No-Fault Compensation Schemes A rapid realist review to develop a context, mechanism, outcomes framework

3 Structured Summary What do we want to know? At present in the UK, compensation for medical injuries can be sought through tort litigation, with payouts made through court or out-of-court settlements. No-fault compensation schemes (NFCSs) can provide an alternative method to redress claims resulting from medical injury. To inform consideration of an administrative compensation scheme relevant to birth injuries, we sought to develop preliminary theoretical frameworks describing the mechanisms that might influence engagement in such schemes and lead to improvements in outcomes for affected individuals and families. We conducted the first part of a realist review, which seeks to identify empirically and theoretically-based contextual, mechanism and outcome (CMO) configurations. We did not test the CMO configurations, so no causal claims are made. Thus, the findings should be read in this light, and should not be interpreted as definitive evidence that the CMO configurations presented below do influence engagement or outcomes. What did we find? We drew on 44 papers relating to medical and non-medical injury, to present a summary of possible mechanisms entailed in no-fault compensation and tort reform that are thought to lead to patient and clinical practice outcomes (see Table A). Table A: Context mechanism outcome configurations Outcomes Context and mechanism potentially influencing outcomes Justice 1: Access to courts To make compensation schemes attractive to claimants, they must offer payment and broader eligibility criteria, to ensure schemes remain more appealing than the tort-based system. Justice 2: Equality of access NFCSs that are free to access improve justice outcomes in that they are accessible to all eligible parties, unlike the tort system, which favours those who can afford legal representation. Justice 3: Transparency of process Transparency of process achieves justice through the representation of the claimant, and mechanisms that improve the consistency of decision making through the use of medical experts and the consideration of precedents. Justice 4: Compensation decoupled from disciplinary procedures Creating a ‘Chinese wall’ between compensation procedures and disciplinary procedures enables improved access to justice and a more efficient compensation scheme, since physicians are more ready to hand over the relevant information. Clinical practice 1: Defensive medicine Tort reform and NFCSs reduce unnecessary tests and procedures and improve access to health care for patients considered ‘riskier’ by clinicians, because doctors are less likely to practise positive and/or negative defensive medicine to protect themselves from litigation. 1 A barrier that separates two or more groups, usually as a means of restricting the flow of information 2 Positive defensive medicine: when clinicians attempt to protect themselves by being over-cautious in their practice. Negative defensive medicine: restricting or denying care or treatment to patients considered too ‘risky’ by clinicians.