As medical negligence or other claims may arise after you retire – or stop practising for some other reason – you need to ensure you are covered for the long term.
Run-off insurance for GPs is a type of cover that specifically relates to historic claims from a time when you were practising.
Not all GPs will need run-off cover in order to deal with historic claims as it depends on the type of cover held while you were practising.
It is the responsibility of doctors to ensure they get insurance to cover the full scope of their practice, including run-off cover where necessary and appropriate.
What is run-off insurance for GPs?
Run-off insurance provides cover claims against a doctor or their estate made after they retire, die or are no longer practising for any other reason. It is legacy cover.
In cases where doctors have always held occurrence based indemnity there is no need for run-off cover. This is because occurrence based indemnity provides cover relating to the time when the incident occurred, regardless of when the claim is made. For this reason, all cover provided by Medical Defense Society is occurrence based.
Those who hold claims based cover need to consider run off insurance as that cover only pays for claims made during the policy period.
Who needs run-off insurance?
Run-off insurance is generally for those who have stopped practising or have retired and, crucially, held claims based rather than occurrence based indemnity while they were working.
Doctors who bought a claims based indemnity cover as a transitional product in the run-up to the introduction of Clinical Negligence Scheme for GPs (CNSGP) were initially advised they would need run-off cover.
It’s vital that GPs check if they were one of those and ensure they have sufficient cover in place. However, agreements have now been reached in many cases for the government to take on historic and existing liabilities predating CNSGP.
When the Government scheme was introduced in April 2019, the Department of Health and Social Care noted CNSGP would not act as run-off cover for those who had previous claims based products. However, there have been successful challenges and subsequent agreements over this.
What is the time limit for medical negligence claims?
Medical negligence claims can be brought years after an incident occurs.
While there is a three-year limit on medical negligence claims, it doesn’t exclude the possibility of proceedings being brought much later.
The three-year time limit states that claims must usually be brought within three years of either the incident or when it was first realised injury had been suffered.
The three-year limit does not begin until the 18th birthday of a child and, in the case of a mental disability, it doesn’t apply unless the person recovers from it.
So, while after three years the risk of an historic claim is likely reduced, the decision over how long to retain run-off cover may be complex.
Do you need advice about run-off cover? Contact us with your indemnity queries.
All of us as GPs will likely carry out at least some paid-for services, but expansion of or an outright switch to private delivery is, obviously, a wide-reaching decision.
It’s one thing to provide HGV medicals and firearms reports that don’t conflict with NHS services and another to step into a for-profit frame of mind.
Whether you are debating joining an existing private practice or forming one yourself these six preliminary considerations may be helpful thought prompts.
1. Moral arguments
Few GPs considering branching out into offering private services will do so without some consideration of the moral arguments.
The debate is one that only individuals can come to a conclusion on but it’s worth remembering with this emotive issue that you’re likely to face strong views in opposition to your own. You may need to be patient with others and develop a thick skin.
As well as the wider conflict over whether or not private services are detrimental to the NHS, there are personal considerations around adjustments to dealing with profit being a factor in care.
If you are seeking to work for a private practice, rather than establish one, close scrutiny of procedures and practises, such as prescribing processes, will allow you to evaluate if your personal beliefs align.
2. Robust division between private and NHS work
Should you be considering running a private practice or perform private work alongside an NHS practice you’ll need to ensure you have robust procedures to keep the two distinct.
The 2019/20 NHS contract prevents signed up GP practices from hosting or advertising paid-for services that fall within the scope of NHS funded primary medical services.
3. Financial arrangements
In private practice you’re likely to need to deal with the priorities and expectations of investors or shareholders either in a direct or indirect way.
For those setting up private practice themselves, specialist accountancy and business advice may need to be tabled, not least in relation to dealing with private medical insurance companies.
Marketing also requires investment and expertise.
4. Revalidation and appraisal arrangements
In private practice you’ll have the same revalidation and appraisal obligations in order to retain and protect your registration.
Processes to allow effective completion are vital.
5. Patient expectations
Patients’ expectations among the privately funded bring different demands to those experienced in the NHS.
Some paying patients might well demand tests or treatments that may be clinically ambiguous.
6. Indemnity cover
A move into private practice brings the need for further consideration of indemnity cover for yourself and staff if you’re employing them.
While the 2019 introduction of the Clinical Negligence Scheme for GPs (CNSGP) did not negate the need for indemnity cover even in traditional, majority NHS practices, in private practice cover must be robust.
