Invalidity Benefit
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Report by the Comptroller and Auditor General NATIONAL AUDIT EICE Invalidity Benefit Ordered by the House of Commons to be printed 13 December 1989 Her Majesty’s Stationery Office, London E4.60 net 91 This report has been prepared under Section 6 of the National Audit Act, 1983 for presentation to the House of Commons in accordance with Section 9 of the Act. John Bourn Comptroller and Auditor General National Audit Office 11 December 1989 The Comptroller and Auditor General is the head of the National Audit Office employing sxne 900 staff. He, and the NAO, are totally independent of Government. He certifies the accounts of all Government departments and a wide range of other public sector bodies; and he has statutory authority to report to Parliament on the economy, efficiency and effectiveness with which departments and other bodies use their resources. Contents Pages Summary and conclusions 1 Part 1: Introduction 6 Part 2: Growth of Benefit Expenditure 8 Part 3: Role of General Practitioners and the Regional Medical Service in the control process 11 Part 4: Control by Local Offices 16 Appendices 1: Legislation and case law on incapacity for work 21 2: Surveys and samples 22 3: Potential savings from improved control 23 Summary and conclusions 1. Invalidity Benefit is paid to those incapable of work because of long-term sickness. Recipients increased horn 760,000 in 1983-84 to just over one million in 1987-88. The Department of Social Security expect that by 1990-91 there will be 1.3 million people drawing the benefit. Between 1983-84 and 1987-88 expenditure increased from E2.39 billion to E3.15 billion, and is forecast to exceed f4 billion in 1990-91 (all at 1989 prices). 2. Invalidity Benefit is payable under the Social Security Act 1975. It is administered by the Department of Social Security who assess and pay benefit. It is non-taxable. To qualify for the benefit, a claimant must be incapable of work. Once incapacity has lasted seven days the claimant normally provides a doctor’s statement signed by a General Practitioner or hospital doctor, advising the claimant to refrain from work for a specified period. If incapacity has lasted six months and the doctor considers the claimant is unlikely ever to become capable of work, the doctor may advise the claimant to refrain from work until further notice. 3. In each local office of the Department of Social Security claims for benefit, and questions arising in connection with claims, are decided by Adjudication Officers. These individuals are independent statutory authorities appointed by Act of Parliament to determine entitlement to benefit in accordance with Social Security legislation. Claimants obtaining a statement advising them to refrain from work will almost invariably be awarded Invalidity Benefit by the Adjudication Officer in the Department of Social Security local office provided they also have an adequate National Insurance Contribution record. 4. In England, the Department of Health’s Regional Medical Service, acting as the Department of Social Security’s agents, are responsible for providing Department of Social Security local offices on request with second opinions on the working capacity of claimants who have been issued doctor’s statements advising them to refrain from work or who have been paid benefit on the basis of other evidence. Most of these opinions are provided by part-time medical referees (practising or retired General Practitioners or retired Regional Medical Officers) employed on a sessional basis. The full-time Regional Medical Officers also undertake liaison duties for the Department of Health. This involves discussions with General Practitioners and others involved in the provision of primary health care services on a wide range of issues. 5. In Wales, the Welsh Office provide this service. In Scotland, the Scottish Home and Health Department provide a similar service, but there a higher proportion of examinations are carried out by full-time Regional Medical Officers. 1 6. In the light of the increase in both beneficiaries and expenditure, the National Audit Office examined the control systems operated by the Department of Social Security through their local offices, General Practitioners and the Regional Medical Service. A number of samples and surveys were conducted by the National Audit Office, including a survey of Regional Medical Service part-time referees. In addition, the National Audit Office commissioned Gallup to conduct a survey of General Practitioners. A summary of the Gallup Survey is published separately and is available, price E5, from the Information Centre, National Audit Office, Buckingham Palace Road, London SWlW 9SP. 7. The National Audit Office addressed three main issues: (a) the reasons for the growth in numbers of beneficiaries and expenditure; (b) whether - the Department of Social Security have ensured that General Practitioners are aware of their obligations in signing medical statements; and that - the Health Departments, in conjunction with the Department of Social Security, have