Intended for healthcare professionals


Indemnity fee rises may make it unviable for GPs to provide out of hours services

BMJ 2015; 351 doi: (Published 08 September 2015) Cite this as: BMJ 2015;351:h3944
  1. Anne Gulland, BMJ Careers
  1. agulland{at}


Anne Gulland reports on the sharp rise in recent years in indemnity fees and hears warnings about the possible effect of these costs on GPs’ ability to provide care out of hours

The indemnity fees that doctors have to pay to practise have been rising for decades. In recent years, however, the increasing costs of securing some types of cover have been threatening the viability of some of the services general practitioners provide.

The issue was raised at the BMA’s annual local medical committee’s conference in May. Delegates at the conference urged the government to acknowledge that the cost of medical defence cover was making it uneconomic for GPs to participate in non-general medical services work, such as minor surgery or medicolegal work.

Andy Purbrick, a GP in Dorset, describes the hike in fees as “eye-watering.” He told BMJ Careers that, because GPs were being called on to do more work outside the normal scope of practice, their insurance risk was increasing.

“We’re being asked to manage more complex patients than ever before both in their own homes and nursing homes,” he says. “However, it would seem that patients, the government and the medical defence organisations are unwilling to accept that risk.”

Other GPs have reported their shock and anger in response to rises in the indemnity fees they are asked to pay (see box).

Doctors doing out of hours work are among those who are seeing the greatest rise in indemnity fees. John Horrocks, chief executive of Urgent Health UK, an umbrella body for out of hours providers, says that rising indemnity is the biggest issue facing his members at the moment. A small pilot survey of 70 GP members of the organisation has found that many are limiting their out of hours work because of the cost of cover.

One GP saw their indemnity fees for two out of hours sessions a week rise from £3270 a year in 2014-15 to £4638 in 2015-16. Another GP reported paying £7395 a year for seven core sessions and two out of hours sessions a week. When the doctor renewed the subscription the fee went up to £9900. And another GP reported being charged an additional £4158 to work one out of hours session each month.

After a claim linked to their practice’s work in prisons, another GP reported indemnity fees going up to more than £20 000. The GP said in the survey: “I have decided to give out of hours a rest for now until the government provides us with crown indemnity.”

“Very bleak” situation

The situation is “very bleak,” Horrocks says. “Our GPs are saying the cost of indemnity is going up, and there’s not always a huge logic to it,” he says. “It’s between the GP and their medical defence organisation—some are seeing much bigger increases than others. Out of hours is one of the biggest problems facing us and we’re going to have a real shortage of GPs willing to work.”

For indemnity organisations, providing cover for out of hours medical work is a risky proposition. Patients using out of hours healthcare services tend to be sicker, they are not seeing their own doctor, and the doctors who treat them do not have access to their medical records.

But Horrocks says incidents among Urgent Health UK members are rare. “The number of claims among our members is very low,” he says. “We do a lot of work in terms of quality and safety processes to minimise the risk. When we speak to defence organisations they simply say the premium reflects their claims experience.”

One reason for the rise in fees is the increasing cost of NHS litigation. According to the NHS Litigation Authority’s annual report, it paid out £1051.2bn in 2013-14, compared with £729.1m in 2010-11.1

The biggest rise occurred between 2010-2011 and 2011-12, when the amount paid out jumped to £1095.3bn. The number of claims has also risen: from 6562 in 2009-10 to 11 945 in 2013-14.

Unscrupulous lawyers

Last month, the government announced plans to cap legal fees charged by lawyers in clinical negligence claims. Unveiling the plans, the health minister Ben Gummer said, “Unscrupulously, some lawyers have used patient claims to load grossly excessive costs on to the NHS and charge far more than the patient receives in compensation.”

Michael Devlin, head of professional standards and liaison at the Medical Defence Union, says the reason fees are rising is because the “cost of claims is spiralling out of control” and urges reform in the way damages are calculated. One such reform would be a repeal of the Law Reform (Personal Injuries) Act 1948, which calculates damages based on the cost of private rather than NHS care.

The Medical Defence Union would also like to see a cap on loss of earnings to three times the average national salary. “We’re not saying the patient shouldn’t be compensated, but they should be compensated in a way that’s fair,” he says.

