Medical Advice Contract - Annual Report

Transcription

1 Civil Service Pension and Compensation Arrangements Medical Advice Contract - Annual Report Year to 31 March

2 Contents Page 1 Introduction 2 2 Ill health retirement benefits 2 3 Medical appeals 16 4 Injury benefit awards 20 5 Complaints under the Internal Dispute Resolution (IDR) procedures and cases referred to the Pensions Ombudsman 22 6 Allocation of pension 23 7 Complaints about the service 24 8 Fees 24 9 Audit of the service Development of the service Other activity with a bearing on the service 28 Monthly Reports 12 months ending March 2010 Quarterly Reports 4 quarters ending March 2010 Service Standards Civil Service structure Annex A Annex B Annex C Annex D 1

3 1. Introduction The Civil Service Pension Division (CSP) of the Cabinet Office, as managers of the Civil Service Pension Scheme (PCSPS) and the Civil Service Compensation Scheme (CSCS), appointed Capita Health Solutions to continue in their role as medical advisers from 1st April 2009 for a further period of four years. There have been personnel changes during this, the first year of the contract. Angela Plumb has retired from her role as contract manager. In her place Cara Thompson has operationally managed the contract, supported by Geoff Hardes (Operations Director.) Dr Simon Sheard remained the Chief Medical Officer for the duration of the contract year. However, Dr Sheard has now moved on from the company. Dr Peter Stuckey has acted as the Deputy Chief Medical Officer for a number of years and has now become the Chief Medical Officer for the contract with Dr Glyn Evans supporting as his Deputy Chief Medical Officer. There is a contractual requirement to provide an annual report. This is the report for the year ending 31 March There are also requirements to produce monthly and quarterly reports. The month 12 (March 2010) report providing cumulative annual data can be found in Annex A and the quarter 4 report providing the cumulative quarterly data for the year can be found in Annex B. The service standards worked to are contained in Annex C. The service standards are challenging bearing in mind the amount of work that is required in order to deliver the medical advice. In this the first year of our current contract, we can report that 91.71% of cases have been completed by the normal completion date defined in the service standards. Annex D contains the Civil Service staff numbers and structure that we have used in compiling this report. 2. Ill-health retirement and early payment of preserved benefits This section provides information about early payment of preserved benefits (EPPA) and early retirement on the grounds of ill health (IHR) for members of the Classic, Premium, Classic Plus and Nuvos schemes. Other than in specific limited circumstances, only members of the Classic scheme may access their preserved benefits early on medical grounds. 2.1 Contractual requirements The service standards anticipate a normal completion time for an Ill Health Retirement case of 10 working days when no further medical information is required. When an appointment is necessary the service standards anticipate a turnaround of 30 working days and 45 working days in case of a third party report being requested. During the contract year 2009/ % of all IHR cases and 90.9% of EPPA cases were completed by the normal completion date defined in the service standards. 2

4 2.2 Trends in early payment of preserved benefits (PCSPS rule 3.14) During the reporting period a total of 230 applications for early payment of preserved benefits were considered. 137 (59.5% of applications) of these cases were supported. Table 1 shows the outcome in applications over the last decade. An increase in referrals was reported for the year 2008 / The number of referrals has fallen this year. The relatively small number of cases means that it is difficult to attach any significance to the inevitable year to year variations. However, eventually there will be a downward trend as the effect of the introduction of the Premium, Classic Plus and Nuvos Schemes (from 2002) occurs. It is really too early to be certain that this trend has already started but there has been a 14% reduction (from 1180 to 1019) in referrals in the last 4 years ( ) compared to the 4 years 2002 to Applications for EPPA are not influenced to the same extent as IHR applications by non-medical factors and the consistency in outcome percentages over the past decade for this specific pension referral is striking. Chart 1 is demonstrating the fluctuation in referral numbers over the past 10 years. Table 2 indicates the proportion of males and females receiving approval.. Tables 3 and 4 provide a breakdown by disease category. Because the numbers of EPPAs considered are so small it is difficult to draw satisfactory conclusions. Table 5 shows Mental Health and Musculoskeletal disorders compared to all other disease categories. If one considers the percentage of cases falling into the mental and muscloskeletal categories (the cases with softer clinical signs) as opposed to those in all other categories (harder clinical signs) then there appears to be a good degree of stability over time. Early payment Early payment Total supported not supported 00/ % 99 36% / % 63 29% / % 81 34% / % % / % % / % % / % % / % % / % % / % 93 40% 230 Table 1 3

5 Early payment not supported /01 01/02 02/03 03/04 04/05 05/06 06/07 Chart 1 07/08 08/09 09/10 Early payment supported Male Female Total 00/ % 71 40% % 01/ % 59 38% % 02/ % 57 36% % 03/ % 90 43% % 04/ % 96 51% % 05/ % 94 55% % 06/ % 81 52% % 07/ % 53 44% % 08/ % 94 53% % 09/ % 69 51% % Table Female Male /01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09 09/10 Chart 2 4

