Dilemma: Conflict of interest with a referral
You are a local GP and hold a small financial share in a local GP provider organisation. Your patient has requested a minor cosmetic surgical procedure on the NHS, which you are aware can be dealt with efficiently and competently by this organisation. How do you avoid being accused of ‘not giving patients a choice’ or ‘not putting the interests of the patient first’?
Refer to GMC guidance and be transparent
Your overriding consideration must be the safety and appropriate treatment of the patient. Would the patient be likely to get a better deal from this referral than from a different provider?
The question of who owns the organisation must be of secondary importance compared with patient care and the quality of that care. There are providers of every flavour nowadays and it is difficult to eliminate conflict of interest issues entirely. For example, no one contests GPs performing NHS procedures for which they themselves are paid.
If the service is considered to be the best option for the patient, it would be wrong to exclude this provider just because you have a small financial share in it. Many general practices are businesses with turnovers in excess of £2m per annum – any return from an individual referral could only rank as insignificant.
The GMC has issued clear guidelines to manage and prevent conflicts of interest. Essentially, the GP should always be transparent about their involvement with the organisation and openly offer alternative options. The patient should be given clear, unbiased information and offered as much
support as they need to help them reach their decision.
Dr Phil Yates is the chair of GP provider organisation GPCare and a GP in Bristol
Offer a second opinion and a list of alternative clinics
The key to success, as always, is openness and honesty in the context of a relationship of respect and trust with your patients.
I hope that in considering making the referral, the doctor would reflect on the relevant sections of Good Medical Practice – primarily paragraphs 77 to 79 – which stipulate the need for honesty in financial and commercial dealings with patients, openness about potential conflicts of interest and a duty to prevent these things affecting patient care (including referral). Good Medical Practice also demands a willingness to exclude oneself if a perceived conflict materialises.
In this case, I would inform my patient that I had commercial links with the clinic, and that this should not necessarily be considered a conflict but in fact a recommendation, as I would hope that I would only be involved with high-quality operations of which I could be proud.
I would explain that the procedure described is straightforward and that it is possible to be clear about the risks and benefits, and that my provider has reliable quality assurance and governance data pointing to high standards.
I would offer a second opinion and a list of alternative clinics and do so carefully, without drawing unsubstantiated comparisons. Lastly, I would ask my patient to provide feedback on their experience at the clinic.
Dr Stephen Bassett is an out-of-hours GP, a barrister and a member of the GPC’s sessional subcommittee. He is also the founder of the cosmetic clinic ShapeCYMRU
Disclose your interest in the provider organisation, or make it clear in another way
Whether a financial share in a provider organisation is small or large, the same principles apply. GPs should avoid conflicts of interest and the new NHS constitution expressly gives patients ‘the right to make choices about the services commissioned by NHS bodies and to information to support these choices’.
Being transparent is a good way to avoid accusations – whether justified or not – of not putting patients first or not giving them a choice. On its own, there is nothing wrong with having a financial interest in a healthcare provider. The GMC’s new guidance is that doctors must be open and honest about interests that could be seen to affect the way they refer patients. The guidance also says doctors must not try to influence patients’ choice of services to benefit themselves.
Ideally, you should have enough confidence in your own objectivity to say: ‘I usually refer patients to X for this procedure. I have an interest in X, and if you would like me to offer you alternatives, please say so.’
Alternatively, you might avoid possible awkwardness by handing the patient a leaflet on the procedure and the provider, which includes some words like ‘Dr Y is a minority shareholder in X. If you would like to consider alternatives to X, we will be happy to give the details of other providers. Please ask any of the GPs here or one of the receptionists.’
David Reissner is a partner and head of healthcare at Charles Russell LLP