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Assessing and credentialing standards of care: the UK Clinical Negligence Scheme for Trusts (CNST, Maternity)

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The Clinical Negligence Scheme for Trusts (CNST) provides NHS trusts with a set of risk management standards for maternity services. These standards are designed to act as a framework, bringing focus to the clinical risk management procedures adopted by maternity services, and to contribute to the development and implementation of clinical governance, thereby improving patient care. Both the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) have endorsed the standards because of their potential to benefit clinical care. By improving clinical risk management procedures within maternity units, the standards are ultimately intended to reduce the level of clinical negligence claims. Assessments against the CNST Maternity Clinical Risk Management Standards are currently conducted by Det Norske Veritas Ltd (DNV) on behalf of the NHS Litigation Authority (NHSLA) to ensure that members’ contributions reflect their standards of clinical risk management. Although the claims data have not been collected on a consistent basis and are too immature to provide conclusions in an area notorious for its long tail, it does indicate that there has been a fall in the number and cost of maternity claims as a percentage of total clinical negligence claims reported to the NHSLA since the inception of CNST. This chapter examines whether there is evidence that the standards have had a measurable effect on clinical negligence claims.

Section snippets

What is CNST and why was it set up?

The NHSLA is a Special Health Authority which was established on 20 November 1995 to indemnify NHS bodies against claims for clinical negligence and to administer CNST. The NHSLA is not an insurance company; it manages CNST, a mutual risk pool which is run on a pay-as-you-go basis whereby each year sufficient money is collected from trusts to cover the payments made during that year on claims arising from incidents since 1st April 1995. In April 2002, responsibility for managing all clinical

Current CNST maternity clinical risk management standards

The assessment is divided into eight risk areas or standards, each of which comprises a number of criteria. The standards, which are designed to be measurable and achievable, are: organization; learning from experience; communication; clinical care; induction, training and competence; health records; implementation of clinical risk management; staffing levels. The standards cover a range of both reactive and proactive risk management systems and processes, and each standard is set at three

Contribution setting and discounts

Each trust's CNST contribution is determined using actuarial techniques based upon a range of factors, such as size and type of trust, specialities practised, claims experience, numbers of staff etc. Since April 2003 CNST contributions have been split between maternity services and all other clinical activities. The contribution calculation for maternity includes the number of births, and a trust will earn discounts from each part of the contribution (maternity and ‘other’) in accordance with

The future of CNST risk management

Trust assessments against the CNST General Clinical Risk Management Standards ended on 31 March 2006. New acute standards incorporating organizational, clinical, and health and safety risks have been developed to replace both the CNST general assessment and Risk Pooling Scheme for Trusts (organizational and non-clinical risk) assessment and have recently been piloted. Separate standards and assessments are being retained for maternity services, and starting in 2007/08 the process of revising

Summary

Based on the need to reduce significant clinical negligence costs, the CNST Maternity Clinical Risk Management Standards have provided trusts with a framework to assist in achieving effective systems and processes to manage clinical risks in maternity services. This broad approach has involved establishing continuous proactive and reactive risk management initiatives to provide lessons to be learned and acted upon, affording the potential to improve patient safety and service provision.

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