Concerned about how to manage your dual roles as a provider and a commissioner? Dr Clare Gerada and Dr Dennis Cox give their tips on avoiding any problems
The NHS reforms will require GP commissioning leaders to understand and deal with conflicts of interest. This doesn't just apply to how they handle budgets, but also where any pre-existing political, personal and ideological beliefs might interfere with decisions they make. Running a consortium is not like running your own practice – it relies on GP leaders being completely transparent about the decisions they make and the resources they allocate.
This applies to the awarding of secondary care or management contracts to new providers, but also to moving resources into primary care by funding local enhanced services, commissioning incentive agreements, payment for equipment or improvements to the GP estate. GP leaders will have to balance a desire to get on with things and cut through red tape with the need to make sure that public money is properly accounted for. Here are some tips.
Understand what conflict of interest means
A quick internet search defines a ‘conflict of interest' as occurring when an individual or organisation is involved in multiple interests, one of which could possibly corrupt the motivation for an act in any other. A conflict of interest can only exist if a person or testimony is entrusted with some impartiality – a modicum of trust is necessary to create it.
The presence of a conflict of interest is independent from the execution of impropriety. Therefore, a conflict of interest can be discovered and voluntarily defused before any corruption occurs.
The World Health Organization defines a potential conflict of interest more broadly: that it can occur when one's ability to exercise judgment in one role is impaired by one's obligations in another by the existence of competing interests. In such situations, there is a risk towards bias in favour of one interest over another.
The definition can be more simply stated by the Daily Mail test – if you might be anxious about explaining a situation to a journalist from the Daily Mail, a conflict probably exists.
Adhere to key principles of public office
Consortium leaders will be bound not just by the GMC's Good Medical Practice, but also by the Nolan Principles, which lay down seven principles for conduct of holders of public office. These principles are:
• Selflessness Holders of public office should act solely in terms of the public interest. They should not do so in order to gain financial or other material benefits for themselves or for their families or their friends.
• Integrity Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties.
• Objectivity Holders of public office should make choices based on merit when carrying out public business, including when making public appointments, awarding contracts, or recommending individuals for rewards and benefits.
• Accountability Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office.
• Openness Holders of public office should be as open as possible about all the decisions and actions they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands.
• Honesty Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest.
• Leadership Holders of public office should promote and support these principles by leadership and example.
The GMC advises GP managers that, when dealing with financial and commercial issues, ‘you must declare any interest you have that could influence or be seen to influence your judgment in any financial or commercial dealings you are responsive for'. In particular, you must not allow your interests to influence:
• the treatment of patients
• purchases from funds for which you are responsible
• the terms or awarding of contracts
• the conduct of research.
Disclose all interests in full
Disclosure is an essential step in dealing with a potential conflict of interest – though in many cases it may not be enough. Disclosure of all potential conflicts of interest should form part of a consortium board member's appointment process and a register of interests should be kept and made available to the public. Trustees of the RCGP, equally, must sign the RCGP's Register of Interest, and abide by the College Code of Conduct.
Interests that are relevant in the area of healthcare include:
• partnership (such as in a general practice that will benefit from a proposal) or employment in a professional partnership, such as a limited liability partnership
• directorships, including non-executive directorships held in private companies or PLCs (with the exception of those of dormant companies)
• ownership or part-ownership of private companies, businesses or consultancies likely or possibly seeking to do business with the NHS
• majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS
• any connection with a voluntary or other organisation contracting to provide NHS services
• research funding/grants that may be received by an individual or their department.
The above also apply to interests of a spouse or partner. If individuals have any doubt about whether something should be disclosed or not, they should always err on the side of caution and disclose.
Take action to modify or remove conflict
Whenever a conflict is declared, the group will have to decide the level of participation appropriate for that member. This can be:
• conditional participation – where the conflict of interest is publicly disclosed at the start of the meeting, is minuted and the individual remains at the meeting throughout
• partial exclusion – for the relevant discussion item
• total exclusion – where the conflict is incompatible with the role an individual is being asked to fulfil.
Dr Jones is the chair of Sunnyside GP Consortium. He is also a shareholder in TopHealth Solutions, a large consultancy firm that has now begun to provide services to support information systems to emerging consortia. Dr Jones feels that TopHealth Solutions offers the best value for money system available and is convinced that his consortium would benefit from the expertise of this company. He does not feel that he has a conflict of interest as his involvement with TopHealth is well known and he has often written about the company and the benefits it can make in commissioning.
A conflict of interest can involve an individual's personal, professional, financial or business interests, which are related to or could be affected by the outcomes of the activity involved.
A conflict of interest can exist even if no unethical or improper act results. Holding shares in a company is rarely unethical and in the case of Dr Jones, perfectly acceptable. However, it is important to recognise that owning shares in a company where you can benefit from financial decisions as a commissioner can create an appearance of impropriety that may undermine confidence in and the reputation of the individual or the organisation, in this case Sunnyside GP Consortium.
Dr Smith was elected to the executive board of his GP consortium. He successfully leads a local vulnerable patients programme (VPP) in his area, which has resulted in a fall in unscheduled admissions to hospital. As part of the VPP, Dr Smith visits local nursing homes with an elderly care physician on a regular basis, offering the VPP services. Other members of the consortium suggest that the VPP work should be expanded and attract a local enhanced service because it is over and above the normal GP contract.
Although Dr Smith is doing the work of visiting nursing homes as part of his GP contract, he now stands to benefit from this work, over and above his role as a GP. There is nothing wrong with this – but it does, however, put Dr Smith in a difficult position, as he does not want others to think that he abused his position as an executive of the consortium. He should, of course, disclose his involvement, but the group needs to make a decision on whether or not to exclude him from further discussions – which poses problems, as he is the local expert in this area.
One way of dealing with this dilemma would be to form a relationship with the local overview and scrutiny committee. They are usually happy to discuss things informally and can be extremely helpful in guiding commissioners. Full details of the arrangement should be openly disclosed to other interested parties and a fair recruitment process should be undertaken. Although it is time consuming, it is also wise to consider consulting on and publicising new developments such as this so that there are no surprises for anyone who might have an interest.
The current reforms build in conflicts of interest and it is important that there is no misunderstanding that decisions about resource allocation, commissioning and rationing are done other than for the best interests of the patient.
Getting the legal issues right is not difficult, but GP leaders should pay particular attention to the importance of protecting their reputation.
As elected (or even appointed) representatives, they will need to set an example by demonstrating the highest standards of probity. They will need to know, understand and incorporate the Nolan Principles into every aspect of GP commissioning and make sure that the decision-making process is as open and inclusive as possible. The RCGP is here to help, and will be working with the NHS Confederation and the GPC to develop fuller guidance in this area.
Dr Clare Gerada is chair of the RCGP and a GP in Lambeth, south London. Dr Dennis Cox is a GP in Cambridge, member of RCGP Council and executive member of CATCH GP commissioning consortiumDealing with conflicts of interest