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Debunking conflict of interest myths

NHS Alliance chief executive Mike Sobanja says the problems are more perceived than real – and some golden rules can go a long way towards solving them

NHS Alliance chief executive Mike Sobanja says the problems are more perceived than real – and some golden rules can go a long way towards solving them

Is there still confusion over conflict of interest?

The issues are slowly becoming clearer and that is largely because of the most recent publication from the Department of Health, Clinical commissioning: our vision for practice-based commissioning.

That said, clinical commissioning and provision should not be seen as conflicting roles but as part of a more sophisticated interplay that involves deploying resources and designing services to best meet population and patient needs.

The vision also warns that robust governance has too often been mistaken to mean drawn-out approval processes or open tendering for all services, partly because of ‘simplistic views about commissioning and provision'. The document advises greater use of the any willing provider model, which would avoid many of these perceived problems.

So I think the direction of travel from the DH is that we don't seek to remove the conflict of interest, we identify where it is.

I think that's the right approach; in my view it is impossible to remove the conflict of interest.

What has been the main sticking point?

People have to separate in their own minds the commissioning responsibility and the provider responsibility. In the past I think some PBC groups submitted business cases to PCTs that tried to address commissioning and provision in the same document.

The problem occurs when people say we'd like to commission a service and our intention is to provide it – that's not terribly helpful. It's about having the right procedures in place. You need to decide to commission a service and only then consider the mechanism by which it's provided.

Also PBC has been an area where there has not been great clarity overall and that has led to confusion. If people on the ground have felt they have got to remove a potential conflict of interest and set off to remove it, they're not going to be successful – but it means a barrier to PBC has gone up.

How easy is it to disentangle commissioning and provision?

41225823I think it's very easy – I don't have a problem with it. GPs have been commissioning for years. The very act of sending a patient to secondary care is a commissioning act so you could argue they've always had this dual role and PBC has just brought it to the fore.

There are a couple of acid tests. If you're into provision, you're normally getting income from it. But if you're doing something which benefits a population, thinking about what the best services are but you're not necessarily going to provide them, that's the commissioning agenda.

The approach of PCTs to this issue has been variable. But people are starting to get a clear picture of this and hopefully the best practice will become the norm.

How have people dealt with confusion?

People have tried to deal with conflict by making a bigger issue out of it than it really is.

Others have put things out to formal tender every time they have wanted to commission a service, which is not required at all. They have gone to competitive tender instead of using the any willing provider model. Sometimes the bureaucracy has got in the way, and sometimes people misunderstand what commissioning is about.

What are the golden rules?

When you're making a proposal, you need to ask yourself whether you are doing it from a commissioning or a providing perspective. If you're doing it as a provider, that's not a commissioning view.

Locally there needs to be some probity-type system in place. I think PECs have a key role in advising PCTs and handling processes and that can be done through clear procedures for identifying and providing business cases.

You need to have people who are interested in developing PBC and have had a conversation with their PCT about conflict of interest from the beginning when there is no particular issue to solve.

You don't want to be dealing with this when there's a hot issue; you want to be dealing with it in the abstract.

Is there guidance available?

The most recent guidance from the DH is crystal clear and it is to be commended for its brevity. You don't want to urge the DH to write detailed guidance because, with the best will in the world, they're not doing it on the ground. The centre's role is to set policy and then step back. The more we will them to fill in the detail, the more it takes away from local activity.

Practice-based commissioners should be having mature conversations with their PCT about conflict of interest. If they are unable to solve these issues, they may want to speak to their SHA, but the main approach should be ‘let's sort it out locally'.

Mike Sobanja is chief executive of the NHS Alliance and a former PCT chief executive in Northamptonshire

Debunking conflict of interest myths Defining conflict of interest

‘PCTs should ensure clear governance and accountability to manage transparently any potential conflicts of interest of GPs working within a PCT and on the PEC or other decision-making boards.

‘Any arrangements should be proportionate and must be in accordance with the Department's Principles and Rules for Co-operation and Competition.'

A conflict of interest, in relation to PBC, could arise if a clinician:
• is a director of, has ownership of or part-ownership of, or is in the employment of, the body submitting the business case (including non-executive directorships)
• is a partner of, or is in the employment
of, or is a close relative of, a person who is
a director of the body submitting the business case
• is a close relative of a member of the practice, where the body submitting
the business case is a practice
• is a close relative of a person in the employment of the body submitting
the business case
• has a beneficial interest in the securities of the body submitting the business case, provides or has provided any services to that body submitting the business case.


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