Dr. Tony Holohan:

I thank Senator Swanick. When we talk about lead clinician in this context we mean the most appropriate clinician in a particular situation. That does not always have to be the clinical director of an institution. It might well be the GP in a particular situation or it might well be another community based clinician who is not a doctor. It depends on who is in the position to know, understand and provide the information and to support a patient through that. If the incident is something that happens in a primary care environment then it is perfectly appropriate if the lead clinician is the person's GP. For its part, the Medical Council - probably more specifically than any of the other regulators - has set out its expectations of practitioners with regard to open disclosure and sees that applying to all registered medical practitioners. I may not have given a full response to Deputy O'Connell's question, but in a hospital the lead clinician may not always be the most senior person, who may not be available at evening time. If an incident occurs out of hours when it may well be more junior medical staff, it can still be perfectly appropriate for those to be the people who provide that information, if that is what the circumstances deem. It might be a situation where a senior clinician has to be called in. It would really be dictated by the nature of the incident and what the patient requires. Clearly, if it is a catastrophic or significant incident with life altering or treatment altering implications then a senior attending physician is going to be called to participate. It is reflecting the reality that from the point of view of a patient who is involved in institutional care and receiving care in a hospital environment, the person who is representing the service and speaking to them is the consultant in charge. That is what we are reflecting, but there is no reason it could not apply similarly in a community based or primary care setting with other professionals.

With regard to the soaring insurance costs, I cannot honestly give the committee an account of what each of the individual insurance providers would say themselves, but my general sense of insurance providers - and it is along lines of what has been said by Dr. MacLellan about the State Claims Agency being the largest indemnifier in the State but not the only one - is that a good standard of open disclosure is the right thing to do and actually leads to a reduction in terms of the risk of future liability. When these kinds of things occur it is less likely that patients whose trust and confidence in providers is maintained through incidents when things go wrong are actually capable of understanding and it does not always end up in litigation. Although there is not a lot of evidence around this, some of the international evidence suggests that engaging in this way can lead to a reduction in future litigation which one would expect to see having a deflating impact on indemnity costs.