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Baroness Gardner of Parkes: My Lords, as I understand it this indemnity is just for professional negligence or failure to treat the patient correctly. It in no way indemnifies the general practitioners who will be left with all these debts after 1st April. I had a dinner-time conversation with a practitioner from

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Slough who is very disturbed at Berkshire Health Authority pushing all the debts on to the GPs' budget on 1st April.

When I first arrived in the UK and wanted to register as a dentist, the first thing I was told I must do was to join one of the protection societies--either the Medical Protection Society or the Medical Defence Union. Towards the end of my time in practice those bodies changed and, under one of the Finance Acts, had to become insurers. Their status changed, and unfortunately the premiums went up a great deal. As I understand it, they then became insurers in the same way as any other insurer. What control do the Government have over what such bodies charge practitioners? There has been a great increase in the cost of "membership", but it is indemnity insurance. We hear that in the United States, the indemnity cover of obstetricians is exceptionally high. In this country, certain practices may become high risk and insurers may ask more from them. Will the Government decide what the limits should be and how the system should be operated?

The Minister answered that everyone in a practice would be covered. Does that mean that no one practitioner in a GP group will be responsible for himself? Is it to be a joint practice insurance which will be taken out by individuals and will cover the people working for them? Can the Minister clarify that the care assistants, physiotherapists, counsellors and so forth who GPs are concerned about losing, will also be covered by the practitioners' insurance? I support the general principle of the amendment.

Lord Colwyn: My Lords, I, too, support the amendment. I must declare several interests: I am a dentist; I have indemnity cover; and I am a council member of the Medical Protection Society. I hate to answer on behalf of the Minister, but I can assure the noble Lord, Lord Clement-Jones, that there are different levels of indemnity for different risks in medicine and dentistry. My noble friend Lady Gardner does not have insurance, but is a member of a society which provides indemnity. It is not an insurance; one is a member of a society which takes care of its members if anything goes wrong.

The introduction of compulsory indemnity cover for doctors and dentists, providing NHS general practitioner services, is long overdue. It is an essential element in the protection of patients. Although the overwhelming majority of GPs subscribe to a medical protection organisation, the irresponsible few who do not must be made to comply. The definition of "approved indemnity cover" in the amendment is cast in broad terms. I venture to suggest that in order to maximise patients' protection, requirements should specify the need for occurrence-based indemnity cover, which I mentioned on Second Reading. Occurrence-based cover simply means that the doctor or dentist will be indemnified provided that he or she was in benefit at the time of the incident giving rise to the claim, no matter when the claim materialises. That may of course be years after the events in question.

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In medical cases, a claim usually occurs between three and five years after the event and in dentistry one or two years later. This cover should be compared with the usual insurance claims-made model in which both the events and claim must take place within the insurance period. Indemnity cover on a claims-made basis can, through administrative oversight or simple misunderstanding of the principle, result in patients being denied the compensation they deserve. At least one other country, Israel, is contemplating introducing a requirement for occurrence-based indemnity cover. I hope that the Minister and her advisers might consider a form of words which specified a type of cover. The mutual societies are occurrence-based, but if cover is provided by an insurance company, it is important to ensure that indemnity includes claims which have not yet been reported or claims which can arise when, for example, a GP has retired and is no longer paying a premium. I support the amendment.

Baroness Masham of Ilton: My Lords, what is the time in which patients or their relatives have to make a claim and who will adjudicate?

Baroness Carnegy of Lour: My Lords, the noble Lord, Lord Clement-Jones, covered all the points about which the British Medical Association wrote to me, so I will not reiterate them. However, I wish to ask the Minister a narrow question. Have the Government taken into account those who are not employees of the National Health Service or the universities, but who by virtue of their medical schools have employees working within the health service?

I ask that question because when I was asked by the local health authority and university to be chairman of the medical research ethics committee, I was tipped the wink by a friend to ask whether I would be indemnified if the ethics committee should make a decision which ultimately resulted in liability for damages. I made the inquiry and discovered that I would not be indemnified, nor would the other lay members of the committee. Therefore, I asked to receive assurance in writing that it would be the case and I did so. However, had I not been tipped the wink I would have run considerable risk during the four years of tenure. Can the Minister reassure us that people who are not employed by the National Health Service or by a university are indemnified?

Lord Nunburnholme: My Lords, will the Minister answer the question posed by the noble Baroness, Lady Masham?

Lord Blackwell: My Lords, it is difficult to disagree with the principle of the amendment, but I worry about the risk of escalating costs. If indemnity insurance is known to be available on these terms, that may encourage the escalation of the compensation paid. One then fears that such an escalation will lead to higher

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insurance premiums. Have the Government considered whether in making indemnity insurance compulsory they can prevent the escalation of large claims?

Lord Hunt of Kings Heath: My Lords, this has been an interesting debate. I will endeavour to answer all the questions that have been asked, but if not I shall write to noble Lords.

The noble Baroness, Lady Masham, asked how long patients have in which to make a claim. I understand that, generally, one has three years in which to make a claim for personal injury, but that can be extended in cases where the injury comes to light only at a later date. Then it would be three years from the time the injury became apparent.

A number of noble Lords asked about the potential liability outwith those employed in the NHS. The professional regulatory bodies--for example, the General Medical Council and the General Dental Practitioners Association--currently recommend that all practitioners should hold professional indemnity cover. If holding such cover were to be made mandatory for all dentists, the route to achieving that would not be through NHS legislation but through legislation concerning the dental profession. If the regulatory bodies concerned wish to take such a step, the order-making power under Clause 47 of the Bill would enable such provision to be made.

A number of questions were asked about funding. First, the charges made for indemnity cover are for market forces, but the number of practitioners who do not have indemnity cover is very small. Therefore, the additional cost to the NHS of that provision should be negligible. It is worth making the point that the cost of that cover falls to the NHS and not the practitioners personally. The cost of indemnity cover is a legitimate practitioner expense and so would fall to be reimbursed within the overall contract arrangements for GPs and dentists, as the existing arrangements made by the great majority already are. We believe that the cost will be marginal and certainly worth paying.

Perhaps I may deal with the point raised by the noble Baroness, Lady Gardner. To provide full protection for patients, the amendment provides for approved practitioners to hold indemnity cover which covers not just themselves--that is, the practitioners on the health authority list--but also claims made in relation to their assistants, deputies, employees and any auxiliary whose work they may direct.

The noble Lord, Lord Clement-Jones, raised the issue of primary care Act pilots. Those are covered by the National Health Service (Primary Care) Act 1997 and I can confirm that they are a Part I service. Health authorities are required by the direction of my right honourable friend the Secretary of State to contract only with providers who undertake to ensure that all their performers have indemnity against claims for negligence.

In dealing with the issue raised by the noble Lord, Lord Colwyn, perhaps I may refer to the issue of occurrence-based cover, which is a term used by

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providers of cover to indicate that they will still meet claims which arise from events when the clinician was covered that only came to light later, perhaps after the period of cover has ceased. Other forms of cover could be claim-based, whereby the claim must be made during the period of cover. Under the amendment, regulations would allow the Secretary of State to specify the type of indemnity cover which would be approved.

9 p.m.

Baroness Carnegy of Lour: My Lords, the Minister has not answered my question about people who are not employed by the health service or the universities and who are lay members. That may be, as in the example I gave, members of ethics committees and other bodies connected with the health service.

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