In August, GP reported that Londonwide LMCs were calling for guidance for clinical commissioning groups (CCGs) as conflicts of interests for board members were set to increase.
Last month, the RCGP Centre for Commissioning and the NHS Confederation released joint guidance on how CCGs should manage potential conflicts of interests. It is entitled Managing conflicts of interest in clinical commissioning groups.
RCGP chairwoman Dr Clare Gerada says: 'For all GPs, maintaining the highest ethical standards in all their activities is fundamental, and this applies to the commissioning of healthcare services through their role in CCGs.'
NHS Confederation chief executive Mike Farrar says: 'Tackling the issue head on now, and providing clarity for clinical commissioners about what are unacceptable conflicts of interest, will help minimise the impact on the commissioning model.'
The guidance says GPs could potentially profit from the decisions of a CCG of which they are also members. This means that questions about their role in the governance of CCGs are legitimate.
'Failure to acknowledge, identify and address them could result in poor decision making, legal challenge and reputational damage.' The key, it says, is to ensure that conflicts are identified, declared and recorded, and that measures are taken to manage or diffuse them.
The Paxman test
It adds: 'One simple check for identifying possible conflicts of interest could be described as "the Paxman test" - if you might be embarrassed if asked to explain a situation to an investigative journalist or reporter, a conflict of interest probably exists.'
The guidance lists four types of conflicts of interest facing CCGs: those involving a direct financial interest; an indirect financial interest; non-financial or personal interests; and conflicts of loyalty.
Direct or indirect financial interest
The guidance says: 'A clear conflict of interest arises when an individual involved in taking or influencing the decisions of an organisation could receive a direct financial benefit as a result of the decisions being taken.
'This may arise as a result of holding an office or shares in a private company or business, or a charity or voluntary organisation that may do business with the NHS.
'Indirect financial interest arises when a close relative of a director or other key person benefits from a decision of the organisation.'
Non-financial or personal conflicts
The guidance says: 'These occur when directors or other key persons receive no financial benefit, but are influenced by external factors, such as gaining some other intangible benefit or kudos, for example, through awarding contracts to friends or personal business contacts.'
Conflict of loyalties
The guidance says: 'Decision-makers may have competing loyalties between the organisation to which they owe a primary duty and some other person or entity.
'For healthcare professionals, this could include loyalties to a particular professional body, society or special interest group, and could involve an interest in a particular condition or treatment due to an individual's own experience or that of a family member.'
It continues that some GPs and patients may feel that commissioners' responsibilities for prioritisation and resource management could conflict with their professional duty to advocate for and protect the interests of patients.
The guidance examines 'perceived conflicts of interests inherent in offering GPs incentives to address referral or treatment patterns or volumes'.
It continues: 'However, it is not unacceptable to reduce referral or treatment rates if this is in line with evidence-based protocols and best practice, particularly if as a result resources are released for other priorities.
'It is good medical practice to critically review and reflect on practice and to recognise the opportunity costs of doing these things is acceptable.'
It says payment must not be related to the outcome of decreasing referrals but is arguably legitimate for taking part in such activities.
'You must declare any interest you have that could influence your judgment in any financial or commercial dealings you are responsible 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.'
Guidance includes: 'Directors of provider companies or those with holdings above 5% should not be on a clinical commissioning management board if their company does business or is likely to do business with the CCG.'
The guidance says: 'Where individuals have a relevant and material interest in a matter to be considered by their organisation, conflict policies will often provide for them to be excluded from the consideration and/or decision-making process.'
It adds that CCG governor selection is key and 'there must be transparency throughout the whole process, as well as fairness'.