6 The breakdown by disease category by numbers is as follows: Mental Disorders Musculoskeletal Circulatory Other Categories Nervous Systems Neoplasms Cancer/ Respiratory System Digestive System Total No. No. No. No. No. No. No. No. No. 01/ / / / / / / / / Table 3 The breakdown by disease category by percentage is as follows: Mental Disorders Musculoskeletal Circulatory Other Categories Nervous Systems Neoplasms Cancer/ Respiratory System Digestive System Total % % % % % % % % % 01/02 13% 23% 15% 10% 16% 19% 3% 1% 100% 02/03 18% 16% 16% 9% 15% 19% 5% 2% 100% 03/04 19% 17% 10% 10% 16% 20% 5% 3% 100% 04/05 18% 21% 14% 9% 14% 18% 4% 2% 100% 05/06 14% 22% 8% 11% 19% 21% 3% 2% 100% 06/07 15% 12% 9% 11% 15% 27% 4% 5% 100% 07/08 17% 15% 8% 13% 11% 28% 5% 3% 100% 08/09 13% 18% 7% 22% 16% 22% 2% <1% 100% 09/10 12% 16% 11% 21% 15% 22% <1% <1% 100% Table 4 5

7 Mental Health and Musculoskeletal compared to all other disease categories Mental and Musculoskeletal Disorders Mental and Musculoskeletal Disorders Other Categories Other Categories Total Total No % No % No. % 01/ % 99 64% % 02/ % % % 03/ % % % 04/ % % % 05/ % % % 06/ % % % 07/ % 82 68% % 08/ % % % 09/ % % % Table 5 6

8 2.3 Trends in ill-health retirements During the reporting period we provided advice for medical retirement purposes on 2178 occasions. On 652 occasions (30%) we supported the application. Table 6 shows the movement in applications over the last 10 years. Chart 3 indicates the proportion of cases not supported and those supported in Classic, Premium, Classic Plus and Nuvos. This year the number of applications has dipped after a high year last year. We have redesigned our reporting to coincide with the start of the current contract (from April 2009) to ensure that the data provided is more specific and accurate. In the past cases may have been referred in one contract year and carried forward to the next contract year. Cases are now isolated within the relevant contract year and in time this should to allow us to draw more accurate conclusions. The number of applications received (2178) in the reporting year is very close to the long-term average of 2246 applications each year over the past decade. The number of applications received shows no discernible trend with management and recruitment policies inevitably impacting on the volumes of referrals. The steady downward trend in percentage of supported applications appeared to have ceased last year. It was previously thought that this figure could bottom out at around 40% of cases supported. In the reporting year there has been a further reduction and only 30% of applications have been supported. The fall in the percentage of IHR applications supported from 75% to 30% contrasts sharply with the stability in the percentage of EPPA applications that have been supported in each year (64% to 60%) over the same period of time. Qualification for ill health retirement is a complex equation involving many factors. The individual scheme medical adviser s assessment can influence outcomes based on each adviser s knowledge of the workplace, occupational health experience and qualifications, pension scheme experience and training, interpretation of criteria and the existence and understanding of specific guidelines All of our scheme advisers hold a high level minimum qualification and virtually all physicians involved over this decade have been accredited specialists. There has been a structured induction programme since From a clinical point of view an ill health retirement decision tree has been developed within our organisation with a series of building blocks. This has been developed to regulate the decision-making approach and improve the consistency of advice and outcome decisions by the medical advisers. This was introduced in It is not plausible that all the many different individual medical advisers involved in this contract over the past decade have maintained a consistent approach to EPPA cases yet have systematically over time altered their approach to IHR cases. It is much more likely that there is some other explanation. IHR cases have significant non-medical influences that do not exist in EPPA cases and these influences may well account for much of the difference in the figures. There are now different sets of pension scheme rules from However, the majority of applications are still from Classic members and the lower tier definition in Premium, Classic Plus and Nuvos is almost identical to the Classic scheme definition. Enhancements are different in the schemes but this appears unlikely to be a major influence with the relatively small numbers of non-classic scheme cases. 7

9 There has been change to the machinery of Government over this time and in certain large departments this could have led to a different organisational culture for sections of the new organisation. Management policies will also have been amended with possible alteration to attendance and performance management, workplace health, redeployment and rehabilitation but also exit routes. Another more generalised change is the social and economic situation that has evolved over the past three years. The combination of these different influences appears a more plausible explanation for a significant proportion of the altered outcome figures for IHR applications. Medical retirement supported Classic Medical retirement supported Premium,Classic Plus and Nuvos Medical retirement not supported No % No % No % Total 00/ % % / % % / % 5 (>1%) % / % 47 2% % / % 72 3% % / % 72 3% % / % 108 6% % / % 74 4% % / % 187 7% % / % 120 5% % 2178 Table Medical retirement not supported No /01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 Chart 3 08/09 09/10 Medical retirement supported Premium,Classic Plus and Nuvos No Medical retirement supported Classic No Table 7 provides a breakdown between the upper and lower tier for premium and classic plus approvals. When the Premium scheme was being developed based on a study of Classic Pension Scheme cases we advised that somewhere between 46.7% and 62.7% of supported cases would qualify for upper tier benefits. It is interesting to note that to date 61% of 8

