On 23 August 2022 NHS Resolution published its report reviewing the first year of the Clinical Negligence Scheme for General Practice (CNSGP). In this article we look at the Report, including the three initial themes identified – two related to commonly reported cause codes (delay/failure in diagnosis and medication errors), and a third relating to issues arising in prison healthcare – and the key recommendations made in the report.
What is CNSGP?
CNSGP – a state backed indemnity scheme for general practice administered by NHS Resolution – was introduced in April 2019 in response to rising indemnity costs and the impact that this was having on recruitment and retention in general practice. The scheme covers all clinical negligence claims for compensation arising from NHS services provided by general practice in England and covers all incidents occurring on or after 1 April 2019 relating to care provided under GP contracts.
NHS Resolution also administer the Existing Liabilities Scheme for General Practice (ELSGP), another state-backed indemnity scheme for general practice covering historical (pre-April 2019) liabilities previously managed by some medical defence organisations, although ELSGP cases were outside the scope of the Report.
Review of the Report
The Report, prepared further to NHS Resolution’s quality and safety functions under the Safety and Learning Directions 2019 with the specific aim of “understanding the causes of claims that occur in general practice and identifying common themes,” looked at 401 cases reported to CNSGP between 1 April 2019 and 31 March 2020. This includes potential claims such as patient safety incidents and complaint responses amounting to an admission of breach of duty. The number of formal claims (where either the pre-action protocol or formal proceedings have been started) notified in this period was 81.
Of particular interest are the statistics around patient conditions and CNSGP cases by cause.
In terms of patient conditions, the top 3 case notifications were:
- Cancer (9.3%);
- Cardiac (7.3%); and
- Sepsis (5.3%).
The most commonly reported cause codes were:
- Delay/failure to diagnose (featuring in 43.5% of CNSGP cases);
- Medication error (18.5%); and
- Delay/failure to refer (10%)
NHS Resolution’s thematic analysis identified three initial themes from the review: 1) delay/failure in diagnosis; 2) medication errors; and 3) issues arising in prison healthcare. The first two themes arise from the most commonly reported cause codes whereas the third – issues arising in prison healthcare – is likely to be a reflection of the fact that, as has been recognised by the CQC, people who use services in secure settings are generally more vulnerable. Further, and as per the research referenced in the Report itself, prison inmates are more likely to suffer ill-health, physical injury and mental health problems than those outside the prison system.
The key recommendations from the report, responding to the three initial themes above, are as follows:
1. Recommend NHS England, the Royal Colleges, Getting It Right First Time and Professional Regulators work together to explore the feasibility of a patient acuity risk (track and trigger system) assessment tool for use in general practice to assist earlier identification of deteriorating patients.
2. Recommend that NHSX with NHS Digital GP IT and NHS England continue to promote existing safety netting tools (including minimising inequalities e.g. enhancing easy reading, translation and digital exclusion) such that they are available nationally.
3. Recommend that policy makers, academic partners and NHS bodies explore feasibility of further development of advice and guidance service that enables improved communication and collaboration between general practice and secondary care.
4. Recommend that NHS bodies, Royal Colleges and associated stakeholders consider collaboration to support introduction of Protected Learning Time across general practice teams.
5. Recommend that professional regulators consider using the Royal Pharmaceutical Society (RPS) competency framework as a benchmark when reviewing prescribers and prescribing in conjunction with National Institute of Clinical Excellence (NICE) guidance on medications management.
6. Recommend that NHSX, as part of its Digital Clinical Safety Strategy, consider research into why clinicians override adverse drug reaction system prompts and how this may be minimised.
7. Recommend that NHS England suggest Integrated Care Systems appoint a Designated Medication Safety Officer supporting clinicians in adhering to the Green Book recommendations on the handling and storage of vaccines and to share any learning from error.
8. Recommend that commissioners, providers and Integrated Care Systems who oversee prison services, consider increasing the use of the telemedicine across the estate working to support primary and secondary care appointments as well as improving continuity of care with community services.
Discussion
As the Report itself recognises, given the relative immaturity of the data available it can only provide an indication of the types of cases that may be seen in the primary care sphere in the coming years; no firm conclusions can be drawn from the first year’s data.
Nevertheless, the Report should be welcomed as another tangible manifestation of one of NHS Resolution’s key strategic priorities to share data and insights as a catalyst for improvement across the whole of the NHS, including primary care. The Report (and subsequent reports) is likely to play a key role in driving positive change for both primary care patients and staff.