ensured that the Regional Medical Service operate efficiently and effectively in providing advice to General Practitioners and second opinions for the Department; (c) whether the control system operated by local offices is being properly and efficiently applied. Growth in 8. In examining the reasons for the growth in expenditure, the National expenditure Audit Office found that: (a) although benefit conditions have been tightened the numbers receiving Invalidity Benefit are expected to continue to grow (paragraphs 2.2 and 2.3); (b) three principal trends underly the increase in numbers receiving benefit: each year more people come on to the benefit than come off and on average individuals are receiving the benefit longer; the average age of recipients is increasing; and the proportion of married women receiving the benefit is also increasing [paragraphs 2.4 to 2~); (c) research undertaken by the Department, and externally, into the reasons for these trends has identified no major increase in the incidence of incapacitating diseases although there is some evidence that within an unchanged incidence of heart disease there is a longer duration of incapacity because of a decrease in mortality (paragraph 2.9); but (d) the research indicates that non-medical factors, including the increase in unemployment in the early 198Os, are likely to have played a significant part in the growth (paragraphs 2.10 and 2.11). 9. The National Audit Office have found that the growth in expenditure on invalidity benefit reflects an increase both in the number and duration of claims. Evidence suggests that non-medical factors have contributed to this growth rather than any underlying increase in the incidence of sickness. 2 General 10. In examining whether the Departments have ensured that General Practitioners and Practitioners are aware of their obligations in signing statements the Regional Medical National Audit Office found that: Service (a) 38 per cent of the General Practitioners who responded to the survey said they had received no routine training or advice. Despite this complaint about the lack of advice, however, only 19 per cent said they consulted the Department’s guidance handbook which is issued to all General Practitioners. The Department of Health told the National Audit Office that these findings conflicted with their own experience of matters raised by General Practitioners (paragraphs 3.15 to 3.19). (b) despite guidance in the handbook only 47 per cent of the General Practitioners identified as one of their roles the provision of factual evidence on a patient’s fitness for alternative work. This is a matter which General Practitioners are asked to consider after an individual’s incapacity has lasted for six months (paragraph 3.20); (c) in advising a patient whether or not to refrain from work, General Practitioners properly take account of family and social circumstances which might have a bearing on the individual’s medical condition. The Gallup survey found that other factors taken into account included loss of benefit if the statement is refused and the fact that a claimant may have been advised by the Job Centre to seek a statement (but since February 1989 the Department of Employment have, at the request of the Department of Social Security, issued letters to claimants and General Practitioners which make it clear that the General Practitioner is asked to provide advice on the claimant’s fitness for work) (paragraph 3.22). 11. In examining whether the Departments have ensured that the Regional Medical Service operate efficiently and effectively, the National Audit Office found that: (a) uncertainty exists among some of the part-time medical staff of the Service as to their role in the benefit process; the Department of Health attribute this to the different considerations these staff apply in their primary role as General Practitioners (paragraph 3.23); (b) both Divisional Medical Officers and referees were concerned about poor quality reports from some General Practitioners, leading to unnecessary work [paragraph 3.27); (c) in England and Wales the Regional Medical Service have had difficulty in dealing as promptly as they would wish with the increasing number of cases requiring second opinions (paragraphs 4.21 and 4.22); (d) the time taken to process referrals for second opinions is a contributory factor to the overall delay in the cessation of benefit for those claimants whom it is ultimately decided no longer qualify (paragraph 4.29). 12. The National Audit Office have found a degree of uncertainty among General Practitioners and, to a much lesser extent, among part-time 3 INvALnJrTYBENEFrr referees, about their responsibilities in considering whether or not an individual is capable of work. The National Audit Office conclude that to a significant extent General Practitioners appear to be overlooking the requirement to consider the individual’s capacity for alternative work. General Practitioners also appear to be giving too much weight to family and and social circumstances, although there are occasions when these factors should properly be considered.