Impact assessment

Death certification reform and the introduction of medical examiners: updated summary of impact

Published 15 April 2024

Applies to England and Wales

Impact assessments

This document provides an updated summary of the potential impact of the introduction of medical examiners and death certification reform in England and Wales. It builds on 2 previous impact assessments published in 2018 and 2022 and should be read alongside these:

1. An impact assessment was published as part of the death certification reforms consultation response in June 2018.
2. This was updated as part of the Health and Care Act 2022: combined impact assessments - see ‘Summary document and analysis of additional measures’ on that page.

The Department of Health and Social Care (DHSC) considers the 2018 English impact assessment, and Welsh impact assessment, as a sufficiently accurate assessment of the costs and benefits. This document seeks to provide updates, where appropriate.

Policy summary

The appropriate legislation permits NHS bodies in England and Wales to appoint medical examiners. The principal function of medical examiners is to scrutinise the medical certificate of cause of death prepared by attending practitioners.

Prior to amendments made to the Coroners and Justice Act 2009 by the Health and Care Act 2022, the policy was that medical examiners would be appointed by local authorities and local health boards respectively in England and Wales. This change was made so that medical examiners employed in the NHS system will have access to information in the sensitive and urgent timescales required to register a death.

Development of this policy

DHSC has developed policy over the past several years which aims to:

• provide a reformed system for certifying non-coronial deaths
• improve the quality and accuracy of medical certificates of cause of death (MCCDs)
• provide adequate scrutiny to identify and deter criminal activity or poor practice

The legal framework is set out in Part 1 of the Coroners and Justice Act 2009. Section 18 was commenced in 2019, sections 18A, 18B,19 and 20 were commenced in December 2023 and section 21 was commenced in 2018.

As part of this work, DHSC ran a consultation from March to June 2016 seeking views on the detail of the operation of the proposed reforms to the death certification process and draft regulations setting out the system within which the services would operate. The consultation document proposed the introduction of a unified system of scrutiny by independent medical examiners, hosted by local authorities, of all deaths in England and Wales that are not investigated by a coroner as set out in the Coroners and Justice Act 2009 and described how the government saw the new system working in practice.

DHSC published its consultation response in June 2018 and set out an approach to introduce a non-statutory medical examiner system by April 2019, where medical examiners were to be appointed within the NHS without the introduction of a fee. An impact assessment was published alongside the June 2018 consultation response, outlining 3 policy options and associated costings for England.

Option 3 outlined the impact of introducing a medical examiner system hosted within the NHS. Since the publication of the 2018 consultation response and impact assessment, a non-statutory medical examiner system has been set up within the NHS in England. To date, all NHS trusts which require a medical examiner office (based on number of deaths) under a statutory system have done so on a non-statutory basis. 

The Welsh Government published an impact assessment for Wales as part of its consultation outcome. See Introduction of the medical examiner role and reforms to death certification: estimated medical examiner costs for Wales.

We had planned to provide an updated impact assessment when laying regulations for the fee mechanism. However, the medical examiner system will now be centrally funded and a fee regulation is no longer required. We are satisfied that the 2018 impact assessment contains all relevant analysis for the 3 regulations to be laid which put in place the centrally funded system.

Rationale for intervention

While the arrangements for scrutinising the cause of death have remained largely unchanged for over 50 years, there are concerns about their efficacy and efficiency, particularly for those cases that are not referred to a coroner. The statutory system was outlined in the Coroners and Justice Act 2009 after the Shipman Inquiry third report (2003) concluded that it was no longer suitable to have different certification processes for cremations and burials, and that all MCCDs should be subject to independent medical scrutiny.

The rationale behind the provisions in the Health and Care Act 2022 allowing NHS bodies in England and Wales to appoint medical examiners instead of local authorities and local health boards respectively, is that medical examiners employed in the NHS system will have access to information in the sensitive and urgent timescales required to register a death. 

