Ethics

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Implementation of the medical examiner system

From April 2019 a new medical examiner led system will begin to be rolled out within hospitals in England and Wales. The non-statutory system will introduce a new level of scrutiny whereby all deaths will be subject to either a medical examiner’s scrutiny or a coroner’s investigation.

Reforms to how death is certified is long overdue and was originally proposed over a decade ago following various independent reviews and reports stemming from the Harold Shipman murders.

After many years of delays, the government announced the introduction of the new system in 2018. We have long supported the reforms and continue to engage with the government on the proposals and implementation.

 

Funding the Medical Examiner system

The government’s original proposals to fund the medical examiners system through Local Authorities has now been scrapped and medical examiners will be funded and employed through the NHS. Owing to this and other ongoing discussions on the public funding of the system, the government have decided to initially roll out the service within secondary care as a non-statutory system. In practice this means the medical examiner system will be introduced within hospitals alongside existing cremation processes and some of the fees paid will help to fund this.

 

How will the system be rolled out?

It is envisaged that once the ME service is established within a Trust, the system will then look to be extended to include deaths within the community/primary care. They have estimated around two years for this to bed in before primary legislation will look to be introduced to remove the existing cremation system and forms 4,5 and 10 and make the ME system statutory including introducing a new public fee to fund the system in its entirety.

The pace by which a Trust implements and extends their ME service will vary, some Trusts have become pilots or early adopters and have had a fully functioning service running for some time, others will take longer – the government are very much supportive of this approach to ensure each service is developed at the right pace.

 

How will the system be funded?

In the new system the medical examiner will complete the existing cremation form 5 and the fee paid will go into funding the ME roles alongside additional funding provided by the DHSC for all deaths requiring burial, child deaths and all costs associated with the setting up, recruitment and training of medical examiners and medical examiner officers.

As outlined in the government’s impact assessment the fee from cremation form 5 in addition to the DHSC funding should be sufficient to fund the ME system. Cremation form 4 and the MCCD will still be completed by the last treating doctor of the deceased and the fee should continue to be paid to the doctor undertaking this work if not part of the doctor’s existing contractual arrangements with the Trust.

Cremation 4 forms are often completed by junior doctors and, due to mortuary access issues in the out-of-hours period, are generally done during normal working hours. A number of employers allow junior doctors to continue to claim the fee for this activity by agreeing time-shifting arrangements. This practice should be allowed to continue. It should also be made clear to Trusts that where such fee-paying work is refused, and is instead expected to be part of the individual’s work scheduled activity, appropriate time must be allocated to allow this work to be completed.

It is important to however also be mindful of the GMC’s position on completing death certification and cremation forms, which highlights that where a clinician is responsible for signing a death or cremation certificate, they should do so without unnecessary delay.

Crematorium medical referees will also continue within their roles until the government legislate for the system to become statutory.

 

The Medical Examiner role

Some Trusts are, or in the process of, recruiting Medical Examiners and Medical Examiner Officers.

The medical examiner role will be employed by the Trust, but their reporting lines will be external and within NHSI – this is to ensure there is the appropriate level of separation required for the roles to remain impartial and objective.

The numbers of ME roles available will vary depending on the number of deaths per trust. We understand that NHS Improvement are developing models for trusts to help them financially plan the service and work out how many MEs will be required. These roles will be part-time and will likely be taken as part of a hospital doctor’s programmed activities. MEs will also have additional functions including reporting concerns of a clinical governance nature by following local reporting procedures.

For GPs the current arrangements for certifying death will continue until the ME system is set up and fully functioning within secondary care. The ME system housed in the trust will then look to expand its remit into the community. GPs are therefore not precluded from applying for an ME role for a Trust and experience working with primary will no doubt be welcome for when the system moves into the community.

All Medical examiners must be fully registered for at least five years as a medical practitioner, hold a licence to practice and have received special training in the role. The Royal College of Pathologists as lead college has developed the compulsory online training and is in the process of drafting standards to support the revalidation process.

Each ME will be assisted in their role by a Medical Examiner Officer (MEO) who will have responsibility for gathering information from different sources and preparing cases for scrutiny. Alongside these new roles a National Medical Examiner will also be appointed and is currently being advertised. This role will, similarly to the chief coroner, be responsible for overseeing all medical examiners and medical examiner officers and providing strategic and overarching guidance and direction.

 

What the BMA are doing

We continue to engage with DHSC and are pursuing further discussions with NHSI to ensure all doctors working as MEs receive appropriate pay and other relevant terms and conditions for the role. We’re also continuing to engage with DHSC about how the new system will impact on GPs once implemented. If you are considering taking on an ME role and you require support with your contract or terms and conditions, please speak to our BMA’s employment advisory service.

Further information including both ME and MEO model job descriptions are available on the RCPath website.