The state-backed scheme offers automatic cover for liabilities relating to acts or omissions relating to the diagnosis, care or treatment of a patient in relation to NHS services only. It’s worth remembering that even private actions that are permissible in NHS practice are not covered by this scheme, which can cause confusion where there are grey areas, in relation to travel vaccinations, for example.
Terms of engagement should be among other legal considerations.
Patients will soon have the right to access their medical records through the NHS app – which is set to bring a renewed focus on what’s actually contained within a person’s file. If it’s easier than ever for patients to request, inspect and challenge the data kept on them, then the importance of record keeping in healthcare will be thrown into an even sharper focus.
Whether it comes naturally or not, all GPs have to accept that record keeping is a key part of their role. Far from getting in the way of patient time, this part of the job is the thing that informs and guides that patient time. It’s also the thing that protects you and your judgement should this later be questioned.
This post will focus on the importance of record keeping in healthcare and offer a timely refresher of some best practice tips for GPs to ensure they and their patients are on the right track.
Record keeping in healthcare
It pays to remind yourself of the end goal when it comes to your record keeping efforts. This part of the job is all about:
- Keeping detailed information about a patient, their condition and their treatment to ensure you have all of the information you need to hand at every checkup or consultation with them.
- Providing a record that could be picked up by a colleague if they need to pick up the care of the patient for themselves.
- Creating a bank of evidence of the care given to a patient should your actions later be questioned.
Important considerations for good record keeping
The General Medical Council’s ethical guidance outlines how GPs should record their work ‘clearly, accurately and legibly’.
Its advice stresses that any records should be made as soon as possible after the events being recorded and that medical professionals should also be mindful of the laws around data protection so that this information can be safely and securely recorded and stored.
It also states that a patient’s clinical records should include:
- Your name and the date for each new entry
- Any relevant clinical findings you have made
- The decisions you have taken as a result of those findings and any action that you have agree to take as a result.
- An outline of any information you have passed on to your patient
- Details of any drugs prescribed
- Details of any further investigation to be carried out or any treatment required.
This record shouldn’t just be a note of face-to-face appointments, it should also contain important details such as:
- X-rays and scans
- Test results
- Notes from telephone conversations
- Discussions with your colleagues about the patient
- Letters sent or copied in to the patient
- Records of any surgery or hospital visit
Top tips on record keeping
How do you ensure you follow all of the above advice when working on a patient’s medical record?
- Don’t try to alter a file. This is a key point to remember at all times. If you’ve made a mistake then you should correct this with a new entry that clearly outlines what has changed. It’s always best to make a new note, even when you’ve made an error, especially because the GMC frowns upon people who try to delete or change notes.
- Use a good pen if you need to write anything by hand. GP handwriting is notorious – and you don’t want to conform to the stereotype. You don’t need to engage in beautiful calligraphy, but you do need to be understood and a good pen can assist with that.
- Don’t be too personal. These records are professional, factual files and there’s no need to try to write in flowery prose or insert personal comments.
- Check everything. It’s surprisingly easy to log notes against the wrong patient, for example. Check you’ve got the right person – and that all the details you’ve written are correct – before you submit your entry.
If you have any concerns about keeping accurate records, get in touch with MDS to see how we can support you.
The nation is set to go to the polls on December 12 for a rare winter General Election that pundits are saying will be crucial for the future of the country.
The Medical Defense Society is strictly neutral on political matters – we’re proud to represent GPs of any political persuasion – but we know that you’ll all be keen to see what the parties are proposing.
In a bid to help you to cut through the noise, we’ve laid out what the major UK-wide parties have said in their manifestos about GP services and their plans for the next five years.
The Conservative Party, led by ex London Mayor Boris Johnson, is bidding to earn a majority in Parliament, after governing with the support of the Democratic Unionist Party of Northern Ireland since 2017.
GPs should note:
- The manifesto promises 6,000 more GPs and add 50 million extra GP appointments a year (a 15% increase). The party says its plan would involve upping the number of GPs in training by about 500 a year. In 2015, then health secretary Jeremy Hunt promised 5,000 more GPs by 2020. However, numbers have actually declined in the past four years.
- It also adds: “We also want to make sure that doctors spend as much time as possible treating patients, so we will address the ‘taper problem’ in doctors’ pensions, which causes many to turn down extra shifts for fear of high tax bills. Within our first 30 days, we will hold an urgent review, working with the British Medical Association and Academy of Medical Royal Colleges to solve the problem.
