The Clinical Negligence Scheme for General Practitioners (CNSGP)

From 1 April 2019, NHS Resolution (NHSR) started operating a new state indemnity scheme for General Practitioners in England. It is called the Clinical Negligence Scheme for General Practice (CNSGP).

The scope of the scheme

As explained on NHSR’s website, “the scheme covers clinical negligence liabilities arising in general practice in relation to incidents that occurred on or after 1 April 2019”. The website goes on to explain the scope of the scheme, which “extends to all GPs and others working for general practice who are carrying out activities in connection with the delivery of primary medical services – including salaried GPs, locums, students and trainees, nurses, clinical pharmacists, agency workers and other practice staff”. It is a scheme with extensive scope, therefore. Essentially, the key question relating to scope is whether the services provided are NHS primary medical services.

It is important to note that treatment provided before 1 April 2019 is not covered by the scheme, even if the claim is reported after that date. On 6 April 2020, another new state indemnity scheme for general practice was established, the Existing Liabilities Scheme for General Practice (ELSGP). This scheme covers the historical liabilities of general practice staff before 1 April 2019 for those who were indemnified by MDDUS and MPS and is intended to complement the CNSGP. In other cases, the incident will need to be reported to the relevant medical defence organisation or other indemnity provider. It is also important to note that there are a number of incidents which fall outside the scheme, including privately funded work undertaken by GPs. NHSR helpfully provides a detailed table setting out the scope of the scheme and whether cover is provided in given situations[1].

The first year of the scheme

As at September 2022, the CNSGP has been running for 3½ years. On 23 August 2022, NHSR published its analysis of the first year of the scheme, 1 April 2019 to 31 March 2020[2]. NHSR notes that, “although 90% of patient contact in the NHS is via primary care, the number of claims are proportionally very low” (401 of 11,682 new claims notified to NHSR in the first year of the scheme, a mere 3.4%). It is no secret that GPs have an increasingly challenging role to play in a complex and difficult healthcare environment and the low number of claims is arguably testament to the quality and hard work of the majority of GPs. However, the figure is also likely to be artificially low, as it may take a few years for a claim to be made (in particular bearing in mind the limitation period of 3 years for adults), and of course pre-1 April 2019 claims fall under the ELSGP. The figures (along with associated costings) must be treated with the utmost caution, therefore, until we have had a few years of the CNSGP and trends can be analysed and the relevance of the ELSGP begins to wane.

What can be learned?

Most GPs are of course “generalists”. One might, perhaps unfairly, call them “jacks of all trades and masters of none” (whilst noting that some GPs undertake work in specialist areas such as minor surgery). As such they need to know a little about a lot of things. Most GPs are also under significant patient consultation time limitation, with time being a luxury GPs tend not to have. Accordingly, it remains very easy to make a mistake. The most frequent case notifications from the first year analysis related to cancer (9.3%), cardiac cases (7.3%) and sepsis (5.3%). Other reasonably frequent notifications included orthopaedic, gastrointestinal and bowel, neurological, dermatological and obstetric injuries, and DVT/pulmonary embolus. The most commonly reported themes were delay/failure to diagnose (43.5%), medication errors (18.5%) and delay/failure to refer (10%). Deaths accounted for 70 instances (18% of all GP notifications), with cardiac deaths making up 26%. Recurring common error themes were identified, which NHSR categorise as follows: communication with and about patients; medication and vaccine provision; errors in investigative processes; treatment and equipment provision; and timely diagnosis and assessment.

From this initial analysis, NHSR has drawn some conclusions. First, reducing delay in the GP cancer care pathway is likely to improve cancer survival, in particular bowel and breast cancer. Secondly, of the cardiac claims, the most common events were myocardial infarction (“heart attack”) and cardiac arrest (totalling 56%), with delay or failure to diagnose being the commonest problem. Thirdly, sepsis is estimated to account for nearly 40,000 deaths per annum in England and it is often a time-critical condition, with early suspicion, diagnosis and treatment being paramount to avoid catastrophic injury (such as amputation or brain injury) or death. Sepsis kills more people than breast, bowel and prostate cancer combined. The commonest error relating to sepsis was delay/failure to diagnose – 81% – which is a very significant proportion.

Avoiding medical errors: recommendations

NHSR has made a number of detailed recommendations in 3 key areas resulting from the analysis, which may reduce the number of medical mistakes.

The first area relates to the delay or failure in diagnosis, a commonly recurring theme in clinical negligence claims generally and certainly not limited to GPs. Diagnosis is a multifaceted and complex topic, nowadays including involving risk assessment, stratification and diagnostic tools, education, research, communication, etc. As a junior doctor, I was taught that up to 90% of accurate working diagnoses can be made if a full and proper history is taken, supplemented by a proper examination. History-taking and examination are skills requiring proper teaching/training, education, practice and experience, but notwithstanding those, one of the main problems is having the time within which to take a detailed history and perform a thorough examination; as noted above, time is a luxury many GPs simply do not have. This is not an easily soluble problem, therefore, and there is no quick fix but affording GPs more time seems key.

The second area relates to medication errors, in particular the topics of failure to prescribe/dispense and adverse reactions. Fortunately, many medication errors do not result in harm so serious claims relating to such errors are low. However, adverse drug reactions do occur and can cause catastrophic injury. I recall as a medical student that the houseman (now called a Foundation Year 1, FY1) in our firm[3] administered 10 times the required dose of digoxin to a patient because the decimal point was in the wrong place on the prescription chart: fortunately, no permanent harm was caused, but it was an early lesson to us soon to be newly qualified doctors as to how easy it is to make a mistake.

Finally, the third area relates to prison healthcare, in that the prison healthcare sector shows very considerable variation in the quantity and quality of provision of medical care which needs addressing.

Conclusion

In conclusion, there is little startling in this initial report by NHSR into the first year of the CNSGP, although the figures must be treated with caution. However, usefully it highlights in particular that claims concerning delay and failure in diagnosis, medication error, cancer, cardiac disease and sepsis are relatively frequent. These are reasonably predictable problem areas for GPs and, indeed, my own current caseload contains claims against GPs relating to most of these topics, which have resulted in life-changing injuries or death and for which substantial compensation is being sought. Such areas are by no means limited to GP care, though. Nevertheless, it will be interesting to see how the statistics over the next few years evolve under the CNSGP and to what extent these areas remain the problem areas.

[1] https://resolution.nhs.uk/wp-content/uploads/2021/10/CNSGP-Scheme-scope-table.pdf

[2] https://resolution.nhs.uk/wp-content/uploads/2022/08/3523-CNSGP-Report-DV5-SINGLE-Access-1.pdf

[3] A “firm” was the name given to a consultant-led team of junior doctors (often a Registrar, Senior House Officer and House Officer), which was replaced after about 2005 when medical training was ‘modernised’, although some wish to see its return as an effective medical apprenticeship model.