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Conflict of interest: how it all arose

Dr James Kingsland, NAPC president and PBC champion, explains the background to the dilemma of conflict of interest.

Dr James Kingsland, NAPC president and PBC champion, explains the background to the dilemma of conflict of interest.

Fear is often born of ignorance, and that is certainly the case with some of the misunderstandings about conflicts of interest in PBC. After all, resolving conflict is merely a part of good risk management. So let's clarify.

GP practices, with their central co-ordinating function, have a major influence on what care a patient receives and how a patient exercises choice. Before PBC, there was no need – with the exception of prescribing – for GPs to consider how their patients were using health service resources and no financial mechanism to secure better and more innovative services for their patients. The aim of PBC was to change this.

GPs have always directed the flow of resources through referral and prescribing activity. They are inherently both providers (through their primary care contract) and commissioners (through their referrals and the unscheduled activity of registered patients). PBC actively encourages these clinicians to make better and ideally fewer referrals, prescribe in the most cost-efficient ways and improve urgent care.

It does this by focusing the primary care team on the provision of a wider range of services and extending patient care in the community. It allows the upskilling of primary care and the expansion of the multidisciplinary teams available to the registered population, providing diagnostics, preventive care, extended ‘in-hours' availability and reduced hospital admissions and lengths of stay. As a consequence the practice ‘makes' more and ‘buys' less, keeping NHS resources within the practice budget, while new services may be funded by extending existing primary care contractual arrangements.

GPs are extending care for those patients who choose to be registered with their practice, and demonstrating the benefit of list-based care. There should not therefore be any conflict of interest.

However, some practices – largely promoted by frustration and a lack of progress with PBC – have started to focus on a new style of practice-based provision and to compete with existing community or hospital services for an unregistered population. These are largely for-profit developments creating new income streams for practices or PBC consortiums (or their commercial partners). These are contestable and need to comply with national choice and competition rules.

In the main, these new-provider services are for elective care for which the PCT should act as a local approver, granting permission for any willing provider (that meets quality standards) to operate in their area. Contracts for these should set out quality requirements but give no income or activity guarantees. Tendering should therefore not normally be required. Only where an unavoidable monopoly would be created should tendering be necessary.

PCTs should monitor these services and ensure patients referred to such a provider service, in which the practice or consortium has a vested financial interest, have been given unbiased choice and information about the financial stake of the referrer (in a similar way to what health authorities used to do for old GMS ‘red book' claims). This should, once again, be part of local governance arrangements.

More detailed instructions are set out in PBC Practical Implementation, published in November 2006, which remains the most recent formal operative guidance and was developed to clarify and strengthen the governance and accountability arrangements to avoid conflicts of interest.

Anyway, life would be dull without a bit of competition and conflict. It put the ‘fun' in fundholding and the same goes for PBC.

Dr James Kingsland is president of the NAPC and a member of the DH's PBC improvement team

Dr James Kingsland Dr James Kingsland

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