Having the correct professional indemnity cover is essential for all GPs. But in the increasingly fragmented world of primary care, with its increase in the numbers of GPSIs and the government's determination to move services from secondary into a community setting, it is harder to be sure that your cover is right for you.
GPSIs, for example, must be clear who is providing indemnity for this work. The DoH/RCGP guidance 'Implementing a Scheme for General Practitioners with Special Interests' highlights the importance of this.
It says: 'If the GP is employed directly by the PCT or acute trust, they will be covered by the Clinical Negligence Scheme for Trusts run by the NHS Litigation Authority ... If the GP is an independent contractor, they will normally be covered by their professional indemnity provider. However, in all circumstances the GP is advised to notify their medical defence organisation.'
The guidance also says that 'appropriate indemnity cover' is an essential element of any GPSI service.
Status and scope
Dr Stephen Green, head of risk management at the Medical Defence Union (MDU), has served on a DoH working party on the accreditation of practitioners with a special interest. He says all GPSIs should check their indemnity status.
'Unless they have a specific contract that mentions indemnity, GPSIs will not be covered by the NHS,' he says.
The MDU, together with all other indemnity providers, says that it is essential that GPs discuss any GPSI work or other new services with their provider.
Pat Woodruff, professional indemnity manager at insurers Towergate MIA, says that they ask all their indemnity customers to complete a new proposal form for policy renewals every three years.
'This means the indemnity cover will be up to date on GPSI work, out-of-hours and so on,' she says. 'If a GP calls to say they are starting a new service, we will ask what qualifications they have and what training they've undergone.'
Stephen Kelly, membership services manager for the Medical and Dental Defence Union of Scotland, says GPs are always told they are covered for all their work 'provided you are competent to do so'.
'With doctors doing something like botox treatment, for example, they must be using the correct resuscitation equipment and following the manufacturers' instructions,' he says.
Competency is a matter of judgment and common sense says Mr Kelly: 'It is hard to make fixed rules but we expect doctors to follow the Good Medical Practice guidance on competence.'
Other changes in primary care, such as the DoH push for more services to be delivered in a community setting and practice-based commissioning (PBC), raise indemnity issues.
Again, it is important that GPs discuss new services with their defence organisation or insurer and look at whether they have any NHS cover for these services and consider the situation of any secondary care doctors involved.
Dr Stephanie Bown, director of education and communications at the Medical Protection Society (MPS), says: 'With the changing face of NHS service provision, shifting from secondary to the primary care setting, and increasing delegation of roles, it is important for all those working in primary care to be clear about their own indemnity arrangements.'
She says that GPs must ensure that all employees and contract workers who carry professional responsibility in their own right have made arrangements for indemnity themselves.
Dr Green adds that this is a new area that will require careful consideration.
'It would be a matter of considering whether the work was outside the NHS - it would all depend on the contractual arrangements,' he says. 'As I recall, under fundholding indemnity came with the consultant.' However, this does not mean the same arrangements will apply under PBC.
A third area of practice activities that GPs should look at carefully is work by nurse prescribers and practitioners. Even though a nurse prescriber should have their own cover, a practice or GP partner might be liable for a claim in the case of a medical error as the employer or because they are deemed to be involved in the patient's care.
Dr Green says it is hard to define a nurse practitioner at present because this is an expanding role, so indemnifiers have to look at each case on the basis of what the nurse does.
'It is no longer tenable that a nurse who sees a patient, alters their medication and advises them without reference to a GP is covered by a GP's vicarious liability,' he says.
Dr Bown warns that this is an area where GPs will have to make efforts to protect themselves as the effects on indemnity and liability are better understood.
'The scope of potential vicarious liabilities is likely to grow with the enhanced roles being played by non-medical professionals,' she warns.
'No one can avoid their vicarious liability, but there are steps that GPs can take to minimise the risk of such claims, and to enhance your defence should it arise.'
She recommends that GPs use job descriptions to establish the boundaries of the duties each employee is authorised to carry out and ensure that employees are competent to carry out the tasks assigned to them.
Clearly, with so much change in primary care it is time for all GPs to review their indemnity.
Dr Bown sums up the situation: 'There has never been a more important time to ensure that you have indemnity in place for yourself and all those responsible for providing care to your patients.'
AVOIDING PROBLEMS AND CLAIMS
- Call your provider even if the matter seems trivial. For example, there have been cases of patients making complaints over confidentiality because the receptionist has come into the consulting room with a cup of coffee for the doctor.
- Calling and asking for advice from your provider is much better than a large claim.
- Do not let matters escalate - deal with them early.
- Tell your provider of any change in the work you do - such as returning to out-of-hours.
- Never assume something will go away or that you are fully covered.
- Always make sure your records are up to date - you cannot rely on your memory.
- Always take care over consent and confidentiality - these are the cases that come up all the time.
MDU - www.the-mdu.com
MDDUS - www.mddus.com
MPS - www.mps.org.uk
Towergate MIA - www.towergatemia.co.uk
Legislation that would make indemnity for doctors compulsory is going through parliament. The regulations (The Medical Act 1983 (Amendment) and Miscellaneous Amendments Order 2006) allow doctors to choose between a contract of insurance, discretionary indemnity or a mixture of both.
The GMC will consider what is 'adequate and appropriate' indemnity.
'Failure to fulfil this requirement will lead to disciplinary action and the possibility of withdrawal of a clinician's licence to practise,' warns Dr Stephanie Bown of the MPS.