If you wish to read the full manifesto, you can download it here.
Jeremy Corbyn is looking to build on the party’s performance two years ago – and has set out a radical manifesto to increase public spending.
GPs should note that:
- The party says, in general, it wants to increase NHS spending by 4.3% a year, abolish prescription charges and end ‘privatisation’.
- The manifesto states: “To support our transition to community health care services, we will expand GP training places to provide resources for 27 million more appointments each year and ensure community pharmacy is supported.”
To read the Labour Party’s full manifesto, follow this link.
Jo Swinson is leading the Liberal Democrats into the 2019 General Election and will hope to hold the balance of power.
For GPs, the manifesto states:
- The party wants to: “End the GP shortfall by 2025 by both training more GPs and making greater appropriate use of nurses, physiotherapists and pharmacists, and also phone or video appointments, where clinically suitable.”
- The party also pledged to support GPs to ‘work with nurses, physiotherapists, mental health and other professionals’ to offer multi-disciplinary services and to improve out of hours and mobile appointments.
Read the full Liberal Democrat manifesto here.
The Green Party will be wanting to build on its one MP, after securing more than two million votes at the recent European elections.
From a GP’s perspective, the party’s manifesto states:
- NHS services to be planned and provided through Health Boards – and increase funding by at least £6 billion a year.
- It also states: “Focus funding to enable the construction of new community health centres, bringing health services closer to people’s homes. These health centres will pioneer preventative healthcare, helping people live healthier lifestyles so that they are less likely to fall ill.”
Read the full manifesto for yourself here.
Nigel Farage’s Brexit Party is standing in more than 300 seats across the country.
Its manifesto – which it calls a ‘contract’ – states:
- A desire to ‘introduce 24-hour GP surgeries to relieve the strain in A&E departments’.
- It also calls for ‘national debate’ on the NHS involving doctors, experts and the public, including a discussion on the ring-fending of the NHS budget and tax revenues that fund it.
Read the full document for yourself here.
Hopefully the above should help you to understand what the parties are saying about GP services as we approach polling day.
Keep an eye on the MDS site for news of any new policies or legislation that is introduced that impacts on GPs.
Whether you view it as a genuine motivator to improve standards and refine practice or an unnecessary burden, for now at least, revalidation appears to be here to stay.
Finally implemented in 2012 after many years of being mooted, the system requires all licensed doctors and GPs to be revalidated by the General Medical Council every five years.
Relying heavily on evidence gathered during the annual appraisal process, revalidation involves amounting 360 feedback, continuous professional development, explanation of significant events and evidence of reflection.
What is revalidation?
Revalidation is an evaluation of a doctors’ fitness to practise and a legal requirement to maintain a licence to do so.
The General Medical Council says it revalidates doctors to keep standards of care high and demonstrate doctors are up-to-date and competent.
Every doctor must revalidate every five years and provide evidence that knowledge is current, they are fit to practice, there are no outstanding concerns about them or their work and they provide good standards of care.
Revalidation is awarded by the General Medical Council (GMC) and is based on submissions made to it.
How does GP revalidation work?
For the majority of doctors the decision is based on the recommendation of a ‘responsible officer,’ who is usually a senior doctor within the applicant’s organisation. The responsible officer relies on annual appraisals and any other relevant information to make the recommendation.
In cases where a ‘responsible officer’ is not available, another senior doctor, known as ‘suitable person,’ can make the recommendation. When neither a ‘responsible officer’ nor ‘suitable person’ is available, an annual return can be completed by the applicant and a written knowledge test may be required.
What are doctors’ responsibilities in relation to revalidation?
The General Medical Council’s Guidance for doctors: Requirements for revalidation and maintaining your licence outlines the responsibilities doctors have in relation to revalidation.
They include the necessity to fully engage with the process of annual appraisals and collect evidence on a day-to-day basis.
Also on the list are:
- Identify your designated body and responsible officer, or suitable person. Or inform GMC you don’t have one. There is a GMC tool to help you find out if you have a connection to a designated body or suitable person.
- Collect suitable supporting information
- Have an annual appraisal (or engage fully with your training programme if you are a
- doctor in training) which covers your whole scope of practice.
