Commissioning with a clear conscience
The Government’s NHS reforms lay GPs open to the risk of serious conflicts of interest. The GPC’s Dr Simon Poole provides his guide to steering clear of controversy
The health bill is, by the Government's own admission, a very ambitious initiative. Although many GPs have been involved in commissioning for some years, the responsibilities and expectations placed upon the profession in future are going to be increased significantly.
GP practices and commissioners will be subject to intense scrutiny of their performance and held to account for their delivery of healthcare by the public, politicians and the media. There is a lot at stake. We must therefore ensure that at all times we are mindful of our responsibilities as doctors. These are enshrined in the GMC's Good Medical Practice guidance (1) and in documents issued by the GPC such as Governance of Consortia, (2) Ensuring Transparency and Probity, (3) Principles of GP Commissioning (4) and the Seven Pillars of GP Commissioning, (5) first published by Pulse in February. If we remain faithful to these principles as I set out here, and demand the highest standards of ourselves and our colleagues, we will secure the trust of patients and the public.
1. GPs must not allow inducements to influence commissioning decisions
GPs cannot accept inducements – for example, through the quality premium – for simply meeting targets for reducing referrals or prescribing bills, or for achieving financial balance. It is very clear that this could breach our ethical and professional standards. Commissioning targets should not be dependent on numerical outcomes – on, for instance, referrals – without reference to appropriate quality of care.
It is, of course, right to resource processes at practice level to enhance quality, but any savings generated by achieving commissioning targets should be reinvested in patient services at the level of the clinical commissioning group (CCG).
It might be acceptable for an incentive to be paid to CCGs for investment in patient services where financial targets are met and high quality of care is also achieved – where money is paid to resource the process and reward an outcome. There are precedents for this in prescribing incentive schemes and the QOF.
2. GPs cannot offer enhanced services to practices without independent scrutiny
Enhanced services will continue to play a pivotal role in delivering more services in the community, and it is entirely appropriate to offer GPs financial support to take on activity and free up resources elsewhere, provided of course that clinical governance and quality issues have been addressed. But CCGs will need to be transparent in their decisions to award GPs enhanced services so there is confidence those decisions have been taken in the best interests of patients.
Where there is a shift of resource from a secondary care service to primary care, it should be routine for clinical commissioners to refer decisions for external scrutiny. Enhanced services will need to be negotiated between the commissioning group and the LMC, and referred for endorsement to an overview and scrutiny committee or similar body, even if the overall amount paid to primary care is unaffected.
It will also be essential that there is due process to assess the cost and viability of enhanced services to ensure the amount paid is appropriate for the work.
3. LMC officers should not also be members of CCG boards
There are bound to be tensions and times of disagreement between GP practices and CCGs, but GP commissioners will only succeed if they enjoy the confidence of the profession. LMCs will therefore have a vital role at the interface between the CCG and GPs, not only in negotiating terms of service agreements, but in resolving areas of dispute that may arise between the CCG and individual practices or doctors – particularly over performance management. LMCs will also have a duty to hold the CCG to account by ensuring its democratic legitimacy.
Because of this, it will not be appropriate for LMC officers to hold board positions on the CCG even when accompanied by the obligatory declaration of interest. Some LMC officers will currently be contributing to the development of shadow CCGs, and that's acceptable for the moment, but won't be once the shadow boards become actual boards with statutory responsibilities and powers.
LMC members, rather than officers, can remain as members of CCG boards. It is, however, one of an LMC's responsibilities to ensure it remains truly representative and balanced in its membership.
4. GPs should avoid any conflict of interest that looks bad
Commissioning is fraught with the risk of conflict of interest. The principles governing this are, in fact, straightforward. GPs will need to understand that if it looks bad, it probably is. We must not be in the business of ‘managing conflicts of interest' or imagine that a conflict declared is a conflict resolved. We must adhere to the standards defined by the GMC, the Nolan Principles of Public Life and GPC documents setting out the financial holdings in provider companies that would be incompatible with board membership, how to register interests and the role of external scrutiny. (2,3)
Where a GP holds significant equity (more than 5%) in a company that has the possibility of a contractual relationship with a CCG, this would be incompatible with board membership. All other financial interests need to be registered as part of an independent process, and standing orders within the constitution need to provide clarity regarding the obligation to declare such interests and the circumstances where members forfeit the right to contribute to a debate or to vote. It is essential that such interests be made available to the public.
There is evidence that some shadow commissioning groups have yet to address these areas of concern to ensure they meet the highest expectations of the profession.
5. Take special care with referral decisions
Conflict of interest is not only an issue for members of CCG boards – it is a potential risk whenever a GP makes a referral decision. Where an individual doctor is referring a patient to a provider in which he or she has a financial interest, GMC guidance applies. Its Good Medical Practice 2006 guidelines1 advise GPs that if they have a financial or commercial interest in a healthcare organisation to which they plan to refer a patient, they have a responsibility to inform both the patient and the provider of the service about this.
6. GPs must protect the NHS against fragmentation and unfair competition
The LMCs conference warned the health bill represented the greatest threat to the NHS since its inception. Perhaps the most significant responsibility resting with CCGs, therefore, is to ensure the very survival of the NHS.
Mark Britnell, previously NHS director-general for commissioning, predicted a future where the NHS would be a state insurance provider, not a state deliverer, and told a conference of private healthcare executives that ‘the NHS will be shown no mercy and the best time to take advantage of this will be in the next couple of years'
It is imperative clinical commissioning embraces the need to uphold the principles and ethos of the NHS, and to measure the effect of decisions on whole-system provision and the stability of existing providers. GP commissioners may use levers to increase quality of care and value for money – but it is essential their costings are reasonable and realistic, they give appropriate priority to training and education and that they recognise services provided in challenging circumstances.
Loss leading, cherry picking, profiteering and the exploitation of the NHS brand must not be tolerated. Commissioners will need to be courageous in their defence of decisions based on integration not competition, and the long-term needs of populations rather than short-term financial expediency.
Partnership with patients and the public, alongside a commitment to working with professional colleagues and representatives of local authorities, will be key. If the constitutions of CCGs express these ideals and principles, and all those involved strive to deliver the best for patients, there is a real possibility clinical commissioning can mitigate the risks of these reforms and improve the experience and outcomes for patients.
Dr Simon Poole is deputy chair of the GPC commissioning and service development sub-committee and a GP in Cambridge
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1 GMC. Good Medical Practice 2006.
2 The governance of consortia. GPC guidance. May 2011.
3 Ensuring transparency and probity. GPC guidance to ensure the honest and transparent operation of clinically led commissioning consortia. May 2011.
4 The principles of GP commissioning: a GPC statement in the context of ‘Liberating the NHS'. GPC August 2010.
5 Poole S. The seven pillars of GP commissioning. Feb 2011.