That makes it more of a challenge, but as Paul said, every request for an audio recording is accommodated.

Nigel Mills: So, bizarrely, you can record the call when I make my appointment, but you cannot record the call when you do the assessment.

Emma-Jane Bannister: I know from our discussions with the Department that it is looking at a longer-term solution. Telephone assessments are still relatively new in the great scheme of things. I know that it is looking at developing a solution.

Q347       Nigel Mills: Is one quicker way just to send the customer a copy of their assessment report? I think we have recommended that before.

Dr Williams: Having listened to the prior evidence, our position is broadly the same. The person for whom the report is written is the DWP decision maker, so we pass the report to them. I imagine that that is the channel by which it is made available. It was part of my routine of clinical practice when I was seeing patients always to send a copy of my letters to other people to that person; I think it is good clinical practice that has been adopted in a wide range of NHS settings, for example, so it makes perfect sense to me. As I am sure you know, there are some safeguards for access to medical reports and so on around third parties being mentioned, so some consideration would need to be given to that, but as a default position it makes perfect sense.

Q348       Nigel Mills: May I ask about medical and third-party evidence? How long do you give your assessors to conduct their assessment, from picking up the file to signing off the report?

Suzie Frew: I have been in the business for many years and have done the assessments. The assessment takes as long as it takes—there is no specific start and end time. Every customer is given the time that they require. Typically, the customer is probably with us for about an hour. The administration prior to the assessment and the writing up of the report can take anywhere from half an hour to an hour; it depends on the individual customer. That gives the practitioner time to look at any medical evidence, look at the questionnaire that the customer has submitted and then write up the report at the end.

Q349       Nigel Mills: So you do not manage your staff throughput and start appraising them if they are not getting through four customers a day, or something—it takes as long as it takes.

Suzie Frew: It does. Typically, the average number of cases a practitioner would see is about five, but that can be very different from day to day; it depends on the complexity. I heard our PIP colleagues mention that customers can have multiple conditions. On average, most customers will have about eight or nine conditions, so that can take time to go through.

For those who come for a work capability assessment and are particularly unwell, the set-up allows us a route to doing an abridged version of the report, because we can get a lot of the information we need to advise DWP that they are quite unwell. That does not necessarily take an hour, because obviously that would be inappropriate if someone were particularly unwell, with breathing issues or whatever it might be. I hope that in most cases we capture those who are particularly unwell at the filework stage, and that we can gather evidence at the very first point when we get the questionnaire.

Q350       Nigel Mills: There is no reason why the assessor would not have the time to read all the evidence, if there is any. We heard from the previous witnesses that informal comments like Seemed to walk in okay and shook hands fine” should have gone now—those are not the observations that you would expect to see in your reports.

Suzie Frew: Informal and formal observations are part of clinical practice anyway, as I am sure Paul would agree, but in the context of the assessment process, informal observations are only a very small part of our overall advice. We look more at the individual set of circumstances than at what we notice someone is able to do during the assessment. It is about the bigger picture. I am very conscious that the decision maker may never get to speak to or see the customer. However, I am either speaking to them or have them face to face, so I am able to portray the difficulties that the customer is having to the decision maker through my report.

Q351       Nigel Mills: Have you gone along the same lines that we heard about from the previous panelwanting more in-depth questioning of what the customer says, rather than just going down a list of standard questions about how they get round the supermarket or whatever the standard things are? Are you taking that approach, or are you still sticking to a pre-planned script?

Suzie Frew: It is very much an exploration of how the customer is able to function. I think that there is sometimes a bit of a misconception from the customers who attend for assessment: they assume that if they are going to see a doctor or a nurse it will be diagnostic or recommending treatment, whereas that is not part of our remit. It is important that we explore the function, because ultimately that is what the report is about. It is about the customer’s ability to function with the medical conditions that they have, so it is important that we explore the variability. I know our customer satisfaction surveys seem to suggest that we are improving at giving the customer time to allow us to explore all those areasnot just how the person is in front of us today or on the telephone, but how they are over an average week or an average month, because most conditions are fluctuating and have variability. It is key that we explore that fully.