10 all supported cases have qualified for the upper tier. The results therefore remain within the parameters that we originally envisaged. Upper tier Lower tier Total 02/ % 2 40% 5 03/ % 18 38% 47 04/ % 25 35% 72 05/ % 24 34% 72 06/ % 43 40% / % 35 47% 74 08/ % 72 38% / % 44 38% 117 Total % % 682 Table 7 Table 8 and Chart 4 indicate the proportion of male and female staff whose applications we supported. Male Female Total 99/ % % % 00/ % % % 01/ % % % 02/ % % % 03/ % % % 04/ % % % 05/ % % % 06/ % % % 07/ % % % 08/ % % % 09/ % % % Table Female Male /00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09 09/10 Chart 4 9

11 2.4 Age at retirement Table 9 provides the breakdown of ill health retirements in the various age groups and again reveals a steady pattern year on year. This provides important evidence of the consistency of the medical advice we have provided and continue to provide to the PCSPS as scheme medical advisors. Under Over / % 24.20% 17.10% 22.60% 28.40% 6.60% 02/ % 19.60% 16.00% 27.00% 29.30% 7.10% 03/ % 20.20% 16.50% 26.00% 29.50% 6.90% 04/ % 19.40% 17.00% 25.10% 32.80% 6.20% 05/ % 21.30% 16.10% 24.00% 31.10% 6.50% 06/ % 22.10% 16.10% 25.70% 29.40% 6.30% 07/ % 15.90% 18.60% 24.30% 32.20% 8.40% 08/ % 20.60% 15.70% 26.30% 28.10% 8.00% 09/ % 14.20% 15.00% 22.00% 31.30% 17% Table 9 When looking at age of retirement we are expecting to see a steady rise in the age of those being medically retired with the majority of retirements taking place after the age of 50. The graph for 2009/10 continues to present the normal very reassuring picture. 10

12 Age at Retirement / Volume Chart 5 As usual there are a small number of supported applications for people aged 35 and below. As explained in previous years, it is to be expected that small numbers of employees will retire on medical grounds at a very young age. There are several reasons for this. There will always be serious and unexpected conditions (eg some cancers) that affect people at a young age and lead to IHR. The outlook for people with serious progressive conditions is changing. Better medical treatment is increasingly available and this means that people who, in the past, would not have lived long enough or would not have been well enough to present themselves for employment, now have the opportunity to work for a limited period. The Disability Discrimination Act (now replaced by the Equality Act) is also an influencing factor. People who would formerly have been denied employment can now compete for jobs and enter the employment market. Many of the individuals are likely to work for years before their condition makes further employment difficult for all parties. It is noticeable that there is a high number of people who in the year or two before their 60 th birthday are considered for early retirement. Pension scheme rules mean that those in the Classic Scheme with service of less than 20 years who retire early on medical grounds can have their service enhanced to what it would have been had they retired at age 65. It is possible that this beneficial provision of the scheme rules is partly responsible for the number of applications from this category of older member. 11

13 2.4 Ill health retirements by department 2009/2010 This year you have provided us with the Civil Service structure demonstrated in Annex D. Department Supported Not Supported Attorney General s departments Communities and Local Government Defence Environment, Food and Rural Affairs 6 17 Foreign and Commonwealth Office 4 5 Health 1 2 HM Revenue and Customs Home Office Justice Security and Intelligence Services 1 3 Business, Enterprise and Regulatory Reform 2 9 Transport 5 15 Work and Pensions Scottish Government Welsh Assembly 2 6 Other Government Departments (with less than 5000 staff) Total Table 10 Table 10 provides numbers of ill-health retirements broken down by departments in accordance with your requirements. Looking at the Office for National Statistics report regarding Civil Service employment we note that the most recent employment figures suggest there were 528,160 employees in the first quarter The rate of medical retirements we supported per 1000 employees for the top four organisations, representing 72.7% of the Civil Service, was 1.34 per 1000 employees Headcount Quarter Headcount Quarter IHR supported rate per 1000 employees 2009 IHR supported rate per 1000 employees 2010 Justice 89,200 85, Work and Pensions 121, , Defence 77,840 77, HM Revenue and Customs 92,990 87, Total Civil Service 524, , Table 11 12