- Reflect on, and discuss with your appraiser, the supporting information you have
- Keeping your connection details up to date in your GMC Online account
A 2018 summary of changes by the Royal College of General Practitioners noted that locums must provide contact details of all the practices where they have worked as part of the process.
Necessary supporting information for revalidation
For revalidation to be successful six types of supporting information are required.
They relate to:
- Continuing professional development
- Quality improvement activities
- Significant events
- Feedback from patients or those to whom you provide medical services
- Feedback from colleagues
- Review of compliments and complaints
More information is available via the GMC’s ‘Guidance on supporting information for appraisal and revalidation’.
How long does preparation for revalidation take?
The amount of time necessary to commit to appraisals and evidence gathering for revalidation can be a controversial topic, with some GPs feeling the burden is too high.
Supporting information for appraisal and revalidation should be focused on quality rather than quantity of supporting information, according to the RCGP.
The guide ‘RCGP Mythbusters – Addressing common misunderstanding about appraisal and revalidation’ says: “We recommend that the final stage of organising the supporting information and completing your portfolio before your appraisal should take no more than half a day, around 3.5 to 4 hours. This is based on the original financial provision for annual appraisal, which was for one day of activity, half to prepare and half to have the appraisal discussion.”
It advises supporting information should be added to your portfolio on a day-to-day basis rather than retrospectively, which would prolong the process.
What recommendations can be made regarding revalidation?
When you have a responsible officer or suitable person to make a recommendation on your revalidation, as is usually the case, there are three options available to them.
- Recommendation to revalidate
- Recommendation to defer
- Recommendation of non-engagement.
Recommendation to defer revalidation
There are two instances when a recommendation to defer is appropriate, those being:
- Where, due to reasonable circumstances, it has not been possible for collection and reflection on all of the required supporting information. Reasonable circumstances include parental or carers leave, a sabbatical, a break from practice, or sickness absence.
- An ongoing HR or disciplinary process
A recommendation to defer revalidation does not imply any judgement about a doctor’s fitness to practise and is not publicly available or published.
Recommendation of non-engagement for revalidation
This is the recommendation when a responsible officer or suitable person feels there has been either a failure to meet requirements or to sufficiently engage with the revalidation process.
When a recommendation of this type is received, the GMC will:
- Write to the doctor concerned to inform them
- Give the opportunity for representations to be made
- If representations are made, refer them back to the responsible officer or suitable person for consideration
- Consider deferring revalidation if efforts are made or representations show efforts to engage in the process
Outcomes and appeals in relation to GP revalidation
Where the GMC revalidates a licence there is no change to it and the rolling process continues with a new revalidation date set (usually five years in the future) and a need for ongoing annual appraisals and engagement with the process.
A decision to defer revalidation means you continue to hold a licence and can practise as normal and a new date for revalidation will be set.
If the GMC is considering withdrawing a licence it will notify of the reasons and allow 28 days for representations to be made. There is a right to appeal if a licence is withdrawn.
Concerns and questions around the revalidation process
Revalidation is a legal process and requirement for all doctors wishing to practise in the UK.
We offer specialist legal advice and representation, a telephone advisory service, training packages, workshops and courses for GPs.
Do contact us for further information.
Failures in safeguarding vulnerable adults can and do result in tragedy and harm to individuals and professionals. It’s a tricky thing for GPs to get right – and vital to focus on.
The case of Joseph O’Hanlon, an alcoholic who was beaten to death in his home after concerns were raised about him being taken advantage of by drinking associates, was one which highlighted the issues around adult safeguarding. While steps taken by authorities in the case were said to have been reasonable and, in some examples, even excellent, the case led to calls for vulnerable adults to be treated in the same way as children at risk of harm. It was felt that had the case involved a vulnerable child ‘there would have been a much greater level of expectation in relation to the actions of professionals’.
A key tenet of safeguarding, both for adults and children, is that it is everyone’s responsibility. And all health care staff, from administrators and receptionists up to GP partners, have minimum standards of competency to meet.
Dr Joy Shacklock, the Royal College of GPs’ Clinical Champion for Good Practice and Safeguarding has said: “Safeguarding adults at risk of harm is a key duty for all who work in healthcare.”
Adult safeguarding: roles and competencies for health care staff
The publication of the Royal College of Nursing’s ‘Adult safeguarding: roles and competencies for health care staff’ in August 2018 was hailed as the first UK guidance to help healthcare staff better protect adults at risk of harm, abuse and neglect.