Q352       Selaine Saxby: Good morning. I am asking about backlogs again, as I did with the first panel. During the pandemic and into 2022, there are concerns that people have been waiting a long time for their work capability assessments, particularly those on universal credit. How long are people waiting with you for each benefit? What is the current size of the backlog?

Dr Williams: I do not know when people get referred to us, so I am not sure where people might be from the date they make initial contact to when we are aware of them. From when we are aware of people, if that is the right terminology, we were down to nine weeks, as I mentioned. During the pandemic, having ceased face-to-face assessments for a while, you will not be surprised to know that at one time that went up to 22 weeks. We are now back down to 12 weeks and heading back to nine.

I know that nine weeks might still seem quite a long time, but we have to build in allowing people three weeks, I think, to complete and return the form. We will typically allow anything up to 20 days to get further medical evidence if possible. We are obliged, as part of the legal underpinnings of the service, to offer people three weeks’ notice for an appointment, although not everybody wants it. By the time you have built in those parts of the system, it is possible to get to less than nine weeks, but something like seven is probably about as quick as you can make it. That may not fully answer your question, because of the people we may not be aware of who are not yet in our part of the programme.

Q353       Selaine Saxby: Do you have any idea how many people are currently waiting?

Dr Williams: I do not, personally. The Department will certainly have those statistics. You will not be surprised to know that at particular timesduring a pandemic, for examplewe would mutually focus more on people who are making new claims, because people who are already in the system are in receipt of benefits. We certainly prioritise so that we can reduce waits as much as possible.

Q354       Selaine Saxby: Are you doing anything further to manage the increasing numbers who are undergoing the work capability assessment for universal credit, rather than ESA, and any other changes you have had to make?

Dr Williams: As I mentioned, we have invested considerably in growing the organisation. We have more than doubled the healthcare staff we employ so that we can see more people, which has led to a substantial improvement in bringing the times down. The short-term issue, as I am sure is obvious, is that we had to suspend face-to-face assessments for public safety reasons, making the queue longer. Now that we are back to telephone and other remote assessments, we have been able to bring that right down again.

Q355       Selaine Saxby: The Department has not published data on work capability assessments for universal credit claimants. Are you able to say what proportion of people you assess are for universal credit rather than ESA?

Dr Williams: Not in any reliable way, I am afraid, because we do not collect data. As I mentioned, from our perspective the clinical assessment is the same. I don’t know if you have any more to add, Emma-Jane?

Emma-Jane Bannister: No.

Dr Williams: It is not data that we would collect.

Q356       Selaine Saxby: Are more people, from the evidence that you are seeing, having work capability assessments now than pre-pandemic? Are there any particular conditions that are driving that?

Dr Williams: I am not aware of any increase in claim numbers overall, I have to say, but I am sure the Department would know.

Q357       Selaine Saxby: Given the length of time that people are still waiting to be assessed, do you consider that you are providing a good service to claimants and to the taxpayer more generally?

Dr Williams: I think we have brought down substantially the time that people are waiting to be assessed. There has been a substantial improvement. Given the timing periods that are built into the processthree weeks to return the form, another two to three weeks to receive further evidence, three weeks’ notice of an appointmentthere is a limit to how much that time can be shortened. Yes, I think overall we are providing good value.

Q358       Chair: You said that you have doubled the number of healthcare professionals. What does that take you up to now?

Dr Williams: At peak we were at just over 1,200. We are currently at just over 1,100.

Q359       Neil Coyle: You said that the current wait time is 12 weeks but will shortly be nine weeks. When will it be nine weeks?

Dr Williams: I wish I could give a categoric answer. It depends very much on the mix of referrals that we have. As an estimate, I am going to say three months, but it could be four. What it is not going to be is years.

Q360       Neil Coyle: You mentioned that you give up to 20 days for the provision of additional medical information. Is there any flexibility in that?