John Tiernan, executive director for member engagement at the Medical Protection Society, points out that the number of complaints made to the General Medical Council has also increased in recent years and rose by 64% between 2010 and 2013.“Our view is that the standard of medical care has never been higher,” he says. “The system is set up to encourage people to have a go [at submitting a claim]. The cost of a doctor’s subscription is driven by the cost of claims.”

Tiernan also believes that legal reform is necessary to bring costs down and a fixed cost regime should be introduced for low value cases. Lawsuits paying out £15 000 to £20 000 end up with costs of £50 000 to £60 000, he says.

For some, the solution is for GPs to be covered by crown indemnity, like hospital doctors. Horrocks believes the clinical negligence scheme for trusts should be extended to out of hours cover, and indeed NHS England did offer this as a one-off to GPs working bank holiday shifts earlier this year. “There was a very limited take up as it was difficult to identify and tie up the extra insurance costs,” says Horrocks.

No panacea

But John Canning, a member of the BMA’s General Practitioners Committee, says that crown indemnity would not be a panacea. He points out that GPs would still have to take out their own cover because of the non-NHS work they do. “It’s a potential solution, but I would be concerned that the crown would make payouts based on financial considerations rather than reputational risk,” he says.

The local medical committees conference urged the BMA’s General Practitioners Committee to carry out a review of the situation and wanted the government to directly reimburse GPs for their indemnity costs, a solution that Canning favours. He also believes that doctors should hold their defence unions to account. “How many doctors attend their organisations’ annual general meetings? They’re not behaving like mutuals but like commercial organisations,” he says.

Shock and anger at fee increases

A GP partner in Leicestershire was shocked to receive a letter from his medical defence organisation last year informing him that his annual indemnity fee had jumped from £7700 to £12 800. The letter explained that, after an underwriting review, he was considered to be a considerably higher risk than previously and that he would have to undertake mandatory educational activities to continue being a member of the organisation.

He was not given a specific reason for the dramatic rise but was allowed to see a list of cases that the underwriters had used in forming their opinion. The list contained nine cases, only one of which concerned litigation and which took place four years previously; the rest were either complaints that were dealt with at the practice stage or simply contacts with the defence organisation for advice.

He was refused cover from rival firms and so reluctantly paid the higher premium and took part in the training, which entailed a six month communication course. His practice also had to undertake a risk review, which he describes as being similar to a Care Quality Commission inspection, including a “four-hour interrogation from a risk assessor.”

He was bruised by his experience and thinks that his risk is no higher than that of any other full time GP who works the occasional out of hours shift. “This has shaken my confidence quite dramatically,” he says. “We’re generally a low complaints practice and we go out of our way to meet patients’ expectations.”

He adds, “The one source of reassurance a GP has as a sole practitioner is that you have an indemnity provider who is going to stand by you and support you providing you haven’t done anything stupid or deliberately caused harm.”

He believes his fees have risen purely because of the number of contacts he has had with his indemnity provider. “My circumstances haven’t changed and the litigation was something that happened a long time ago,” he says. “If they’d had an issue with me they would have asked me to cough up more at the time. They system is so opaque and there is no transparency,” he says.

Another GP was told by his defence organisation that it could no longer offer him any cover as he was considered too high a risk. He has 32 years’ experience as a GP and had a clean sheet until two years ago, when the practice had two claims against it. The GP attended the mandatory communications training demanded by the organisation and heard nothing until last December, when they said he could no longer be a member.

He says he was deemed too high a risk because he was the “last man standing” at the practice. He was the sole GP partner with a list of 8500 patients and unable to recruit any more GPs. “Of course I’m not looking after 8500 patients on my own as we have three advanced nurse practitioners, and two salaried GPs, as well as locums,” he says. The other defence organisations also refused to offer him cover and he was forced to go to the open market, which initially offered him cover costing £85 000 for the year. However, he has managed to get it down to £25 000 for the year with a £25 000 excess—a stark difference from the £6800 he paid previously.

He blames his large hike in fees on a wider complaints culture. But he is also angry at his defence union, which he believes marked him down every time he contacted them. “The defence organisation says that if we have a complaint we should go to them but on the other hand they give us bad marks every time we call them,” he says.



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