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Dilemma: Vested interests

As a GP partner you are concerned that one of your salaried GPs is consistently referring to a private primary care provider organisation in which their spouse is a major shareholder. The referrals are clinically appropriate.

Would you intervene and how might you address this?

Refer to GPC and GMC guidance

Dr Laura Edwards- online

Since the introduction of the Health and Social Care Act and the introduction of Any Qualified Provider contracts, it may mean that this scenario becomes more likely.

NHS England has stressed in its guidance that perceived and potential conflicts of interest may be as damaging as actual conflicts of interest. The GPC has released concise guidance which covers conflicts of interest for GPs as both commissioners and providers.

In this case, the doctor has grounds for a conflict of interest at least from a patient’s point of view and would need to be mindful of paragraph 78 in the GMC´s Good Medical Practice: ‘You must not allow any interests you have to affect the way you prescribe for, treat, refer or commission services for patients.’ The GMC has also issued specific guidance, stating that ‘you must not try to influence patients’ choice of healthcare services to benefit you, someone close to you or your employer’.

The BMA guidance also advises that if a doctor stands to benefit from a referral decision then they need to make this clear to the patient. They must inform the patient and document this in the clinical notes, taking into account the patient’s wishes if a clinically appropriate referral happens to be one in which they have a vested interest like in this case. The fact that this has been raised means that it needs to be dealt with by the practice and should be discussed openly with the GP. Your LMC would offer advice and support.

Ultimately this could result in a GMC referral if it was felt the GP’s clinical referral behaviour was motivated by personal financial gain, and they refused to change their activity.

Dr Laura Edwards is a sessional GP near Southampton and medical director of Wessex LMCs

Transparency is vital

Dr Richard Van Mellaerts - LMCs conference 2013 - online

Source: Jon Enoch

Managing conflicts of interest is an increasingly common issue since the advent of GP commissioning. We are all commissioners and many of us are providers or have close links to providers. Whether declaring interests when commissioning as a CCG from a provider you have an interest in, or referring to the same, these issues are arising far more frequently than ever before.

While the referrals are all clinically appropriate to this service and there is no suggestion or evidence of impropriety, transparency is vital. Having an informal discussion with the doctor will help to clear up any potential problems. It would allow the opportunity to lay out what you have found and for the doctor to discuss their perspective on the situation.

Ensuring that the patients are informed of his link to the provider and that they are offered a menu of clinically appropriate options for referral in the consultation will help to prevent this perceived conflict of interest becoming a problem.

For the future, developing a formal practice policy relating to potential conflicts of interest may be useful in avoiding these concerns.

Discussion in appraisal would also be a useful exercise.

Dr Richard van Mellaerts is a GP in Kingston and GPC member

Conflict of interest here is minute

Phil Yates - Online

My company, GP Care, is owned by 700 GPs and sees 12,000 patients per year. Its Articles of Association preclude bigger dividend payouts than would be allowed in any normal social enterprise company. In reality, though GPs invested their own capital, to date it has reinvested every penny into developing new patient services.

Even if this GP made 50 referrals to us per annum that would still only constitute 0.42% of turnover. Assuming an income per patient referral of £300 and a ‘margin’ of 25% – this referrer’s spouse would get 1/700th of that profit – a princely £5.36 in total and hardly an incentive to refer, when you compare that to practice turnovers and profitability.

The conflict of interest here is minute and should be kept firmly in perspective.

Nevertheless, the first priority is patient protection and ‘palpable probity’. It is important that primary care provider organisations are set up in a way that effectively manages conflict of interest on behalf of its members as GP Care has – protecting doctors and patients from accusations of foul practice and ensuring best interest for the patient not the referrer. I would talk to my salaried colleague: comparative data is powerful and it might help the doctor to understand he/she is an outlier in number of referrals.

The primary issue though, is whether or not the patient has made an informed choice of provider (in the full knowledge of the commercial interest of the referrer). Making sure such ownership interest is included in all our literature for patients helps to ensure patients are properly informed.

Dr Phil Yates is a GP in Bristol and chairman of private provider organisation GP Care

Conflicts should be recorded

Dr Natalie Hayes - online

Conflicts can arise when GPs have a direct or indirect financial interest or a non-financial or personal interest in an organisation to which they are referring patients, such as a pharmacy or nursing home.

As the GMC reminds us, doctors must not allow any interests they have to affect the way they prescribe for, treat, refer or commission services for patients and they are advised to be honest about any conflict, and to exclude themselves from decision making. The GP must not influence the patient’s choice of provider and should tell the patient about their interest in the organisation before making the referral, making a note of this in the records.  

If there is an unavoidable conflict, for example because there is no other suitable organisation to which the patient could be referred, the GP should also record this in the records (as per Financial and commercial arrangements and conflicts of interest, GMC, 2013).

If you are concerned that the GP partner isn’t following this guidance, you should speak to him or her in the first instance about your concerns.

If the GP’s explanation doesn’t satisfy you, you may need to raise your concerns with a senior colleague and/or raise the issue at a practice meeting, if appropriate.

You should remember your own obligations to act in patients’ best interests, so if your concerns remain, you may ultimately need to raise the matter with the GMC.  

Dr Natalie Hayes is a medico-legal adviser at the MDU

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