Dr Williams: Yes. We try to reach a judgment; Suzie can probably comment a bit more. There is a bit of a cut-off based on how long we wait and how likely we are to get more evidence. If we try to phone and remind and encourage, we may get an increased return. We have certainly made big improvements in return rates. The last time we were in front of the Committee, in 2018, I think we were getting further medical evidence in 40% of cases; it is a little over 50% now, so we have made improvements. But sooner or later, we have to form a judgment about the balance: “Should we continue to wait, and is that less good customer service, or should we try to proceed on the evidence that we have and either make a telephone call or carry out some other form of assessment?”

Q361       Neil Coyle: The reason I ask is that the pressure the NHS is under and the backlog for routine and life-saving treatments are common knowledge. The requirement to see a consultant for this purpose seems to be a lower priority. Have you made representations to DWP, or do you feel that it is not part of your contractual relationship?

Dr Williams: We are regularly in discussions about where we might get different sources of information. I mentioned, while acknowledging the pressures that many of our NHS colleagues are under, that if anything our return rates are better than they were historically. As a company and with DWP support, we undertook a number of initiatives with GPs. We have clinician ambassadors in each of our regions, so we attend GP trainee events and practitioner events. If there are any GPs listening, I think one of the main values of further medical evidence is that if we can advise about the customer, based on the paper evidence, it saves us from needing to see them face-to-face. Now, of course, it might be by telephone, but any information that GPs provide can be valuable to their patients.

Q362       Neil Coyle: I want to come on to that wider support. Disabled people and welfare organisations tell us that this is a very stressful and difficult process, and sadly often a negative one. Do you have views on the advocacy support suggested in the Shaping future support Green Paper?

Dr Williams: Yes, we do. We very much welcome advocatesprobably for anybody, but for some types of customer more than others. Suzie, you assess—what do you think?

Suzie Frew: At any time, where an advocate, an appointee or even just a companion comes with someone to an assessment or accompanies them during a telephone assessment, we absolutely welcome that. There is information that can be helpful. It is important that we talk to the customer directly as well, because we are doing a lot of assessing during that, but it is also important where the customer may not be able to answer. We absolutely welcome advocates, appointees and companions as a support to customers.

Q363       Neil Coyle: Do you have any views or opinions on the role of the advocacy service provided by VoiceAbility in Scotland?

Dr Williams: I don’t have a specific knowledge of that service.

Suzie Frew: I am afraid I don’t either.

Q364       Neil Coyle: Is there any particular organisation that you think does advocacy or support for the claimants you are seeing particularly well?

Dr Williams: As I mentioned, we work with a wide range of representative groups. I would not like to pick one out over another, because there are different types of advocacy: there is almost professional advocacy from those with a specific knowledge of the types of challenge that somebody might have, and then there is closer advocacy from carers or family. Advocacy can come in different shapes and sizes.

Q365       Neil Coyle: From what you have just said, do you think that an advocacy service or wider support commissioned by the DWP needs to be independent from the DWP?

Dr Williams: If a much broader advocacy service were involved, it would be critical for it to be seen as independent from our assessors, from our organisation and from the DWP. That independence would be really important to people.

Q366       Neil Coyle: This is probably a question for Suzie. The Department has told us that it is developing the clinical governance quality standards framework. How are you involved? Given your professional experience and your role in the process, how are you shaping that?

Suzie Frew: Clinical governance is one of my areas of speciality within the business; I am one of the clinical governance leads in Maximus. I also work closely with the DWP on its clinical governance framework and join it on the forum, so I could talk all day about clinical governance, although I am very conscious that I should not. It is a key priority within the business, and we are looking to restructure it within Maximus to make it even more powerful and have everyone involved.

Q367       Neil Coyle: What will disabled people see differently and better as a result of this framework?

