Health Service Trusts are financially responsible for the costs of defending and settling all medical negligence claims brought against them.

Increasing demands on limited resources have prompted reviews of the management of clinical claims and a number of trusts have discovered that some aspects can be as effectively carried out in-house as by the trust's lawyers.

An increasing number of trusts are now successfully managing many smaller claims with little or no legal support.It is frequently difficult to pigeon hole claims or complaints as 'small' or 'large' in the early stages.

It may be possible to estimate the cost of the claim but, from the trust's point of view, all claims should be properly investigated before deciding on 'size' and 'complexity'.Most cases begin with a letter before action setting out the reasons why the patient thinks that he or she has a claim for medical negligence and requesting disclosure of the medical notes.

The response of the trust is to gather facts and seek medical opinion on the nature and the potential liability of the case.

An experienced claims handler should be able to undertake this stage with little or no reference to a lawyer.

The benefit of conducting this stage of the process in-house -- in addition to reducing costs -- is in gaining the co-operation of hospital staff and allaying their fears.The experience of most claims managers is that clinical staff do not distinguish between large and small claims.

Any claim or complaint is taken as an attack on the individual's credibility and character and staff require much persuasion to consider the claim objectively and provide a factual summary and a considered opinion.

This can be better achieved by direct liaison and discussion with the claims handler than via letters between staff and the trust's lawyers.It is a matter of experience and judgment to identify which claims can be effectively handled without legal advice.

In my own practice these claims typically fall into the following groups: small value claims for which liability is not in dispute (simple settlers); claims for which the patient's story is unrealistic and/or inaccurate and the medical opinion is that there is no evidence of poor care, ie it is the view of the hospital that once the plaintiff sees the story from the records the case will be dropped; and claims for which the trust may be liable but for which the cost is up to £5000 (the current limit for ex gratia payments without legal advice).The next stage can take one of two routes: either simple disclosure of records with or without a medical opinion or an attempt to open up negotiations directly with the patient, if legally unrepresented, or with the lawyers, if represented.

I try to ascertain what it is the patient is seeking.

Sometimes, a simple apology and recognition of failure is all that is sought.

Other patients are driven by monetary gain and others fall in the spectrum in between these two.I have found an increasing number of plaintiff lawyers who are pleased to have the opportunity to discuss cases directly, to ask questions for clarification and to seek ways of resolving the question of whether there is a genuine case.

Such discussions on a 'without prejudice' basis can save both the hospital and the plaintiff considerable time and expense.I attempt to reach an economic settlement as swiftly as possible where there are undisputed facts pointing to a lapse in clinical care.

If appropriate, I may offer the patient the opportunity to see an independent doctor at the trust's expense so that an objective assessment can be carried out.

This is akin to a 'one expert' system but I have found it to be welcomed by a number of plaintiffs.I may turn to the trust's lawyers for an estimate of quantum, with relevant reports to back it up.

These I offer to the plaintiff or the legal representative during the course of the negotiation.

And, for a plaintiff in person, I will suggest that some legal advice be taken on the settlement offered and will offer to pay costs of that review.In-house handling is the desirable way forward for skilled claims managers who have been properly trained and are supported both in house and by the trust's lawyers.

The following are prerequisites for successful in-house claims handling.-- A trained, experienced, confident claims handler with training in medical litigation, complaints procedures, and negotiation skills.-- Medical staff and trust manager who are willing to accept the principle of in-house negotiation and settlement.-- Effective team working between consultants and claims manager for case discussion and meetings with patients.

-- Willingness to use 'in house' or independent experts.

We have found a second opinion to be very valuable in reducing both large and small claims.

A small cost to the trust can reduce subsequent potential costs of 'no hopers' dramatically.

-- Confidence to know when to call in legal help either for advice or to hand over the file.

The following prompt me to seek advice: when loss of earnings is claimed, when causation is complex, when professional reputations are at stake, and cases involving psychological claims, eg post traumatic stress disorder