A conflict of interest can be defined as ‘a set of conditions in which professional judgement concerning a primary interest (such as a patient’s welfare) could be influenced by a secondary interest (such as a financial gain).’1 A Pulse investigation in 2012 revealed that more than one in five GP board members have a potential conflict of interest, and this issue has been the subject of much press and political discussion before and since.2
This article will attempt to give a checklist of situations in which conflicts of interest can arise for GPs, and suggests ways of guarding against accusations of impropriety, while realising all the advantages for patients that primary-care lead commissioning can offer.
1. Declare an interest when making referrals
Broadly speaking there are two situations where a conflict of interest can arise as a GP provider. The emphasis on choice and competition in the NHS and the ability of ‘Any Qualified Provider’ to offer certain services to patients means that many GPs will have financial interests in organisations other than their own practice. Examples could include community services, pharmacies or GP with special interests. GMC guidelines state that ‘you must not try to influence patient’s choice of healthcare services to benefit you, someone close to you, or your employer’.3(4)
BMA guidance suggests that if the best service for your patient happens to be the one in which you have a financial interest, you should declare this to your patient and record this in the medical notes.
2. Assess an incentive scheme using the BMA checklist
The BMA guidelines provide the following checklist to help explore these issues:
‘Incentive schemes MUST:
- Have good clinical evidence
- Be of benefit to a community of patients or to individual patients
- Ensure that patients continue to receive the clinical care to meet their individual needs
- Reward decisions or outcomes for large groups or populations of patients
- Ensure that payments arising from the scheme are used to improve patient services.
Incentive schemes MUST NOT:
- Change clinical activity without a sound evidence base
- Compromise patient safety
- Encourage a uniform or blanket approach to all patients with the same condition
- Directly reward decisions relating to individual patients’.4(7)
Individual practitioners should ‘review evidence base for such schemes and satisfied themselves that in participating, they will not be compromising patient care’.5(4)Ultimately, the GMC could take action against doctors engaging in processes that breach their duties as outlined in Good Medical Practice.
3. Keep a register of interests at your CCG
The Health and Social Care Act legislation sets out the legal framework to ensure CCGs have a good governance framework and transparent decision – making processes. NHS England has set out clear guidance on both statutory requirements and processes for managing conflicts of interest3. CCGs must set out in their constitution their proposed arrangements for managing these issues. Anyone who can influence CCG decisions must declare any conflicts-of-interest; this obligation is written into the constitution of our CCG and also its employment contracts. The CCG will then keep a register that is available for scrutiny by external bodies and the public. The RCGP suggest that this should be ‘updated regularly,’ without specifying a time interval: this will likely vary between CCGs, but we have a standing at agenda item at the start of each meeting where conflicts of interest are declared and updated by all participants. The register is then updated accordingly. 1
There are more stringent rules for CCG board members. NHS England states that any individual with a ‘material interest’ in an organisation that provides or is likely to provide the substantial business to a CCG should not be a member of the governing body. The BMA guidelines suggest that an ‘equity interest in the business of more than 5% should be considered a material interest.’3
The RCGP offers further advice, suggesting the use of the ‘Paxman Test’: if you might be embarrassed if asked to explain a situation to a reporter, a conflict-of-interest probably exists.
4. Set up external scrutiny for your CCG
CCGs will have a clear policy for managing conflicts of interest for board members or decision-makers in the procurement process. Options include excluding GPs from the relevant parts of meetings, or participating in discussion but not taking part in any decisions, however it is also vital to manage the process in a clear and transparent way to avoid the impression of undue ‘behind the scenes’ influence.
The BMA suggests that seeking external scrutiny from other CCGs, lay members, the Health and Wellbeing board, the NHS England area team and public health doctors can be useful.4 They go on to suggest setting up an external scrutiny committee that could be shared amongst a number of CCGs. NHS England guidelines advise consulting Commissioning Support Units when deciding on the best procurement method-this again provides assurance of transparency.5 It goes on to state that the details and value of all contracts should be published as soon as they are agreed, and outlined in the CCGs annual report.
Monitor is ultimately responsible for policing procurement regulations, and can fine up to 10% of a provider’s annual turnover if these are breached. The GMC can investigate where it is thought that an individual GP’s fitness to practice is under question.
Dr Neil Fraser is a GP in Rushcliffe and the head of long-term conditions on Rushcliffe CCG.
1 Thompson, D. Understanding Financial Conflicts of Interests. 1993. New England Journal of Medicine, 329(8), 573.
2 Pulse. Revealed: One in five CCG board members have potential conflict of interest. December 2012.
4 BMA. Conflicts of interest in the new commissioning system: Doctors as providers. April 2013.
5 NHS England. Conflicts of interest. 2012.