Suzie Frew: I hope that it gives our customers reassurance. I mentioned earlier that people probably have a bit of a misunderstanding about the benefit process in general. We are absolutely keen on any kind of transparency, whether it is with DWP or within Maximusanything we can do to make what we do more transparent and give customers the confidence that coming to have an assessment is not mystifying. We have 1,100 professional clinicians doing a very good job and they should have confidence in that.

Q368       Neil Coyle: But we are seven years in, and you are suggesting that information should be improved. That seems quite weak after seven years. Are there other specifics? Will we see better guidance for disabled people? Will we see a reduction in the huge cost in appeals and tribunals? What will be the tangible outcomes so that we can test whether DWP and you have improved the process as a result of this new framework?

Dr Williams: Clinical governance is a bit like good financial governance. For example, does an organisation have people who are properly trained and up to date in their professional standards? Are we listening to complaints? Are issues being raised correctly? Are all the healthcare professionals behaving within their professional standards? As well as being a doctor, I am head of the company, so we have a clinical governance report that I have to sign off legally. There is overlap, but it does not inherently lead to differences in information and explanation or broader service changes, if that makes sense.

Q369       Neil Coyle: There is a bit of crossover here, because the Department has told us that the new framework is to improve the customer experience, but you are saying that it is about whether someone is qualified to do the job that you have given them. That seems a bit of a disjoint.

Let us focus on whether you think the guidance that the DWP provides to disabled people is good enough. From what you have just said about information, it does not sound as if you do, but please tell me your view.

Suzie Frew: As we said at the start, there is always room for improvement. If we get feedback that information is perhaps not as clear as it should be, we want to take that away and try to address it. It is a process that can be quite daunting to go through, so if we can do anything to make that better, we are keen to work with the DWP to make it as stress-free a process for people to go through as possible.

Emma-Jane Bannister: We have made some improvements over the years. We work quite closely with the Department on the communications that customers receive. We have introduced more text reminders about the service. In our call centre we have a questionnaire support team who help customers who are particularly struggling with the claim form and talk them through it. We see from customer feedback—we get rich insights, because comments over the phone are shared with us verbatim—that those who have known what to expect and have gone through that process have a better experience than those who have not. We have a customer experience group that we work with, with the Department, and we feed into our charity partners and disabled people’s organisations. It is a continuous loop of how we improve information at the point of source.

Q370       Neil Coyle: That is fantastic. What are the group’s top three priorities for improving the process further to make sure that a disabled person’s experience is better and the process is better, so that your assessors have the information they need and there is no mandatory reconsideration and no appeal?

Emma-Jane Bannister: One of the key things that we talk about a lot with our customer representative group is understanding the process, particularly with fluctuating conditions, and how they support their customers and members to get across in an assessment the impact of their condition on their daily lives and their functions, which is obviously what the assessment is about and what the clinicians are trying to get to. It is supposed to be a dialogue, not a question and answer session. If customers have a better idea of what to expect and how that will work, they will find the experience a lot less stressful.

Q371       Neil Coyle: That is two. Were there three?

Emma-Jane Bannister: We have made quite a lot of changes to our website. I recognise that a lot of people do not go to the website, but if customers call our call centre with queries or confusion about the process, which they do in very high numbers, they will be helped on the call, but they will also be referred to our website, which has videos. It is all about accessible information, not just reams of paper. We have videos of what to expect in an assessment and through the process.

Q372       Neil Coyle: The Committee has previously recommended that the Department and assessors learn from overturned decisions. How is that process working better these days? Are you hearing directly from presenting officers or the DWP on what your assessors need to look for? How has that been improved, if at all?

Suzie Frew: We get feedback from presenting officers, and we look at specific cases to see if there is room where we could have given different advice. It is important to remember that our report is one small part of the benefit-making decision; the appeals are often based on the benefit outcome, and our report is a small part of that.

I assume that the Committee already knows this, but in case not: when, as a nurse, I do an assessment, write my report and it goes off to the DWP, I know what my advice in the report is, but I do not know what the benefit outcome will be, because I do not know any information that the DWP might have that I have not been privy to or that the customer may have submitted at another point.

