Are you suitably protected?

As practice nurses' autonomy increases, so does the risk of litigation — but as they are usually employed by GP partnerships, practice nurses do not have NHS indemnity. Kate Taylor, Clinical Risk Manager at the Medical Protection Society, outlines the changes to nursing roles and the need for professional indemnity

The role of the practice nurse and nurse practitioner has developed and evolved over the years as they take on more extended roles. One of the concerns is that as nurses' autonomy increases, so does the risk of litigation. Nurses working at an advanced level manage their own workload and work across professional, organisational, agency and system boundaries to improve services and develop practice. Nurses in primary care are usually employed by a GP partnership and therefore do not have NHS Indemnity.

NURSE INDEMNITY

EU legislation on professional indemnity insurance is anticipated to be adopted by the UK government by the end of October 2014.¹ This will make it a legal requirement for nurses and midwives to have an indemnity arrangement as part of their registration with the Nursing and Midwifery Council (NMC).² Many nurses working within general practice will have professional indemnity arrangements in place with their employer; however, it is the professional responsibility of each nurse to ensure that they have sufficient protection in place to reflect the risks associated with their scope of clinical practice.

Changes to the Royal College of Nursing (RCN) indemnity arrangements in January 2012 have affected many nurses employed in general practice as they withdrew indemnity cover for work carried out under a practice nurse's contract of employment.³

TYPES OF INDEMNITY ARRANGEMENTS

There are different ways of arranging professional indemnity for nurses working within general practice, mainly:

Arrangements made by a GP partnership or other employer

Often, indemnity is arranged by a GP practice, either as a benefit of membership with a medical defence organisation (MDO) practice package, or less commonly under a policy purchased from a commercial insurer. Where a number of GPs belong to an MDO, nurses and other healthcare professionals may be offered free membership. Nurses undertaking extended roles are usually charged an additional subscription. While such arrangements will provide access to indemnity in the event of a claim, they will not usually provide professional support and advice for the nurse him or herself, for example where a nurse faces a disciplinary hearing or a complaint to the NMC.

Individual indemnity arrangements

Nurses who are unable to access membership benefits including indemnity via an MDO practice package scheme, or who wish to ensure personal access to professional support and advice may join an MDO such as the Medical Protection Society or approach a commercial insurer. This is likely to provide access to professional support and advice for the nurse, for example if a nurse was to face a disciplinary hearing or complaint to the NMC. This option is especially relevant for nurses who wish to have access to indemnity for work performed outside their main practice.

WHAT ABOUT VICARIOUS LIABILITY?

Vicarious liability is a legal principle through which an employer can be held liable for the actions of staff. This means that GP partners employing a nurse can generally be held liable for any claims arising from the nurse's negligence. As a result, most claims brought by patients are directed against the practice, rather than against an individual nurse. While many nurses will be protected against the financial cost of claims through their employer in this way, it is not always safe to assume that a GP's personal indemnity arrangements will make provision for their vicarious liability. Nurses relying on an employer's indemnity arrangements should check that they are included.

EXTENDED ROLES FOR NURSES

As patient care increasingly shifts from hospitals to primary care, the role of nurses working in general practice is ever changing. There can be an expectation that nurses will take on additional responsibilities and exercise increased autonomy, ranging from chronic disease management clinics, nurse triage, family planning and immunisations alongside the introduction of the advanced nurse practitioner role and independent nurse prescribing.

The NMC Code of Conduct (2008) is clear in its guidance for nurses:

• You must have the knowledge and skills for safe and effective practice when working without direct supervision
• You must keep your knowledge and skills up to date throughout your working life
• You must deliver care based on the best available evidence or best practice
• You must ensure any advice you give is evidence based if you are suggesting healthcare products or services4

Examples of extended skills might include:

• Prescribing
• Contraception and HRT management including prescribing
• Triage
• Minor illness or minor injury clinics
• The insertion and removal of contraceptive implants
• Anti-coagulation therapy — including the management and dosing of warfarin

Nurses undertaking advanced roles will be aware of their individual professional responsibility to ensure that they are properly trained and competent, and to seek advice or refer to a GP where issues arise outside their own sphere of clinical competence.

What is perhaps less understood is a nurse's professional responsibility to ensure that he or she is adequately indemnified for their work. When applying to join the NMC register or renewing registration, nurses and midwives are required to complete a self-declaration of fitness to practise. It is vitally important to understand that by signing this self-declaration, nurses and midwives have specifically declared that whenever they practise they will ensure that an indemnity arrangement is in place.

All nurses, particularly those undertaking advanced roles, should be wary of signing the declaration without being sure of their indemnity arrangements.

INDEMNITY ARRANGEMENTS FOR HCAs

The general principles discussed above will also apply to healthcare assistants (HCAs), who provide invaluable support to nurses and GPs in primary care. Since HCAs are not registered nurses, they do not have an explicit responsibility to make indemnity arrangements. However, GPs and nurses delegating tasks to HCAs must ensure that adequate indemnity is in place. As with primary care nursing, the HCA role has developed over time and many HCAs have undertaken extensive training locally at national vocational levels to undertake patient measurements, phlebotomy, ECG recording, new patient checks and, in some practices a limited range of vaccinations/immunisations and basic ear care. Indemnity is often accessed as a benefit of membership of an MDO practice package scheme; however it is important to ensure that the practice informs their MDO of any extension to HCA roles as partners will retain vicarious liability.

CONCLUSION

General practice nursing will continue to develop and evolve and nurses working in general practice will find themselves working more autonomously. This may increase the risk of litigation; therefore, they must ensure that they have suitable professional advice and support as well as adequate professional indemnity arrangements.

REFERENCES

1. Health Care and Associated Professions (Indemnity Arrangements) Order 2013

2. NMC Registration

http://www.nmc-uk.org/registration/

3. RCN Indemnity Scheme

http://www.rcn.org.uk/support/legal/indemnityscheme

4. NMC (2008) The code: Standards of conduct, performance and ethics for nurses and midwives

http://www.nmc-uk.org/Documents/Standards/The-code-A4-20100406.pdf

5. NICE (2008) National clinical guidelines for management in primary and secondary care.

http://www.nice.org.uk/nicemedia/pdf/CG66diabetesfullguideline.pdf