Published: 03/02/2005, Volume II4, No. 5941 Page 31

As a GP, providing medical advice to relatives or friends is very difficult. It is hard to get the balance right and there is a tendency to be overly cautious or reassuring. However, such patient-based conflicts of interest are an inherent part of family practice as we often live and work in the same areas as our patients (and families).

Because of the independent contractor status of GPs, conflicts of interest may also affect other aspects of general practice.

For example, as a dispensing GP I worry about the link between profits and prescribing. Are patients with sore throats more likely to be given an expensive antibiotic if such an antibiotic is nearing the end of its shelf life in the practice dispensary?

As a result of fundholding, general practices were permitted to use some of the allocated healthcare budget to extend their premises.

Years later, some former fundholding GPs are now retiring with healthy lump sums.

As commissioners, a number of GPs were more likely to provide a wider range of services themselves.

This may be appropriate in some circumstances, but there are others where it is inappropriate.

For example, if skin cancers are treated using poorer surgical techniques or with lower use of pathology services than in a specialist setting, there is a need to be confident that patients are not being short-changed.

Likewise, some GPs persist in using rigid sigmoidoscopy as a screening test for bowel cancer in patients with rectal bleeding. This is in direct conflict with national guidance recommending flexible sigmoidoscopy - which unfortunately requires more infrastructure, equipment and training.

The great strength of the recent guidance on practice-based commissioning is that it seeks to pre-empt some of the potential conflicts of interest. There will be a requirement for needs assessment and multi-professional service planning and any savings derived from the indicative budgets held by practices will only be used for patient services. Approval will have to be sought from the primary care trust board following a recommendation by the professional executive committee.

With a plurality of potential healthcare providers, including the independent sector, the commissioning guidance also makes it clear that the PCT and the strategic health authority have a key role in ensuring that patients 'do not feel unduly pressurised to choose the practice as a provider'.

This principle is further underpinned by an explicit commitment to quality assurance.

PCTs will have a key role in ensuring that proper clinical governance procedures and appropriate standards for the services provided or commissioned are in place. Such governance arrangements should apply to the planning as well as the delivery of services.

The one major problem with practice-based commissioning remains the role of the PCT. Putting aside concerns about managerial capacity and capabilities, PCTs also suffer from conflicts of interest as service providers.

Currently, they can directly deliver primary care clinical services and, interestingly, community hospitals are now defined as 'PCT-managed' institutions. If PCTs are to become effective regulators of practice-based commissioning, as well as enhancing their skills they need to be divested of any residual provider responsibilities.

Nick Summerton is a GP and PCT medical director.