Identifying, disclosing and managing conflicts of interest will help prevent the risk of issues coming back to haunt you, advise Jonathan Hayden and Ben Troke.
There are differing views on the subject of conflicts of interest for clinical commissioning groups. For some this is a real worry, threatening to undermine the doctor-patient relationship; for others, conflicts mean just a few procedural hoops to jump through. To some extent both are right, but it does depend on the type of conflict you mean – and a perception of bad faith can be as poisonous as the reality.
There are probably two main types of conflict that will arise: the first in the CCG boardroom where decision makers may have an interest in a commissioning decision; the second in the consulting room, where an individual doctor may have an interest in a decision about referring an individual patient.
Although simplest to explain in terms of money, conflicts of interest are not necessarily financial. They can affect any role or relationship the public perceives to be able to impair or influence an individual’s judgement or actions.
CCGs will control about £60bn of the NHS budget. Given the focus on services being provided in the community, it is possible companies in which GPs and other CCG members have an interest will want to provide services commissioned by the CCG.
If Dr Smith is on the governing body of a CCG and, after a procurement exercise, that CCG decides to accept a bid submitted by Dr Smith’s company, unsuccessful bidders will take a close look at the integrity of the decision-making process. Of course, this isn’t just about management of conflicts. The CCG must also make sure its procurement processes comply with relevant legislation, policy and guidance. The Any Qualified Provider initiative may help here (at least at CCG level).
Equally, if Dr Smith’s practice decides not to refer a person for a particular treatment, it will be vital to show the decision wasn’t motivated by a desire to increase the practice’s share of any “quality premium” payment the CCG might attract and then decide to distribute among member practices. The Royal College of General Practitioners has expressed concern about the impact this could have on the doctor–patient relationship.
If Dr Smith is making a referral and the options are provider A and provider B, it will be essential for him to disclose any interests he has in either. At an individual level, although GPs have always had a wider duty toward equitable allocation of resources, their first concern was always their patient and General Medical Council guidance has always reflected this. It is less straightforward for doctors to play the role of patient advocate when they can no longer fight the patient’s corner against a (non) funding primary care trust but, instead, effectively become the CCG’s advocate to the patient. The CCG will, presumably, need to have robust policies in place to ensure a common approach.
Any tension at practice level is unlikely to ease as resources tighten while need, demand and expectations continue to grow. Dealing with these conflicts at all levels needs common sense, clarity and good communication.
It is always better to anticipate or disclose a conflict and deal with it before any decision is made, than to try to unpick the decision later. The perception of a conflict can be as damaging as an actual conflict. If unsure, it is better to assume a conflict exists. The perception of wrongdoing will be more difficult to dispel if the conflict comes to light subsequently or reluctantly.
CCGs will need to specify in their constitution how they will manage conflicts. The NHS Commissioning Board offers guidance on identifying, declaring and managing these. In brief, CCGs must proactively seek declarations of interests and ensure any arising interests are disclosed at meetings. They should record all interests in publicly available registers of interests and manage that interest.
Open and upfront
This may mean excluding the person with the conflict from relevant meetings and decisions (the model constitution suggests some workarounds where this causes problems with quorum).
For individual GPs the same principles apply. They must be open and upfront with patients about any interest they have in a company to which a referral is an option. “No decision about me without me” means giving the patient all the relevant information. If in doubt about whether to tell them, GPs should ask themselves how they would feel and react if they learned of the interest after treatment by the company in question.
GPs must be as open as possible about how decisions are made to commission in general, and the need to assign resources fairly and cost effectively.
The authors will be speaking at the Commissioning Show on 25 June.