14 A key factor in terms of cost of pension schemes is the variation of rates of ill health retirement between pension schemes. It may be worthwhile to compare some published work and figures in this arena with the Civil Service statistics. This is particularly topical given the current Government interest in pension scheme costs. Khan investigated retirement from an aerospace company. Between 1992 and 1994 there was an annual rate of retirements per 1,000 employees. The occupational physicians commented that management, trade unions, employees and general practitioners sometimes found it preferable for an employee to be retired on medical grounds than to be made redundant or dismissed. It was felt that significant pressure might be placed on physicians to medically retire employees in situations where a physician may not normally have considered medical retirement. The need for clearer guidance on medical early retirement was identified. Between 1995 and 1996 audits were performed on a series of difficult medical retirement cases and discussions took place. Detailed guidance on criteria for medical early retirement was produced. During the years 1997 to 1999 the annual rate of medical retirements was 0.31 retirements per 1,000 employees. Analysis showed the largest reductions to be in the musculoskeletal and cardiovascular categories. Geographical differences in retirement rates for some conditions were felt to reflect individual physician s behaviour. A study by Poole in 1997 demonstrated a significant variation in rates of ill health retirement in six large organisations in a cross sectional study. There was a mix of private and public sector companies. The results showed a variation from 2 to 25 per 1000 that has significant cost implications. Certain schemes work more effectively in terms of overall costs. A study by Wilson in 2005 investigated the effects of an alteration of the criteria for IHR. The scheme in the study (Royal Mail) introduced a medical severance payment on 1 st April 2000 for individuals deemed unfit for their role but not permanently incapacitated from employment elsewhere. Previously such individuals would have been likely to meet the criteria for ill health retirement and this represents a form of tiering. The rate of ill health retirement fell from 8.89 to 2.90 per 1000 members and the median age at IHR increased from 50 to 55 years. This resulted in a reduction in costs of the scheme by 25 million per year. A study by Poole et al in 2007 calculated the rates of retirement for 222 NHS Trusts and 132 Local Authorities with more than 1500 employees and highlights the need for ongoing monitoring and development in this area. This data gives a picture of the situation after the developments to many schemes including increased guidance, audit and doctor training. The median rates of retirement were 2.11/1000 active members of NHS Trusts and 4.10/1000 Local Authority employees. This represents a significant variation in rate of ill health retirement despite the changes that had been introduced. The figures for the Civil Service compare favourably to many of these reported figures, particularly figures from other public sector organisations. There is limited variation from one agency to another and considering the large departments the ill health retirement rate for the Justice Department is three times that for DWP. 13

15 2.6 Ill-health retirement by disease category Mental Disorders Musculoskeletal Circulatory Other Categories Nervous Systems Neoplasms Cancer/ Respiratory System Digestive System Total No No No No No No No No No 00/ / / / / / / / / / Table 12 Mental Disorders Musculoskeletal Circulatory Other Categories Nervous Systems Neoplasms Cancer/ Respiratory System Digestive System Total No No No No No No No No No 00/01 27% 27% 14% 11% 9% 7% 3% 2% 100% 01/02 25% 27% 14% 10% 11% 8% 3% 2% 100% 02/03 26% 27% 14% 10% 11% 8% 2% 2% 100% 03/04 23% 24% 13% 9% 13% 12% 4% 2% 100% 04/05 20% 24% 12% 11% 16% 12% 3% 2% 100% 05/06 20% 23% 12% 10% 14% 15% 4% 2% 100% 06/07 18% 20% 12% 13% 15% 16% 3% 2% 100% 07/08 11% 21% 10% 15% 18% 19% 4% 1% 100% 08/09 17% 20% 9% 19% 15% 15% 3% 2% 100% 09/10 11% 20% 9% 17% 16% 22% 3% 1% 100% Table 13 14

16 Tables 12 and 13 identify ill-health retirements by disease category. The results this year continue to be broadly consistent with the last three years. The numbers of retirements attributable to diseases of the nervous system, respiratory system, digestive system and cancers is close to the mean figures of the last 8 years. However these cases represent a greater proportion of the overall numbers supported. These effects are likely to reflect progress in medical management of chronic progressive diseases such as cancer, ischaemic heart disease and neurological conditions along with robust enforcement of ill health retirement criteria for cases of mental ill health and musculo-skeletal problems. Good progress appears to have been made over the past decade in applying the scheme rules in what is an objective and evidence-based manner to musculoskeletal and mental health cases. The percentage of ill health retirements caused by these disorders is now much nearer to the figure for EPPA than it was seven years ago. We may now have reached the point where further progress becomes more difficult. Table 14 provides a comparison between medical retirements and early payments across the disease categories showing how the proportions have moved over the years. Mental Disorders Musculoskeletal Circulatory Other Categories Nervous Systems Cancer/ Neoplasms % % % % % % % % % 01/02 IHR 25% 27% 14% 10% 11% 8% 3% 2% 100% EPPA 13% 23% 15% 10% 16% 19% 3% 1% 100% 09/10 IHR 11% 20% 9% 17% 16% 22% 3% 1% 100% EPPA 12% 16% 11% 21% 15% 22% <1% <1% 100% Respiratory System Digestive System Total Table 14 Table 15 shows the way that the combined percentage of supported applications in the mental and musculoskeletal disorders category has changed. In some organisations, there is an excess of retirements caused by mental and musculoskeletal disorders at peaks of retirement that occur at points at which enhancements take effect. This may indicate that these conditions allow more discretion as to when the individuals affected present themselves for consideration of ill health retirement than do cardiovascular, respiratory, neurological conditions and neoplastic disease. 15

