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Inside Medical Liability

Third Quarter 2021

 

Changing Environment Challenges U.K. Healthcare, MPL

A Conversation with Christine Tomkins, MD

 

In September, Christine Tomkins, MD, will be moving from her role as chief executive of the Medical Defence Union (MDU) into a new position as strategic advisor. Inside Medical Liability recently talked with her about her time at the MDU, her view of the changes in healthcare, and how COVID has altered MPL in the United Kingdom.

IML: What inspired you to become a physician?

Tomkins: When I was young, I often visited my cousin, who was a medical student. He was, and still is, an enthusiast for the subject, and when I was about 10 or 11 years old, he let me look at his books and models of skeletons. I think that’s where I first got the idea that medicine was for me. I enjoyed science at senior school and wanted to do something that mattered to people and wouldn’t be boring. I had also noticed that the doctors in South Wales where I grew up were valued and respected members of the community. All these things set me on the path to being a physician quite early on, and gave me focus.

IML: How did you come to join MDU?

Tomkins: I practiced as an ophthalmologist for five years. Joining the MDU staff was a serendipitous accident.

I enjoyed ophthalmology—every minute of it. It’s a great specialty that combines medicine and surgery. Using surgical skills, you can make a dramatic difference to the quality of a patient’s life and the medicine is often quite complex and interesting, offering enormous job satisfaction. I’ve never lost my interest in ophthalmology—I remain a fellow of the Royal College of Ophthalmologists, and I keep up my contacts with my ophthalmology colleagues.

One day I saw an ad in the British Medical Journal for the role of a medico-legal advisor and a clinical negligence claim handler at the MDU. I was curious so I rang the MDU and Dr. John Wall answered—he later became the chief executive of the MDU. A real enthusiast for the job and the organization, John showed me around the office, and I met some very impressive people. The atmosphere was engaging and I was attracted to the idea of doing something worthwhile, enjoyable and challenging. So I decided to take a short deviation, maybe six months or a year out of ophthalmology. It would, I thought, be an unusual and useful experience to add to my CV.

I got the job and when I walked through the door of the MDU, I found myself on a vertical learning curve. There wasn’t a day went by that I didn’t learn something—and honestly, it’s still like that now. The MDU is a great place to work and completely worthwhile. We’re helping members treat patients while relieving them of the stress of medicolegal problems. It’s a privilege to guide, support and defend fellow doctors, dentists and healthcare professionals, just as the MDU has done since 1885.

IML: What are the biggest changes you have seen in healthcare in the United Kingdom during your time at MDU?

Tomkins: Healthcare has changed almost beyond recognition from when I qualified more than 40 years ago. There have been so many changes, so I’ll just touch on a few.

I think the biggest change I’ve seen is the sheer extent of what we are now able to treat. Take myocardial infarction, for instance. Today, you can treat the patient at the first sign with clot busters and other therapies. Forty years ago, you could do almost nothing except to deal with their pain.

As treatments get more sophisticated, the potential to allege that a healthcare provider should have done something more or different arises, too. Patients have high expectations about what can be done; expectations that are sometimes misaligned with reality.

There has also been a complete change to how healthcare teams work together. The hierarchical structure of the past—doctors working with little intervention from other healthcare professionals—has almost disappeared completely. Now you have multidisciplinary teams with highly qualified healthcare practitioners all working together for the patient.

The emphasis on preventative medicine is also much greater than it was when I qualified, especially in primary care. Primary healthcare teams are screening patients, providing public health advice, lifestyle guidance, vaccines, etc. For example, primary care teams in the U.K. have been fundamental to the success of the nation’s COVID vaccine program.

The contract between doctor and patient has also altered. Years ago, a physician would recommend a course of treatment and the patient would simply say, “Do what you think is best.” Now, happily, there is much more joint decision-making and dialogue and a partnership between patient and doctor.

IML: How has the medical indemnity environment changed?

Tomkins: There has been a huge increase in accountability. When I first started, medico-legal problems were reasonably rare. Today, most practitioners will experience claims and complaints during their career.

There has also been an increase in the number of ways doctors can be called to account. In the U.K., from a single allegation relating to your clinical practice, you can face a clinical negligence claim, a disciplinary action from your employer, or from your regulator. If the patient died, you would have to account for yourself at an inquest before the coroner. You can also be accused of criminal action, and the media may take a huge interest in reporting on the allegations—but not, sadly, when you are exonerated.

There’s also been a massive change in the cost of clinical negligence claims. The idea that you would pay out vast sums of money to settle a negligence claim wouldn’t have crossed anyone’s mind when I qualified.

