Friday, January 27, 2017

Medical Indemnity: Protection or Compensation?

One of the (many) puzzling elements of the NMC anti-midwifery fiasco is the NMC's insistence that, by shutting down midwives whom they judge to have "insufficient" indemnity cover, they are thereby "mak[ing] sure that all women and their babies are provided with a sufficient level of protection should anything go wrong," and that they "had to act quickly in the interests of public safety."

This rhetoric strikes me as deeply misleading.  Indemnity cover is not a public safety issue.  Not only does it do nothing to prevent bad medical outcomes from occurring in the first place, it cannot even ensure in general that financial support is available when needed for increased caring costs associated with (e.g.) disability.  All that indemnity cover does for patients is ensure that greater compensation can be paid in a malpractice lawsuit -- a very rare and specific set of circumstances.

Indemnity cannot be relied upon to "protect" families "should anything go wrong" because it does not cover anything going wrong, but only things going wrong due to malpractice on the part of the medical practitioner.  If a baby suffers brain damage due to unavoidable complications, for example, indemnity will not help. For that, we need disability support as part of the general social safety net.

As it stands, indemnity cover (even at a level deemed "insufficient" by the NMC) increases the cost of obtaining an independent midwife by around £500 or so.  This can be expected to price out some women who would have preferred the superior care available outside of the overburdened NHS (even at the cost of reduced compensation in the unlikely event of a malpractice lawsuit).  As such, a legal requirement to have indemnity cover can actually be expected to lead to worse health outcomes in aggregate, as the added cost deprives some women of the opportunity for independent care, and adds to the demands being placed upon an already over-burdened NHS.

(And that is quite apart from the more general concerns about paternalism and patient autonomy noted in my previous post.  Even for those of us who can afford to pay extra for indemnity cover, it isn't at all clear what business the government has forcing us to do this.)

Given that it is really a matter of enabling compensation rather than ensuring protection, medical indemnity cover for private practitioners is not a public safety issue, or even a matter of legitimate public interest at all.  It should be up to individual practitioners and their clients to decide for themselves whether this is something that they feel that they want or need, and if so, to what degree of coverage.

It is certainly not so pressing and urgent a need that it can justify depriving a woman of her chosen midwife, with all the associated harms noted previously.


  1. I wouldn't say that requiring indemnity cover has literally nothing to do with public safety. If midwives need indemnity cover to be able to operate, then I imagine midwives with a history of bad outcomes would be driven out of the business by high premiums.

    1. Hmm, possibly, though I'm not sure whether premiums are priced separately for individual practitioners in that way. (Cover does not actually seem to be available for individual practitioners in the UK. Midwives are covered through their employer, and independent midwives through their organization IMUK. I suspect each such organization just has a single standard package, such that any pricing adjustments would be organization-wide rather than tailored to individuals? Not sure though.)

      I expect that there are more direct ways of detecting and addressing such problems, in any case -- that's the sort of thing that the NMC presumably exists for, rather than trying to outsource the job of maintaining public safety to insurers (though I can see how the latter might work in a more libertarian state with a more competitive insurance marketplace than we seem to have here).


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