The Professional Indemnity Review: what did it accomplish?
In a previous article,* Richard Tjiong criticised the Professional Indemnity Review's specific recommendations for reform of professional indemnity insurance. But the Review covered many other issues, particularly to do with identifying, evaluating and reducing adverse outcomes of medical procedures. Charlotta Blomberg highlights some of the key findings (and failings) of the Review's Final Report.
MJA 1996; 164: 502
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Introduction - New research into health outcomes - Preventing adverse outcomes - Litigation crisis? - Compensation schemes - Drawing together medicine and law - In conclusion ... - References - Authors' details
- - ©MJA1997
The Review of Professional Indemnity Arrangements for Health Care
Professionals (chaired by Fiona Tito) was established against a
background of increasing litigation, or fear of litigation, among
health care professionals (see Box). Its purpose was to report to the
then Minister for Health, Housing and Community Services
The last duty remains largely unfulfilled in the Final Report. Despite 168 detailed recommendations for changes of varying degrees, there is little discussion of feasibility, appropriateness or, more importantly, estimated costs and benefits.
New research into health outcomes
The Review embarked upon a 41/2-year investigation of the health care system and
produced 19 publications (listed in Appendix C of the Report) in
addition to the Final Report. The Review looked at the incidence and
nature of health care injuries, compensation and structured
settlements for personal injuries, facilities for the disabled,
professional indemnity arrangements, "defensive" medicine and
informed consent, birthing issues and information guidelines for
patients and providers.
At the start of the Review there was no information on the nature and extent of adverse outcomes, no readily available information on the number and types of health-related compensation claims and little publicly available information on the business operations of the medical defence organisations. The Report argues that lack of information on the issues under review required several individual studies to obtain the information required for decision making. Therefore, a major part of the Review was information gathering.
It commissioned the Quality in Australian Health Care Study, which investigated the nature and extent of injuries suffered by patients in Australian hospitals. The preliminary results of this study were released in June 1995 and provoked considerable media attention. After peer review, the results were recently published in the MJA.12 With this study and others, the Review produced the first detailed analysis of the system of compensation for personal injury resulting from health care in Australia.
The Final Report attempts to tie this considerable research work together with far-reaching recommendations which, if implemented in full, would radically alter the delivery and funding of health care in Australia.
Preventing adverse outcomes
The Quality in Australian Health Care Study defined an adverse event
as "an unintended injury to a patient which resulted in a temporary or
permanent disability, prolonged length of stay or death, and which
was caused by health care management not by the patient's underlying
disease".11 Under this
broad definition the study found that hospital-based care produced
over 400 000 adverse outcomes, with an estimated 230 000 of these being
preventable. As a result, a considerable part of the Final Report
concentrates on proposals aimed at preventing adverse outcomes.
The solutions proposed involve the development of clinical practice guidelines based on evidence gained through the Cochrane Collaboration (which focuses on evidence derived from randomised controlled trials, conducted around the world and collectively analysed at the Cochrane Centre, Oxford University, UK). Medical services will be assessed on their efficacy and cost effectiveness. The Review recommends review of current services under the Medicare Benefits Schedule to establish their efficaciousness and cost-effectiveness. Commonwealth funding for those that fail these tests should cease (see Report recommendations 16, 19, 23, 28, 29 and 33).11
The emphasis on the development of clinical practice guidelines appears to stem from one of the findings of the Quality in Australian Health Care Study that system errors account for 16% of all adverse outcomes, with 53% of these due to the absence of or failure to use a policy, protocol or plan.12 However, the Study also concluded that "half of all AEs [adverse events] are deemed to have low or no preventability" and that this should be remembered "to avoid an inappropriate presumption of culpability when things go wrong".12
The Review does not address the difficulties associated with implementing a guidelines-based system of health care. The cost or cost-effectiveness of implementing these recommendations is not discussed, and no mention is made of what is involved (such as time and resources) in evidence-based reviews. There appears to be an underlying assumption that, if evidence-based guidelines are developed and followed, adverse outcomes will, in the main, be prevented. This "cookbook" approach to medicine has been criticised elsewhere.13 Without further debate of the issues, the Final Report fails to convince that strict adherence to evidence-based practice guidelines will achieve perfect outcomes.
In the Final Report, the issues of professional indemnity,
negligence actions and adverse outcomes were described as
surrounded by myths and assertions supported by little hard data.