Our part is the report in the middle, so we take learnings where we can. We have very close relationships with the DWP; I have several meetings each month just looking at things like presenting officer outcomes. We take that away, look at it and feed back. If there is a learning need for the practitioner, we will address that. We do not get huge numbers back, but we pick up any specific ones that the DWP feels are important.

Q373       Siobhan Baillie: My colleague has nicked my question a little bit, but I will follow up. Is it not routine for the DWP to let you know when there has been an overturn at MR or tribunal? I think it should be.

Separately, are you able to identify whether an assessor under your umbrella is experiencing a high number of decisions, or is the issue with the feedback from the DWP clouding that? Can you monitor down to that level?

Suzie Frew: We do a high level of case review and auditing with our practitioners. Depending on the experience of the practitioner and whether we have picked up that someone may be struggling in a certain area, we will put in additional support and so on. It is not always necessarily coming from DWP; we have a lot of internal checks that allow us to make sure that we have confidence in the reports that have been produced. The Department also has auditors who are completely independent from us; they give us feedback as well, and we use that.

It is never just about identifying an issue and assuming that a practitioner has made a mistake, and that that is it. It is about asking, “If one practitioner has made that mistake, is there is a likelihood that other people can? We take a step back, look at the bigger picture and build it into our continuous medical education programme if we notice any trends. We do it for every practitioner, regardless of who they are—the minute I do an assessment and you can guarantee that someone will be auditing my case.

It is a way for us to ensure that all our practitioners are providing high-quality reports, because our report is an important part of the decision-making processa small part, but an important part. We are dealing with the most vulnerable people in society, so it is absolutely key that our reports are helpful to the decision maker.

Q374       Siobhan Baillie: You can improve that process by feeding back to improve your teams and things like that, but the ultimate performance is the outcome. If it is being challenged at the other end and you are not getting to hear about it, is that not a gap in what you can do with your assessors and teams?

Suzie Frew: We hear in broad terms, but we do not hear individually. We would welcome any work that we can do with the DWP that supports us to make sure that we are channelling our training in the right direction.

Q375       Debbie Abrahams: Good morning, everyone. I will continue my questions on safeguarding. What safeguarding policies do you have? How have they changed over the years?

Suzie Frew: I am afraid it is me again. We take safeguarding incredibly seriously in Maximus. I refer to Paul as well: as clinicians, it is in our very DNA. Whenever you have a patient in a clinical environment, or a customer in our environment, you are never not thinking about how you safeguard. The process that we use most to safeguard our customers is the unexpected findings process, which our PIP colleagues mentioned as well. It is a very long-established process whereby if I identify something about a customer—if their blood pressure is high, if I notice a suspicious mole on their head, if they mention that their mental health has taken a turn for the worseI have a duty of care as a clinician to make the person responsible for their care aware of that. We do that through our unexpected findings form.

I do not know if there is time for an example, but in the last couple of weeks I was listening to a call where the customer was really struggling. She was underplaying how much she was struggling: she was saying, “Yes, I do this and I manage that.Quite rightly, the practitioner said, “Would it be okay if I talked to your GP about that?” She initially said, “No, I don’t want that.It turned out that she had not been able to speak to her GP other than by a virtual appointment, so the practitioner said, “What if I wrote to your GP and asked if you could be seen face to face?” The customer said, “Yes, that would be great. Could you do that?” To me, that is safeguarding, and it is something that we are doing every day.

That is the most common way that we safeguard, but we also have a formal safeguarding policy. If we feel that someone is experiencing abuse or may be at risk from abuse, we have a formal process that allows us to escalate it to the local safeguarding authority. That is more the social services route, but primarily we use the unexpected findings process.

Q376       Debbie Abrahams: What about prevention—is that included? You have just stated, and I totally agree, that you are dealing with the most vulnerable people in society. How do you prevent the process from exacerbating and making them even more vulnerable?