DHSC will be introducing a medical examiner certification for the exceptional circumstances where either:

• there is no attending practitioner
• an attending practitioner is not available within a reasonable time

In either of these circumstances, the death is referred to the senior coroner by a referring medical practitioner (not a medical examiner) and the senior coroner decides not to investigate. In these circumstances only, the senior coroner should refer the case to a medical examiner to certify the death by completing a medical examiner MCCD.

Other policy options considered

An impact assessment was published alongside the 2018 consultation response, outlining 3 policy options and associated costings for England. The impact assessment outlined in this paragraph is England-specific.

The preferred option (and that consistent with the consultation response) was option 3:

Reform the current system for cremations and burials by introducing a new universal check by a medical examiner applicable to all non-coronial deaths. The system will initially be funded through cremation form fee revenues sourced from efficiencies in the system and DHSC. Following the interim period, the medical examiner system would be primarily funded through a fee for cremations and burials.

Costs and benefits

The impacts of the full statutory system for England are set out in the June 2018 impact assessment, and for Wales in a separate impact assessment which uses the same methodology, where policy option 3 set out the estimated costs and benefits of introducing a national statutory system of medical examiners based in the NHS. The national statutory medical examiner system set out at option 3 in these impact assessments is an accurate representation of the system (apart from funding solution).

The main policy change since 2018 is on funding. During the pandemic, cremation form 5 (the cremation form completed by the second doctor) was suspended, and funding for the non-statutory medical examiner system was provided by central government. In March 2022, the suspension of cremation form 5 was made permanent through legislation, and from that point forward funding for the medical examiner system in England and Wales will be provided centrally, rather than from a public fee.

Costs to business

As the June 2018 (England) impact assessment sets out in paragraphs 77 to 79, it is anticipated that any new net cost to business from implementing the statutory system would be minimal or zero. These included potential familiarisation costs for doctors employed in both the NHS and private sector to understand new procedures and establish contacts with new medical examiners, although those costs ought to be mitigated to a large extent as DHSC has not made significant changes to the MCCD itself.

In the 2018 impact assessment, we outlined that there may have been the potential for increased costs to funeral directors who must collect cremation fees from the bereaved on the behalf of doctors. However, central funding for the medical examiner system removes this risk entirely.

Minimal or zero costs to businesses are also expected in Wales from policy option 3.

DHSC has further confidence that there will be no additional costs to businesses stemming from this policy, as a non-statutory national system of medical examiner offices has been established from 2019 within the NHS in England. This means that the medical examiner system has moved away from the ‘do nothing’ option which was the baseline for the 2018 impact assessment.

Importantly, to date, all NHS trusts which require a medical examiner office under a statutory system have done so on a non-statutory basis. Moving from the non-statutory system to the statutory system is unlikely to result in further medical examiner offices being established, resulting in minimal set-up costs.

Updated costs

The June 2018 impact assessment for England outlined that the set-up and running costs of the statutory system will not fall on private businesses. The non-statutory arrangements currently in place in trusts reflect the arrangements that would be in place in the statutory scheme. 

The June 2018 impact assessment gave an estimated running cost (to DHSC and the public) of approximately £34 million to £41 million a year in England (using 2018 prices).

In the 2022 combined impact assessment, based on more representative and recent cost data, NHS England estimated that the cost of the medical examiner system would be £54 million for 2022 to 2023 (in 2022 prices), which is a public sector cost. Updating this, NHS England estimates that the costs are £56.5 million for 2024 to 2025 (in 2024 prices).

Economic costs for Wales are outlined in the Welsh impact assessment and were updated to provide a best estimate of £3.1 million a year. The updated estimate for costs in Wales are £4.3 million for 2024 to 2025 (in 2023 prices).The benefits of the scheme are not monetised and remain the same as outlined in the 2018 impact assessment (for England). These costs and benefits are for the statutory system as a whole and relate to the set of primary and secondary legislation which underpins it.

Conclusion

DHSC considers that our previous assessment of the costs and benefits of the medical examiner system published in the 2018 impact assessment for England, and Welsh impact assessment, remain sufficiently accurate for the purposes of estimating the costs and benefits of establishing a statutory scheme.

Once the statutory scheme has commenced, please refer to the previous impact assessments for the purpose of understanding the impact of the statutory scheme.