17 IHR EPPA Mental Musculo Total Mental Musculo Disorders Skeletal Disorders Skeletal Total disorders disorders 01/02 25% 27% 52% 13% 23% 36% 02/03 26% 27% 53% 18% 16% 34% 03/04 23% 24% 47% 19% 17% 42% 04/05 20% 24% 44% 18% 21% 39% 05/06 20% 23% 43% 14% 22% 36% 06/07 18% 20% 38% 15% 14% 29% 07/08 11% 21% 32% 17% 15% 32% 08/09 17% 20% 37% 13% 18% 31% 09/10 11% 20% 31% 12% 16% 28% Table Medical Appeals This section provides information about appeals against medical decisions taken in connection with ill health retirement and early payment of preserved benefits. The appeal procedure has three separate stages. Stage 1 involves a review by the clinician who made the original decision. Where the appeal is not upheld it proceeds automatically to Stage 2 and is reviewed by Dr Stuckey or Dr Evans. Stage 3 involves a referral to a Medical Appeal Board. Although the arrangements are made by CHS, the Board and its members are completely independent of CHS. 3.1 Contractual requirements When an appeal is lodged CHS is expected to: conduct an initial review of the papers within 10 working days of receipt in 95% of cases; and, where the appeal cannot be resolved at the initial stage: complete a further review and any other action needed and notify the administrator of the outcome within 20 working days in 95% of cases If a further appeal is made, CHS will: within 5 working days appoint a Chairperson thereby enabling them to convene a Board; report the findings of the Board to the administrator within 10 working days of receipt of the Board s decision. 16

18 Table 16 shows the total number of appeals and the numbers that upheld at stage 1. This is the first year that information about the outcome of appeals at stage 1 of the appeals procedure has been gathered. At stage 1 we offer the scheme member a consultation with one of our doctors if there was not such a consultation at the initial application. We would not generally offer a consultation at the initial application if there is a contemporaneous consultation with a physician from departments OH provider. The objective in following that course is to avoid duplication of evidence and to ensure public money is not wasted. An appeal can be started without the submission of further medical evidence from the appellant. Such circumstances were common in the past, but nowadays the overwhelming majority of appeals include fresh medical evidence when the appeal is submitted. 39.5% of appeals are upheld at stage 1 Stage 1 appeals submitted Appeals upheld at Stage 1 Cases referred to Appeal Stage 2 No % No % No % 09/ % % % Table 16 Table 17 shows the number of appeals that have proceeded to Stage 2. Of the total of 220 appeals considered at Stage 2, 67 were upheld. 28 of those that were not upheld proceeded to Stage 3 to be assessed by an Independent Medical Appeal Board. When assessing Stage 2 reviews we continue to go to considerable lengths to identify the deficiencies that exist in the medical evidence before us. We also encourage applicants, employers and other interested parties to consider the Medical Review and Appeals guidance issued by Civil Service Pensions as this also gives advice on the evidence required for a successful appeal. The percentage of cases that are successful at stage 2 has continued at a steady level over the past decade. 17

19 Stage 2 appeals submitted Appeals upheld at Stage 2 Cases referred to independent medical appeal board (Stage 3) No % No % No % 01/ % 50 32% 29 18% 02/ % 55 26% 38 18% 03/ % 59 24% 22 9% 04/ % 83 26% 31 10% 05/ % 47 16% 33 11% 06/ % 62 23% 46 17% 07/ % 43 15% 40 14% 08/ % 88 29% 39 12% 09/ % 67 35% 28 14% Table 17 Table 18 shows the total number of appeals and the numbers that upheld at stage1 & 2 There are a variety of possible reasons why appeals against refusal of medical retirement or application of a particular tier of retirement may succeed. The evidence presented at initial application may be incomplete or lacking in detail. The medical condition may have spontaneously deteriorated or improved since the original recommendation, whilst further treatment may have taken place. Further treatment without sufficient effect may lead to chronicity of the medical condition. Alternatively, the further treatment may have led to improvement or resolution of the medical condition. Finally, the existing medical evidence when once again reviewed may lead to a different conclusion. The possible reasons for successful appeal mentioned above are all relevant when the appeal process is open or live when any change in medical circumstances can be measured against the relevant pension scheme rules. In the situation of the appeal operating under a closed system of review and the medical circumstances at the time of the original advice are what is important there are more limited reasons for any appeal being upheld. The Civil Service operates a live medical appeal system. The procedural rules mean that it may be nine to twelve months after the original recommendation before an appeal is completed. Scheme members therefore have considerable time to receive further treatment that can be taken into account at the appeal stage. The considerable lengths we go to identify the deficiencies that exist in the medical evidence before us and information given to the scheme member on how to correct those deficiencies and the live process provide the scheme member with the best possible opportunity to obtain their desired result. Overall 58.2% of appeals are successful at stages 1 & 2. This may appear a high figure but it needs to be considered in the context of the defined live appeal procedure and the total number of cases on which advice is given. In the year there were 2408 cases of which 789 were supported and 1619 rejected. 44 cases were supported at lower tier. It is exceedingly rare to receive an appeal when IHR is supported and an appeal against provision of upper tier benefits has not been 18