Suzie Frew: Emma-Jane mentioned things that we have done to try to help the customer at the start of the processassistance with completing the questionnaire, reminders about the appointment, the ability to bring someone along. Those things can absolutely help. With the first part of the process, the paper-based assessment, we hope that if there is anything in the questionnaire, in medical evidence or even in a previous report, we will look at that and say, “Yes, this person might be particularly unwell.We then have the opportunity to try to gain some evidence that would allow us to satisfy the requirements on paper. I am conscious that that is not always the case: sometimes people do need assessment.

Q377       Debbie Abrahams: Are you aware of evidence from the DWP from an FOI in 2019 that shows that 274 claimants die every month within six months of being found fit for work?

Dr Williams: I have become aware of it in the last few days, so I do not have more detailed knowledge. My emotional reaction to hearing that is probably as much as a doctor as it is as the head of a service. Everybody we interact withby definition, really, if they are applying for this benefithas a long-term and significant health problem and we see a million a year, but that is a striking number to hear like that. I want to understand the circumstances so that we can understand what is going on there.

Q378       Debbie Abrahams: Absolutely. On what you said about the advice and the decision, we have not seen any data, to my knowledge, about the ratio between the advice that you give and the decisions that are made, or how they compare. That is something that we should be asking for.

Are you aware of the peer-reviewed article that was in the Journal of Epidemiology and Community Health in 2016? I appreciate that it related to 2010 to 2013, but it showed that there were excess deaths—I think about excess in terms of suicides—of six per 10,000 people going through the work capability assessment process. These excess deaths, and there were other mental health effects as well, were not necessarily of people who presented with mental health conditions. Is that something that you are not aware of?

Dr Williams: It is a John Moores and Oxford Brookes paper, I think.

Debbie Abrahams: It is Liverpool University and Oxford University.

Dr Williams: Yes, I am aware of that paper. If you are talking specifically about the paper, I think that it looked at wards and indices of deprivation and linked that with—

Debbie Abrahams: It is a metadata study, yes.

Dr Williams: I suspect the point of your question is probably not to go into details about the paper. We recognise that for anybody, whether they primarily have a mental health condition that is the reason that they are out of work or whether they have become out of work through some other health condition, to lose your ability to work and support yourself and your family is a very difficult situation to find yourself in.

Debbie Abrahams: Sorry to interrupt, but their point—

Dr Williams: Sorry, perhaps I am not understanding.

Debbie Abrahams: —is that there is an association, not a cause. I worked with some of those colleagues at Liverpool. There is an association with the actual process that is harmful to the extent that it was quantified. I wondered whether you recognise that.

Dr Williams: I am aware of the paper and we are aware, as I say, that everybody who comes through this processeverybody applying for WCA, whether it is through ESA or UC—is in a vulnerable position, whatever the wider definition of vulnerable is. Our approach to that is to try to look at every touchpoint that we have with people. We have invested considerably in making changes to the written communications. We have invested in additional crisis handling and awareness for all our call centre staff. We have provided all our people who work in assessment centresthey now tend to be on the phone introducing the assessmentwith additional sensitivity and awareness training.

Q379       Debbie Abrahams: I recognise that you are doing your best. I wondered whether you felt that it was an inherent issue with the process itself. I will put that to one side.

We have heard about how you notify people you are concerned about in safeguarding. What about the Department? How does it contact you with concerns about evidence that you may not have? I am thinking about the people who die, and your involvement with the internal process reviews and so on. Is that automatic? Are you occasionally involved? What is the actual information that you receive about people who die after being found fit for work through the process?

Dr Williams: Our involvement in the process, assuming it is one of our customers, is that we will turn over any documents or any records that we have that will help to inform the process. I think the system of peer review is relatively new. The information that we get back from it is probably less—we do not generally actively participate in the review process.

Q380       Siobhan Baillie: You were in the room earlier, so you heard my questions about performance targets. We have heard a little about measures that you are working towards in your evidence already. Have the measures set in your contracts changed in recent years? What is your current performance against them?

