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How being open helped clear our stumbling block over conflict of interest

Four GPs explains how their PBC group tackled the issue of potential conflicts of interest. First, Dr Shane Gordon explains how his PBC group tackled this ‘elephant in the room’.

Four GPs explains how their PBC group tackled the issue of potential conflicts of interest. First, Dr Shane Gordon explains how his PBC group tackled this ‘elephant in the room'.

There was a blockage. Why hadn't our PBC group managed to get a single new service into place yet?

When Colchester PBC group was set up in January 2006, we thought we had neatly avoided the problem of conflict of interest as we were a not-for profit company focusing solely on commissioning.

Yet after 18 months we were struggling to get any new services in place.

The PCT board organised a series of joint workshops and the problem soon became apparent – there was great nervousness on the part of the PCT about conflict of interest and it was putting a spanner in the works.

It seemed the 23 practices in the group had been scuppered by the very thing they thought they had side-stepped as an issue. We thought that the early decision to be ‘commissioning only', even if member GPs might potentially provide some services later on, was a good step in terms of managing conflict of interest.

41225774I don't think we appreciated how big a problem it was going to be because we had set ourselves up like that to deal with it.

Within two workshop sessions it became crystal clear that conflict of interest was the elephant in the room.

By autumn 2007 we had been unable to progress any projects, and it turned out the PCT also felt uneasy about us as providers drawing up things for us to do as GPs.

I don't know who the PCT thought would be specifying the services if it was not the experienced people who were planning to provide them, and that has been the fundamental problem with commissioning.

What we did

Following the workshops, Colchester PBC group re-drafted its terms of reference to include explicit requirements to publicly declare a list of interests for each member of the PBC board. These interests are posted on our website and any potential conflicts declared at meetings.

We went back to the PCT and told it what steps we had taken and checked whether they were adequate. We got a very strong reassurance that they were.

The PCT also decided that decisions about how procurement should happen would go to a different committee, which means we don't have any involvement. Although we can specify a service, it could go to a completely different type of provider.

These simple solutions (see box) meant the blockage of services waiting to be commissioned suddenly cleared overnight and more than a dozen new services have been commissioned in a year.

Those services use a wide range of providers from NHS hospitals to private hospitals, community services, willing providers, and GP enhanced services.

Lessons learned

We feel other PBC groups can learn from our experience. In Colchester, we GPs thought we had done everything by the book but we had not accounted for the amount of concern over conflict of interest at PCT level.

In designing services we took a stakeholder engagement approach to ensure that we had broad input from the right clinicians, managers and patients to develop a service specification.

Where possible we tried to ensure the specifications were agnostic about how and who should deliver the service.

However, over time it became clear this was not enough to quell the anxieties of our management colleagues.

I can't overestimate the importance of addressing these concerns and any PBC group that hasn't tackled this issue should do so urgently. They may not even realise that conflict of interest is a stumbling block.

At the beginning, you have to be really strong about internal governance within your PBC cluster and how you identify and manage conflict of interest.

It does not really matter what national policy says, this has to be sorted out locally as so much depends on individual attitudes within the PCT.

I don't think any amount of guidance could have solved our issues – it was individual anxieties around the accusations of people lining their pockets.

What you need to do is identify whether conflict of interest is an issue and, if so, sit down and work out how to overcome the problem so it cannot become an excuse that holds PBC back.

Dr Shane Gordon is a GP in Tiptree and CEO of Colchester PBC Group and national co-lead of the NHS Alliance PBC federation

How we deal with conflict of interest issues

Dr Amit Bhargava, a GP in West Sussex, is both chair of Crawley PBC Group and a director of Health 4 Crawley, a consortium of 10 general practices providing a range of services. He believes that whether you are a manager or clinician working within the NHS conflict is inevitable – but it's how you deal with it that counts.

Three of the six doctors running the provider company are also part of the PBC executive board. We won the contract, which started on 1 April, for the Darzi centre so there is a huge conflict of interest around commissioning and providing.

What we have done is to be very clear and open about that conflict of interest. Because I chair the PBC group, one of the things we have to keep saying is: ‘This is a commissioning decision – would we buy it if it was being sold to us rather than by us? Is it needed?'

Commissioning board members who are not part of the company are briefed to be completely brutal if there is any suggestion of us overstepping the mark.

We're trying to improve the services for our community. As long as the health of the population is improving, we can keep health services integrated and we are getting value for money, then we are able to step over the conflict of interest issue.

It would be completely mad if you said you should have completely separate commissioning and provider groups – we need to take a broader view around what we are trying to achieve.

In terms of money, there isn't a great deal to be made. Most of us are not expecting to get wealthy – or even cover our costs.

Dr Neil Shroff, a GP in Nottingham, faced many hurdles in setting up his primary care skin lesions clinic – not least the perceived conflict of interest of him treating his own patients.

We set up our service in April 2007 and have been working it up since then. I have an interest in skin lesions and had been working in the local hospital, so when we started moving into the community we had the backing of the PCT.

Alongside the issues of accreditation and lack of support from secondary care colleagues was a growing perception that we were siphoning patients away from other services, especially as the community service was proving very popular and knowledge of it spread without the GPs advertising it. Before long we were inundated.
Patients from my GP practice were asking to be referred to the clinic as they wanted to be treated locally. I agreed to treat them but explained they could have it done at the hospital if they preferred.

At the same time the PCT was starting to question the amount of work being done by the primary care service. A decision was amicably reached that we would stick to doing basal cell carcinomas, which would take the pressure off secondary care services but also ensure primary care was not overwhelmed.
We did not want to be accused of profiteering so we spoke to the GMC about ‘conflicts of interest' and they suggested documenting it more formally.
The consultation is now documented on computer with a tick box stating ‘patient offered choice of provider' explaining to the patient that we get paid for the work we do. This is Read-coded for the PCT. Every patient is offered choice.

Generally patients want to come to us – they get seen and assessed by the same doctor who does the surgery.
Patients are often bemused by the term ‘choice' as when they come to us their GP has already discussed choice with them and most are not bothered by the debate over conflict of interest and choice. They are concerned about when their surgery will happen and the final outcome.

Gerry McLean (pictured), executive chair of MAC2 Consulting, has been involved in setting up more than 40 PBC consortiums, most of which have commissioning and provider arms.

There will always be the issue of conflict of interest. What we do is ensure consortiums have membership agreements in place and governance regulations about how they present themselves to the patient.
The GP can't direct a patient to a service, only advise them of its existence. Governance agreements ensure there is absolute transparency between the GP and the patient.
Hospital consultants have been able to manage NHS lists and be private providers for many years, so we know it can be done.

From the beginning a group needs to decide whether they want to have a provision wing, then what kind of organisational model they want and why. Once you've picked your organisational vehicle, you must ensure the rules of engagement are enshrined in the membership or shareholder agreement.

Make sure you have agreed governance requirements in place that allow maximum transparency for the patient.
I can't see why there is confusion if things are done properly. The commissioning needs to be designed to reflect the needs of the local population and to improve services.
The safeguards are all there.

Dr Shane Gordon How to solve conflict of interest problems Our solutions

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