Malpractice, Vicarious and Entity insurances are commonly misunderstood in the context of Primary Care. This presentation seeks to demystify risk exposure and address common misconceptions regularly made by Practices, Vanguards, Federations and MCPs when reviewing their insurances.

1. Indemnity Protection: The Changing
Landscape Of Primary Care
Presented by Tristan Lennox-Gentle Cert CII, BA (Hons)

2. Introductions
Tristan Lennox-Gentle
Director, MIAB
Tristan.lennox-gentle@miab.co.uk
01438 730213

3. Agenda
• Introductions
• About MIAB
• GP Forward View
• Context of current models
• New care models
• Risk and misconceptions
• Bridging the gap
• Cover considerations
• Questions

4. About MIAB
MIAB was established in 2002, with the primary goal of being
To be the UK’s most trusted medical insurance broker
and this remains our Mission Statement to this day.
15 years on MIAB are proud to have…
• 40 staff
• 4500 policyholders across locum, surgery and
malpractice insurance products
• Approved supplier status to The LMCBGF, FPM
and others
• Close relationships with NHSE, PCPA and RCGP

5. The GP Forward View
The GP 5 Year Forward View recognises
that the delivery of primary care is
changing
Address key topics of workforce,
workload, infrastructure and care
redesign
Promotes consolidation and collaboration
Encouragement of more care delivery at a
primary level
Outlines the current care model as outdated
and in need of review
Ramifications for your business and its
insurances

6. Business Exposures – Common
Insurance Solutions
Negligence covered by
Malpractice Insurance
– for all allied healthcare
professionals and GPs
Entity covered by
Vicarious Liability –for
the business entity it’s
staff, their errors and
omissions and litigation
brought against the
business through the
actions of the employees
Sickness covered by
Absence Insurance –
for all clinicians, GPs and
practice staff in the event
of unforeseen absence
Asset preservation
covered by Practice
Insurance – Liability
insurance and indemnity
against the common
perils affecting the bricks,
mortar, contents and
turnover and breakdown
of equipment.

7. Context - The Old Model of Care
• Linear
• Simple
• Funding and contract provision was easily
understood
• One-dimensional
• Primary care reliant on secondary care for
everything except initial triage in most cases

8. Context - The Old Model of Insurance
• Clinical treatment administered by GPs and nurses only
• Defence union coverage was adequate in most cases
• Limited exposures – singular clinician involvement
• Purchased with the individual in mind, rather than the entity
• Insurance was simple!

9. The Impact of The Forward View
By 2020 NHSE anticipates that practices will federate/consolidate to just 1500 from
9000+ presently
Most practices can expect to experience a change in their business model in the next
few years
Traditional understanding of risk and exposure does not transfer to new care models
New role creation within primary care (pharmacists, ECPs etc.)
Multiple touchpoints in care delivery from within the entity
Secondary care now offered at a primary level

10. Emerging Entities
Prescribed by the Forward View, new
entities are forming and emerging, aided
by the right to tender for contracts by Any
Qualified Provider (AQP):
• Federations
• Vanguards/MCPs
• Provider Companies
• Private Companies
• Social Enterprises

11. Adapting Traditional Insurance to Future
Models
As with most things, evolution is both
necessary and inevitable.
In emerging entities policies for buildings,
contents, liabilities and sickness remain
necessary and traditional policies can adapt to
entity models relatively easily.
However traditional methods of malpractice
indemnity are yet to adapt to the changes
outlined in the Forward View.
New policies, designed to cover emerging care
models and their exposures, are now available
and are essential to avoid insurance gaps.

12. My GPs Have Indemnity, So We’re
Covered, Right?
In newly emerging care models it can
sometimes be hard to identify who is
responsible for negligence because of care
delivery being shared between many
clinicians. As a result a solicitor may take
action against one or all of the following:
• The GP
• Other involved clinicians
• The practice entity

13. Common Malpractice Misconceptions
• GP MDO cover extends always extends to
other clinical staff automatically
• Claims against the business are also picked
up by the treating GP’s MDO
• Clerical staff don’t present risk
• The wrongdoing is the employee’s problem
not the business’s
• The Surgery Insurance covers our business if
a claim was made against it
• My entity doesn’t directly employ clinical staff
so we have no exposure
• I’ll go to my MDO for cover for my staff
• What’s the worst that can happen?

14. GP MDO cover extends to other clinical
staff?
This is the most common misunderstanding we see at MIAB
MDO cover extensions often have a number of limitations:
• Nurse cover rarely extends to Practitioner or Prescriber roles for ‘free’
• Only offered to selected staff with low-risk duties
• Emerging allied healthcare roles are sometimes not covered
• Cover for the entity is usually very limited or not included at all
• Often a requirement for a group policy to be in force before cover extends to
other staff
• Varies by MDO

15. Claims Against The Business Are Picked
Up By The Treating GP’s MDO?
• Legal action follows the route of least resistance – this may not always be
against the GP
• MDOs rarely exercise discretion negatively but if they do, there is no
recourse
• In a federation or vanguard with multiple touchpoints, attributing failure
to just one clinician is much harder than in a traditional model
• Where other clinicians are involved, it is possible for an MDO or insurer to
resist acceptance of liability
• Only in exceptional circumstances will a GP’s MDO cover extend to the
entity. Providing this cover increases an MDO’s exposure so is rarely
provided in a GPs annual subscription for free.