20 made. This means that there were 1663 cases at greater risk of appeal. 359 (21.6%) appeals were lodged. 209 (12.6%) were successful. It is difficult if not impossible to realistically benchmark what should be expected. Different schemes have different processes that are not directly comparable. However, a scheme that has operated a closed appeal process has experienced between 18% and 37% of appeals being successful at one of two stages of a two stage appeal process. Given the difference in procedure the Civil Service figures appear understandable. Appeals submitted Appeals upheld at Stage 1 & 2 Cases referred to independent medical appeal board (Stage 3) No % No % No % 09/ % % % Table 18 19

21 3.2 Medical Appeal Boards Table 16 shows the number of cases assessed by an Independent Medical Appeal Board and the number and percentage of cases upheld. Cases assessed by independent Medical Appeal Board (Stage 3) Cases upheld by Medical Appeal Board No % No % 00/ % 23 44% 01/ % 10 35% 02/ % 10 26% 03/ % 9 41% 04/ % 14 45% 05/ % 19 57% 06/ % 25 54% 07/ % 18 58% 08/ % 40 74% 09/ % 16 53% Table 19 Four of the cases assessed during the period were Premium/Classic Plus appeals. Three of these were supported. One early payment case was considered and supported. 4. Injury benefit awards This section provides information about injury benefits when a member of the pension scheme applies for a benefit on the grounds that they have been injured at work. Injury benefits represent perhaps the most complex area of pension scheme work. For this reason all requests for injury benefit awards are handled by a smaller team of senior occupational health specialists within our core clinical team. This ensures a consistent and high quality approach. 4.1 Contractual requirements The service standards anticipate a normal completion time for injury benefit awards of 10 working days when no further medical information is required. Annex C sets out the normal completion times where a consultation or third party report is required. Of 1116 referrals received for injury benefit 993 were completed by the normal completion date defined in the service standards. 4.2 Trends in injury benefit claims A total of 1116 injury benefit applications were considered by CHS during the year and 707 (63%) of applications were supported. Table 20 shows the way that applications and outcomes have moved during the last ten years. The number of cases received appears significantly lower than last year however the percentage supported remains in line with previous performance. 20

22 Over the years the changing criteria used to determine whether or not a person suffered a qualifying injury has been a likely major impact on both the number of cases referred for advice and the number of cases that we support. Between 1 April 1997 and 31 March 2003 a qualifying injury is one that occurs in the course of official duty and is solely attributable to the nature of the duty. On 1 April 2003 the definition changed and for injuries from that date a qualifying injury is one that occurs in the course of official duty and is wholly or mainly attributable to the nature of the duty. Mainly is a less substantial hurdle to cross than solely and this change in criteria accounts for the rise in both the number of cases received and the proportion of cases supported after that time. The ruling from the Northern Ireland Tribunal which is currently not disputed by Civil Service Pensions about the way that an individual s perceptions should be taken account of when determining whether a qualifying injury has occurred inevitably means that applications that would formerly have failed will now be supported. The dramatic reduction in the number of cases referred for advice is more difficult to satisfactorily explain. It will be interesting to see if this reduced volume of referrals continues in future years or whether it is a temporary aberration. Any comments are highly speculative, but if the low volume continues it could suggest there has been a change in attitude within the Civil Service. This could have some association with the current national economic climate or could even be linked to improved health and safety risk assessment and management. Cases referred for advice on whether injury qualifies for benefit Cases where advice given that qualifying injury supported No % No % 00/01 *Not available N/A 369 N/A 01/ % % 02/ % % 03/ % % 04/ % % 05/ % % 06/ % % 07/ % % 08/ % % 09/ % % Table 20 21

23 Table 21 indicates the number of applications broken down by department in 2009/10. Department Supported Not Supported Attorney General s departments 1 0 Communities and Local Government 2 0 Defence Environment, Food and Rural Affairs 0 1 Foreign and Commonwealth Office 1 0 Health 2 0 HM Revenue and Customs Home Office Justice Security and Intelligence Services 3 1 Business, Enterprise and Regulatory Reform 4 0 Transport 1 2 Work and Pensions Scottish Government Welsh Assembly 4 5 Other Government Departments (with less than 5000 staff) Total Table Medical Appeals against injury benefit decisions There is a formal appeals procedure which applies to injuries sustained on or after 1 April 2003 and extends to the assessed level of earnings impairment or the medically assessed level of apportionment. There have been 34 formal appeals during this reporting period. We have also reviewed 58 cases in the reporting year. 1. Complaints under the Internal Dispute Resolution procedures and cases referred by the Pensions Ombudsman Where members of the pension scheme are dissatisfied with decisions, they have the right to complain using the Internal Dispute Resolution (IDR) procedures or to the Pensions Ombudsman. 5.1 Contractual requirements When a complaint is made CHS will provide a response to IDR cases within: 10 working days of receipt. If not possible CHS will acknowledge such cases within 5 working days of receipt together with an explanation as to why there is a delay and when CSP can expect a response. CHS will provide a response to Pensions Ombudsman cases within: 5 working days of receipt. 22