Dr Williams: Perhaps I will start at the end and work backwards. We are currently meeting all our contractual targets.

Q381       Chair: Are those the 14 quality targets that you mentioned, or is this some other set?

Dr Williams: Those are included, but there is a wide range of others as well. Our contract is open book. You mentioned that the current systems were not publicly available; that came as a surprise to me, I must say, as I thought they were. I am happy to share them with the Committee afterwards. Last time, at a rough count, I think we had 64 main targets and some of those had subsections, so it is probably not possible to go into them all today.

The major changes that happened have come in two ways. One is that we review those targets mutually—usually annually by default, but if there is a particular reason it may happen anyway—and decide whether they are conceptually still relevant and are delivering what we aspire to. We also decide whether the level that we are being asked to achieve is still appropriate. That is a process that has always gone on to drive continuous improvement. Given that during the pandemic we suspended the face-to-face assessments and went into a different type of service, some of those targets changed to reflect the new service. It is probably a lot easier to write to you afterwards with the details, if that is acceptable.

Q382       Siobhan Baillie: Then we would have two out of three of the businesses wanting sunlight, so we would be very grateful.

Did the Department tell you not to talk about profits earned in the pandemic period and changes to contracts?

Dr Williams: I am not aware that it told me. I did not ask, but I am not aware of that.

Q383       Siobhan Baillie: Were there increased profits during the pandemic period?

Dr Williams: No, quite the opposite. Our main guiding light in the pandemic—to be fair, this was mutual with the DWP—was to keep people safe. We had doctors and nurses we could send to the NHSwe had 1,000 people who volunteered for thatand we tried to keep the service going for those most vulnerable. We focused particularly on the paper claims. We never actually stopped, but we did stop face-to-face.

The way our contract works is that we are not paid per assessment; it is an overall cost envelope, a cost-plus contract with incentives and targets in it. Having suspended the face-to-face, most of those clauses became somewhat irrelevant for the time being, so we went to a cost reimbursement type of model. I do not think that it was in anybody’s interest to lose the staff for when we reopened, so we could preserve people’s salaries and employment while we were either supporting the NHS or continuing with the paper-based assessment service that we had. I will not say that the profit margins completely disappeared, but they were severely curtailed.

Q384       Chair: Thank you very much. You have said that you will drop us a line about the targets that you have.

Dr Williams: We may need to check with the Department, relevant to Siobhan’s point earlier, but assuming that it is happy, we as an organisation are very transparent about our contracts, so I am more than happy to share that.

Q385       Chair: We would certainly be interested. From what you have said, you have 64 of them and you are achieving them all. Is that right? [Interruption.]

Dr Williams: I am advised that it is 68. That was pre-pandemic, so there are a raft of different ones as well now.

Emma-Jane Bannister: They are largely customer service metrics. We talked about quality earlier; there are volumes and things, but a large proportion are customer service metrics for making sure that customers are being seen in a timely way and are not getting cancelled, and that waiting times in assessment centres, when people are coming in for face-to-face, are not too longthose sorts of things.

Chair: We would be very interested to see that list.

Thank you all very much for being willing to answer our questions so fully and helpfully. We are grateful.

Dr Williams: I do not want to take up any Committee member’s time, but many of you have been to visit, and I have mentioned that we are very transparent. Our doctors, nurses, physios and others who work for us are only too happy if people want to come and visit. For those who have, you know that we do not roll out red carpets. You are very welcome to observe the process, so if any members of the Committee have not had the opportunity to do so, whether you are in Parliament or in your constituency, we would not dream of telling you what to do, but we would be delighted and would encourage you to come and observe.

Q386       Chair: That is a very helpful and welcome invitation. How many locations do you have around the country?

Dr Williams: For this service, we have about 150, give or take. Some are in more isolated places—“pop-up is not the correct technical phrase, but they may open up temporarily in other sites. We have something like 120 or 130 permanent sites, so there is almost certainly one near all of you.

Chair: Thank you for that invitation. We will take it on board.