It was designed to be relevant to all healthcare and social care professionals and outlines to what degree staff at all levels must be proficient in the subject. In addition, it underlines the necessity for ongoing professional development and training within this area.
For ‘Level One’ staff, including receptionists and administrators, the document says there is a necessity to know the signs of possible neglect, harm or abuse and who to contact for advice over concerns. This includes the requirement to be willing to listen to concerns about risk, recognise how personal beliefs, experience and attitudes may influence safeguarding work and recognise how their own actions may impact on others.
‘Level Two’ staff, including GP practice managers, must have increased levels of competency including ensuring action is taken where necessary, including to organise advocacy for the individual where required. There is also a requirement to understand mental capacity legislation relevant to the country of practice, which varies between UK countries.
For staff considered ‘Level Three,’ including GPs, it outlines a comprehensive list of necessary competencies, knowledge and attitudes.
There is a further tier of competency for those in specialist roles including named GPs/doctors for organisations commissioning primary care.
The six principles of adult safeguarding
Six foundation principles of adult safeguarding, set out by the Department of Health, inform how professionals should engage with people at risk of abuse, harm or neglect.
The principles in themselves are open to a certain level of interpretation and highlight the potential for complexity in decision making and the balancing act involved in properly meeting safeguarding requirements.
The premise of the principles is around ensuring safeguarding is something that is done with patients and not to them.
The principles are:
- Empowerment There is a presumption of informed consent and for the patient to be involved in the safeguarding process, desired outcomes and any resulting action
- Prevention There is a duty to ensure help is given to allow patients to recognise what abuse is and pathways to support
- Proportionality A responsibility exists to provide the least intrusive response to the level of risk posed
- Protection This principle hinges around ensuring those who need support and representation to report abuse receive it.
- Partnership It’s necessary to ensure information is only shared to the degree that is helpful and necessary even where consent is obtained and that the patient has confidence in this.
- Accountability Patients need to know who is involved in the safeguarding process and in what ways they are involved.
What constitutes abuse, neglect and harm?
In order to fulfil obligations, GPs and their teams must be alert to the full range of potential abuse, neglect and harm and not constrained in their view of what can qualify as a potential safeguarding issue.
This can include:
- Physical abuse including inappropriate restraint or physical sanctions
- Sexual abuse including all non consensual or coerced acts, sexual harassment and non-contact acts such as indecent exposure and online abuse
- Psychological and emotional abuse inclusive of threats of harm or abandonment, coercion, isolation and unjustified withdrawal of support
- Financial or material abuse including theft, fraud, exploitation or coercion. ‘Cuckooing’ should also be considered, which is where a person’s property is taken over and used for illegal activity, particularly drug dealing
- Neglect and acts of omission inclusive of failing to provide access to appropriate health and social care, necessities of life or the necessary support to access those
- Self neglect as well as basics such as personal hygiene, health and environment. This may include certain behaviours such as hoarding
- Domestic abuse, which may occur within relationships irrespective of gender and is inclusive of coercive and controlling behaviour, female genital mutilation and honour based violence
- Discriminatory abuse unequal treatment due to any protected characteristics
- Organisational abuse may relate to one-off or ongoing failures or practices
- Modern slavery where people are forced to endure a life of abuse, servtitude or inhumane treatment.
An overview: safeguarding vulnerable adults
Adult safeguarding is a complex area of practice with heavy moral, as well as legislative requirements. It is an area that is open to interpretation at many stages, involves a wide client group and can involve many service providers.
The Care Act 2014, does not use the term ‘vulnerable adult,’ instead referring to adults with a care or support need – a reminder that all adults may fall into the category at certain times. A carer may be in need of safeguarding as a result of the pressures upon them or behaviour of their charge. Similarly an individual may become ‘vulnerable’ temporarily due to a specific period of ill health or mental strain.
GP practices must do everything possible to ensure adults at risk are protected via proper and effective training, information and protocols for all staff.
As well as being aware of legislative requirements, GPs may also have additional contractual obligations with commissioners in relation to safeguarding vulnerable adults.
Safeguarding is naturally interlocked with confidentiality, data protection and mental capacity legislation. Certain disclosures are required at certain times according to relevant legislation.
A breach in relation to responsibilities to safeguard vulnerable adults is a legitimate concern and can cause conflict in terms of doctor-patient confidentiality, for example.
For advice on any situation regarding safeguarding vulnerable adults contact us.