24 Any difficulties in meeting this requirement are reported immediately together with an explanation as to why there is a delay and when CSP can expect a response. Appropriate advice has been given to the timescales agreed with CSP. During the year 13 cases were submitted through the IDR procedures. The majority of these relate to injury benefit awards as opposed to IHR and in the main revolve around the refusal of injury benefit awards. Stage 1 Stage 2 Total 01/ / / / / / / / / Table Allocation of pension 2005/06 saw a dramatic rise in the number of allocation cases. This was explained by a change in the pension scheme rules that closed the scheme whereby members of Classic who retired before October 2002 could allocate a proportion of their pension to their spouse. The run up to this saw a significant but one off rise in receipts of allocation cases. The effect ran over into 2006/07 but for the last 3 years the numbers have returned to the very low levels that would be expected. A member must show they are in good health at the time an allocation is made so a fitness assessment is made by CHS. Applications submitted 01/ / / / / / / / /10 2 Table 23 23

25 7. Complaints about service provided by CHS There is a formal complaints procedure in place and if an employer is dissatisfied with the way that CHS have handled a referral they are expected to follow the procedures that Civil Service Pensions have put in place and make their complaint using the Form Med 9. However we do still get some complaints that are made orally, by or by letter without using the Med 9 and will ensure that all are responded to regardless of format they are received in. We actively encourage all individuals to raise the complaints in the appropriate manner. We endeavour to ensure that all complaints are logged and dealt with in a consistent and timely fashion. A dedicated complaints management team is in place at our National Service Centre in Coventry and this team is responsible for overseeing the handling and investigation of complaints and for providing a timely response. Complaints of an administrative nature are, where appropriate, reviewed by the Operational Lead for the PSCPS contract (Cara Thompson). Dr Stuckey reviews and provides substantial input into all complaints of a medical nature. Complaints, investigations and responses are available for scrutiny by CSP if required. In 2009/10 we received 23 complaints using the Med 9 form and 42 complaints where no Med 9 was submitted. Of the 23 complaints received on a Med 9, 9 related to the clinical conduct of the case and the remainder related to administrative issues. The administrative issues fell into two main categories; the length of time taken to provide outcomes and perceived procedural irregularities. 8. Fees Table 24 sets out the overall costs of the service in each of the last eight years. This sum included fees paid to GPs and specialists for 3 rd party reports that are required by the PCSPS medical advisers. It also includes the Medical Appeal Board fees paid to the Chair and Board Member. 2009/10 has seen a significant reduction in the fees paid compared with the previous year. Total charge 00/01 1,067,199 01/02 1,310,218 02/03 1,376,168 03/04 1,424,791 04/05 1,422,664 05/06 1,549,728 06/07 1,345,840 07/08 1,000,593 08/09 1,067,541 09/10 941,910 Table 24 24

26 We provide details of how our charges have been broken down by the principal pension scheme products that we have delivered to employers during the year. Table 25 provides this breakdown. It is difficult to always obtain an accurate correlation between products charged and outcomes. This is because some referrals do not result in a definitive outcome. There are a number of reasons for this including a sizable quantity of incomplete referrals which attract the primary product charge, referrals that are withdrawn and referrals where it is not possible to provide definitive advice etc. We are only therefore reporting on cases that we have provided outcomes on in the table below. 25

27 Product Quantity Ill Health Retirement ,842 Injury Benefit Award Early Payment Preserved Award , mins PCSPS Consultation , mins PCSPS Consultation 30 8,760 PCSPS Medical Report 41 1,271 Impairment certificate 66 6,468 Medical Appeal First Stage ,689 Medical Appeal Second Stage ,149 Medical Appeal Arrangement Fee 23 4,117 Pension Fees to Board Chairman 23 14,490 Pension Fees to Board Members 23 12,190 Injury Benefit Appeal Case 30 2,940 Internal Dispute Resolution 9 0 Re-Referral - Ill Health Retirement 144 8,496 Re-Referral Injury Benefits 122 7,198 OHP Full Day PCSPS 1 1,288 OHP Hourly Rate PCSPS 14 2,646 Allocation report Medical Opinion (Pension) Upper tier review 12 1,140 OH third party GP report ,847 OH third party Consultant report ,835 Other 220,781 Total 721,129 Table 25 26