Much of the information relating to the "litigation crisis" was
anecdotal: "evidence for a so-called claims crisis is scant", said
the Report, concluding that a crisis mentality has been fostered by
some medical defence organisations to deflect attention from their
own "irresponsible financial management".11 Although an increase in the rate of
incident reporting was noted, the Final Report held that this did not
appear to be reflected in an increase in claims filed in courts. It did
acknowledge that there is often a considerable time lag between the
reporting of an incident and the filing of a claim in court, which may
imply recognition that the crisis may yet eventuate.
The Review has rightly identified a lack of readily available information on common law negligence cases. A database of common law personal injury cases would be a valuable tool for monitoring the nature and frequency of legal claims, patterns of claims, the frequency of settlement and the amounts of awards and settlements. Such a project would require Commonwealth-State cooperation, as common law matters fall outside the Commonwealth's jurisdiction.
The Report cites the register currently operating in South Australia and the National Practitioner Data Bank in the United States as models, but does not estimate the amount or nominate the source for funding of such a project. It does recommend that such a register would provide "a positive quality link between the tort system and the [practitioner] registration system" (Report, pages 154-155).11 This proposal must be studied further. It could mean registration would be subject to the frequency or value of claims incurred each year. It could mean a type of peer review that may establish that common law negligence is not to be equated with medical negligence. Unfortunately, the Report is not clear on what is meant.
In relation to compensation for those who have suffered personal
injury as a result of health care, the Review recommended against the
introduction of a "no-fault" scheme of compensation. Such a scheme
would remove the need to prove negligence (fault) to receive
compensation; proof of injury would suffice. It was rejected on
grounds of inequity. The public interest is served by those who cause
injury paying compensation. A no-fault scheme would mean that the
full burden of assistance for injured persons would fall on the
community as a whole through increased taxes and an overall reduction
in resources available to those suffering injury as a result of health
care.11 While recognising
that there is inequity between the allocation of resources for those
with compensable injuries and those with non-compensable injuries,
the Report suggests that the overall public interest would be better
served by the retention of the current system.
The Review did investigate means of compensation other than the current lump sum awards. In many cases these, although seemingly generous, have proved to be inadequate when taken over the lifetime of a severely disabled person. Structured or serial payments in the place of lump-sum awards were offered as a solution. This is an alternative worthy of further consideration as it may provide security of assistance for those with severe permanent disabilities and solve the problem of awards being dissipated, eventually leaving the injured party relying on the public system.
Drawing together medicine and law
The Review has made useful recommendations in relation to the
medicolegal system. Incorporating the study of legal issues into the
training for health care professionals (Report recommendation 8),
introducing a system of peer support for health professionals
involved in negligence litigation (recommendation 89) and
accrediting specialist health negligence lawyers (recommendation
94) are all worthy of further investigation.
Greater positive and cooperative interaction between law and medicine is a desirable goal. Both professions would benefit from greater understanding and appreciation of each other's workings. Often people injured during medical procedures say that their main reason for pursuing legal actions is to find out what went wrong.14 This suggests that many potential actions may be prevented through appropriate advice at an early stage. A key factor in this process is access to expert opinions.
The Review recommends a college-based system of encouraging high quality health professionals to provide expert opinions in medicolegal cases (Report recommendation 98). This type of system, along with appropriate legal training for medical experts, has been under review by the Australian Medical Association since last year. The existence of a pool of peer-recognised medicolegal experts available to give advice to plaintiffs, defendants and even the court itself may well have a positive effect on reducing litigation and delays inherent in the current system. Judges are keenly aware of the delays and costs attaching to civil actions and actively consider means to speed up their progress. The public interest is not served by lengthy delays and costly litigation.
In conclusion . . . it's inconclusive
|The Final Report of the Review has not lived up to its high expectations. It has identified and investigated issues and proposed recommendations which raise more questions than they answer. There is little real assessment of the financial effect of the recommendations or the impact on current medical practice. The focus is on providing information for more effective decision-making. The legacy of the Review will be even more extensive consultations and reviews to develop practical solutions to the problems it has identified.
* See: Tjiong RTT. The Professional Indemnity Review. A lost opportunity for reform. MJA 1996; 164: 371-374.
Authors' detailsAustralian Medical Association, Canberra, ACT.
Charlotta Blomberg, BA(Hons), LLB, Legal Advisor.
Reprints: Ms Charlotta Blomberg, AMA, 42 Macquarie Street,
Barton, ACT 2600.
© 1997 Medical Journal of Australia.