I remember the shock at the sheer size of the first million-pound claim in 1988. Today we hear of claims where payments over the life of a patient can reach £37 million. These sums would have been absolutely unthinkable only a few years ago. The rate of claims inflation has outstripped any other sort of inflation by a country mile. Society is starting to realize this is unsustainable and ultimately very bad for patients’ access to healthcare.

IML: What are some lessons learned from COVID in healthcare and in medical indemnity?

Tomkins: What we saw at the height of the pandemic was physicians going above and beyond— an ophthalmologist, for example, perhaps running an accident and emergency department because there was no one else available. Practitioners did their very best and bravely stepped up. But that same ophthalmologist may find they are being judged in the future by emergency room consultant standards, which is unrealistic.

We don’t know how the courts will find their way through this. I very much fear that by the time these claims come in, the real and very grim circumstances in which our members were practicing, to the best of their abilities while exposing themselves and their families to personal risk, will be forgotten.

What everyone learned is that our healthcare workers are amazing. This was a major test of their dedication and resolve, and they stepped up and made some huge sacrifices. We can all be very proud of the way healthcare workers in the U.K. responded.

We also learned we must keep innovating in medicine and do so at speed. In the pandemic, we changed delivery of healthcare in ways that might otherwise have taken 20 years to evolve. We shifted to remote consultations, physicians tried new treatments without years of clinical trials, COVID vaccines were developed in 12 months. Some advances achieved were little short of a miracle, in my opinion. We need to keep and build on what we have learnt in the pandemic.

At the MDU we were able to flip over our entire workforce to home working literally overnight, without a blip in our service to members. This was important because our members needed seamless, quick and supportive service more than ever in the pandemic. Guidance and novel clinical situations came at them left, right and center, and they needed our help finding their way through it.

We also found we could reach a great many of our members with webinars and online educational programs. We will definitely go back to personal face-to-face service but our ability to get medico-legal information and clinical risk management advice to members has been much enhanced by online programs.

Another lesson learned was that we need to concentrate very hard on healthcare professionals’ well-being. They have been through the fire and burnout is to be expected—we can’t ignore it and must look after them. On top of this, getting a claim is a very stressful event for doctors, dentists, and other healthcare providers. They may become depressed, their relationships with their families and their colleagues may suffer and they may lose enthusiasm for their work.

This pandemic has left them in a fragile state. Add a claim to that and it's adding insult to injury. That is why we have been campaigning hard for healthcare professionals to be exempt from COVID related claims.

And will there be complaints and claims? Yes. There is a huge backlog of patients who need treatment—in the U.K. we have over five million people waiting for treatment. These patients haven’t been able to get the diagnoses and the treatments they need, because we’ve had all hands to the pump for COVID. Patients will have suffered damage as a result of that delay and there will be claims.

Getting over the backlog is going to require a fighting fit National Health Service (NHS) and workforce. There is still much uncertainty about COVID and we have a workforce who have taken a battering. They are frightened and worried about the claims that could arise. The risk is that we’ll lose them from the profession.

IML: What challenges do you see now in the post-pandemic indemnity area in the U.K. and in the global market?

Tomkins: We are trying to tell those who are responsible for our laws that there is a good case for COVID claims exemptions and, indeed, for complete tort reform. For NHS hospitals in England alone, the bill for known claims and events that have happened and will turn into claims is about £83 billion. That’s an unimaginable sum of money coming directly from funds meant for frontline delivery of healthcare. We are told that a consultation on tort reform may be emerging soon from the Department of Health and Social Care, so we may be making some progress. I very much hope so.

The irreversible digitalization of medicine is another challenge to which we will all have to adapt. It changes the social contract with patients, it impacts on the stresses of the job and the risks for doctors and patients. We also need to look at how international boundaries are breaking down. We need an international solution so patients can reap the benefits of dissolving borders and greater delivery of remote care.

IML: What is the recipe for success for medical defence organizations in the coming years?

Tomkins: Our aim, at the heart of everything we do, is to look after members. Guiding, supporting, and defending our members is, and always has been, what it’s all about. All change still takes us back to looking after our fellow doctors and dentists and the wider healthcare team. We will continue to listen to what they want, adapt to what they need, make sure we’re thinking ahead and adjusting to changes in the political, legal, and medical environments so we help our members do what they do best—caring for patients.

We must provide members with the absolute highest quality of service. Whether members phone us on a regular day or just after the country’s gone into lockdown and everyone has been told to work from home, we must ensure that the phone is still answered in 20 seconds, and the person who answers is a technical expert who will give you the answer you need—but will also be empathetic and kind when your professional practice is being challenged. The quality of that service to members is key.

Of course, you have to get your underwriting right, the basics of running an organization, making sure you have the right talent, the funds to provide the services for members and so on. But it basically boils down to what we’ve always done—putting our members first.