28 9. Audit of the service We audit a sample of cases examining both their clinical quality and the administrative handling by our clinicians. Dr Stuckey and Dr Evans carry out the clinical audits. Any case that is unsatisfactory or worse is the subject of a detailed report to the relevant clinician and line manager. Table 26 and 27 below provide the results of this work on a quarterly basis. Administrative audit Good Satisfactory Below standard Unacceptable Q Q Q Q Total Table 26 Clinical audit Good Satisfactory Below standard Unacceptable Q Q Q Q Total Table Development of the service This was the first year of a new four year contract and has seen us close all old contract cases down and focus on moving forward. This has allowed us to develop our reporting and provide you data with increased accuracy. We have also: Worked to tighter KPI s put in place for the new contract. The hope was that the new submission forms would ensure that we would be able to provide the maximum amount of advice on a paper basis rather than needing to obtain further medical information. Unfortunately this was not successful due to departmental issues in completion. Internal guidance and training has been carried out over the year in conjunction with the development of the dedicated PCSPS team. By ringfencing the work flow we have increased the contract specific knowledge base as well as allowing for closer control over KPI s. Worked with you to implement the changes made necessary by the GMC guidance released in October

29 Training for the new members of the core clinical team. In addition however we have continued to: Attend the quarterly meetings of the User Group. We believe that our relationship with the departmental users remains as strong as ever. We take every opportunity to visit and support individual departments and agencies. Hold our regular popular programme of workshops for Users with the aim of improving knowledge of medical aspects of the pension scheme Hold regular in house training and induction sessions for our authorised clinicians as part of their continuous professional development. 11. Other activity with a bearing on the service Capita Health Solutions have always been committed to the provision of high quality pension advice that is objective and evidence-based but that is equitable and fair to all stakeholders. As a part of this commitment we have also been keen to contribute to the limited body of research work that exists on ill health retirement advice. Four MSc and MFOM dissertations have been completed in 1999, 2003, 2007 and 2010 by authorised Civil Service Pension Scheme advisers. This work has been a key element in the development of our procedures leading to the best possible consistency of advice. Whilst research has been undertaken on various aspects of ill health retirement pension schemes, there is very limited research on two tiered schemes such as the most recent versions of the Civil Service Pension Scheme. The overall research on single tiered schemes does not demonstrate high levels of consistency or agreement between medical advisers. The research work undertaken on the provision of advice to civil service pensions suggests consistency that compares very favourably to consistency elsewhere. It is possible to postulate that the level of agreement between medical advisers may be lower in a two tiered scheme than a single tiered scheme and that the introduction of a tiered scheme will lead to greater inconsistency of advice. In many ways it is difficult to predict the impact a two tiered scheme will have on the consistency of outcome advice, particularly in light of the lack of research available in this area. Based on the data available for single tiered schemes, including the multi factorial influences on the decision making process and variation between study results Clare Piper decided to investigate the hypothesis that the introduction of a tiered scheme will lead to a reduced level of agreement between medical advisers. She approached the study by retrospectively analysing actual outcomes over the past decade on cases from four private pension schemes that we advise. The central part of the study was a questionnaire survey on simulated ill health retirement cases according to the Classic Plus/Premium definition for upper and lower tier. Clare completed her research in spring The results showed an overall multi rater kappa coefficient of 0.30 (95% confidence interval of ) for the level of agreement between the eight medical advisers which can be considered as fair agreement. This shows better agreement than most other studies and provides evidence that the introduction of a two tiered scheme is 28

30 unlikely to have ethical issues in terms of fairness and consistency of advice for scheme members. This should be reassuring to Civil Service Pensions. The results were further analysed by dividing the medical advisers into two groups according to length of time undertaking PCSPS IHR work and the kappa coefficients for level of agreement within each group calculated. Each group contained four medical advisers. The medical advisors in group A all undertake or have undertaken higher level appeal casework and two had been involved this work for 12 years, whilst the other two members had done so for 7 years and 18 months respectively. Group B contained four medical advisers who trained to undertake PCSPS IHR work within 12 months of the study and did not complete higher level appeals. The results indicated moderate agreement between physicians in group A and fair agreement between advisers in group B. The table below is taken from Clare s study. The combined Kappa Coefficient for the Agreement between Medical Advisors in Group A and Group B Kappa coefficient Group A 0.5 ( ) Group B 0.26 ( ) Group A: > 18 months undertaking PCSPS IHR work Group B: < 12 months undertaking PCSPS IHR work 95% Confidence intervals in brackets Experience of pension scheme work in general has been suggested in other studies as likely to lead to improved consistency of advice. Clare s work demonstrates for the first time that experience of a specific pension scheme rather than general pension experience does lead to statistically significant improved consistency of advice for that scheme. This also should be reassuring for Civil Service Pensions with three of the four most experienced advisers still working on this contract. DR PETER STUCKEY Chief Medical Officer Capita Health Solutions November