16. Clerical Staff Don’t Present Risk?
Clerical staff are being asked to take on more responsibility outside of the
scope of their traditional role, but this creates risk:
Who is responsible for Janet on reception
if she...
• Passes the wrong GP advice to a patient
• Forgets to process a GP’s request for an
urgent cancer referral
• Discloses medical information to the wrong
person
• Triages the urgency of a patient’s
appointment request
• Incorrectly advises a patient of their blood
test result
What could happen if any of the above
went wrong?

17. The Wrongdoing Is The Employee’s
Problem, Not The Business’s?
Not true. This is known as vicarious liability.
Employers can be held liable for the actions of their
employees, even if the employer played no physical role
in the harm or action against a third party.
Employers are seen as directors of the employees
behaviour; the employees actions may be derived from
the instructions of business managers or simply as a
result of the culture of the company. If this leads to a
situation where a third party requires compensation,
the business ultimately becomes accountable.
If the employee is uninsured, the business is
liable.
Case law reinforces this position Mohamud v WM
Morrison Supermarkets and Cox v Ministry of Justice

18. The Surgery Insurance Covers Our
Business?
Many practice (commercial combined) insurance policies include legal cover,
however in 99% of cases this legal cover excludes malpractice and clinical
negligence.
Commercial legal protection has a very small limit of indemnity, usually a
maximum of £250,000. With claims regularly exceeding 7 figures for clinical
negligence, even if covered, a majority of the liability would still remain with
the practice.

19. My Entity Doesn’t Directly Employ
Clinical Staff So We Have No Exposure?
Contract services but don’t have employees?
Create protocol for others to follow?
Involved in organisation and structure of other practices?
Claims can be made against an entity with overall responsibility for failure of business
processes not under the direct control of the insured practitioner
Typical situations where Entity defence cover would be relevant, outside malpractice, would
also include:
• Identity Fraud in establishing that someone has fraudulently entered into an agreement
with a third party by representing themselves as the entity.
• Corporate Manslaughter in defending a prosecution brought under the Corporate
Manslaughter and Corporate Homicide Act
• Breach of Contract Investigations in defending a claim which alleges breach of contract
for goods or services provided.
• Pollution
• Regulatory – Health and Safety etc.

20. I’ll Go To My MDO For Cover For My
Staff?
We actively encourage the use of MDOs for individual GP indemnity.
However not all MDOs are ready to support the range of AHP roles in
primary care. Our customers have offered a range of feedback including:
• The premiums were disproportionately high
• The MDO didn’t fully understand the role
• Part of the core job role was excluded from cover
• They knew about individual exposures, but not those of the entity
It is therefore important to seek a range of advice, including from MDOs to
ensure you are appraised of your exposures and how to plug them.

21. What’s The Worst That Can Happen?
Joint and several liability is used to describe the proportional responsibility
of a partnership to debts, profit and contractual obligations.
The knot illustrates the complexity of a
partnership.
Each rope denotes a partner, with each
partner being integral to the knot.
Think about the knot in financial terms,
every profit is shared, but so is every loss,
all the way back to each partner.
As partnership liability is unlimited, personal
assets of each partner can be exposed if
there is a large uninsured loss and the
business cannot meet the award
It is critical that insurance is purchased to
protect the partners and the partnership

22. Bridge the Gap – Eliminate Risk
Regularly review all of your clinical indemnity for adequacy –
terms, limits, exclusions, renewal dates and providers
Remember claims can be lodged against both individuals and
the business. Is everyone insured, including all AHPs?
Consider a master policy which covers all staff and the business
Seek advice and guidance from experts; insurers, LMC, MIAB
Allocate time to think about your needs

23. When Arranging Cover Consider
• Consolidation of insurance by type via just one insurer to avoid doubt
over claims settlement
• Maximise economies of scale – merge separate policies for your staff
into one, akin to buying in bulk
• Minimise administration – create common renewal dates to trim
paperwork to only a few dates in the year
• Protect the entity and the staff – new care models create litigation
challenges for solicitors which are overcome by targeting the business
itself, protect it.
• Take ownership of insurance – reassure yourself and the business that
you have complete control over your cover and terms by taking over the
responsibility for arranging it from your staff.
• Incorporate all AHPs – these emerging roles present unquantified risk to
the business and need to be considered when buying insurance

24. Don’t Make Assumptions.
Take Advice.
01438 730213 www.miab.co.uk