Thursday, 14 March 2013

BMJ finds conflicts of interest "rife" on new NHS commissioning boards.


An investigation for the prestigious British Medical Journal (BMJ) published today finds GP conflicts of interest “rife” on the new NHS commissioning boards.

More than a third of general practitioners on the boards of new clinical commissioning groups (CCGs) have a conflict of interest due to directorships or shares held in private companies providing services for the NHS.

The report provides the clearest evidence to date of the conflicts many doctors will have to manage from April 1, when the GP-led groups are handed statutory responsibility for commissioning around £60bn of NHS healthcare.

The BMJ used Freedom of Information requests and CCG websites to analyse the registered interests of almost 2,500 board members across 176 of the 211 commissioning groups in England.

It found 426 (36%) of the 1,179 GPs in executive positions had a financial interest in a for-profit private provider beyond their own GP practice – a provider from which their CCG could potentially commission services.

These ranged from senior directorships in local for-profit firms - set up to provide services such as diagnostics, minor surgery, GP out of hours and pharmacy - to shareholdings in large private sector health firms providing care in conjunction with local doctors, such as Harmoni and Circle Health.

In some cases, the majority of GPs on the CCG governing body had financial interests in the same private healthcare provider.

Although some doctors have relinquished interests in private enterprises because of their new roles as commissioners, the BMJ found that in total, 555 (23%) of 2,426 governing body members – including all clinical, lay, and managerial representatives – have a financial stake in a for-profit company.

Last week, the BMA’s UK Consultants’ Committee passed a motion at their conference expressing concern at “the clear conflict of interest of GP commissioners who run their own private companies”, and calling on GP commissioners to “be barred from being involved in companies that they are giving contracts to.”

The NHS Commissioning Board has issued a code of conduct to CCGs stating that board members must remove themselves from decisions that they could materially benefit from. But doctors’ leaders have expressed concern that clinical input into commissioning decisions may become diluted if too many doctors are forced to remove themselves from particular decisions.

All of the CCGs found to have notable conflicts told the BMJ they had robust systems in place for managing potential conflicts, including publishing conflict of interest policies, and regularly updating members’ declarations of interest.

But Michael Dixon, chair of NHS Alliance and interim president of NHS Clinical Commissioners, warned placing too much emphasis on the issue may prevent clinical commissioners from bringing more care into community settings.

The NHS Commissioning Board said it was reviewing its existing guidance and would shortly be publishing “final, comprehensive guidance on managing conflict of interest”

The Department of Health has also acknowledged that concerns about conflicts needed addressing, and pledged to strengthen Monitor’s power to act where conflicts “may affect the integrity of a commissioner’s decision."

Dr Fiona Godlee, editor in chief of the BMJ, said: “This is the first time the full extent of the involvement of CCG GP board members in private health companies has been revealed.

“These conflicts will make the commissioning of some services difficult. Although board members can excuse themselves from meetings when conflicts arise, this could mean some decisions are made by a group of predominantly lay people.

“Some of these conflicts of interest are too great to be ‘managed’. We think that those GPs who have positions at executive board level in private provider companies need to choose between their competing interests and, if need be, step down from the commissioning boards.”

BMA calls for safeguards against conflicts of interests


Commenting on the BMJ investigation into potential conflicts of interest for GPs involved in commissioning, Dr Laurence Buckman, Chair of the BMA’s GPs Committee, said:

“While the majority of GPs have no involvement in private companies, we have long called for stronger safeguards against possible conflicts of interest in the new commissioning process.

“In our view, GPs who are directors of, or who have significant financial interests in, companies who might be awarded contracts to provide services should seriously consider their membership of CCG governing bodies. Alternatively, they should consider their position within provider companies.

“We support the principle of greater clinician involvement in commissioning, but it must not come at the expense of the trust of patients. Measures to prevent conflicts of interest will improve confidence that decisions are being made to benefit patients.”

Waiting for the horse to bolt before shutting the stable door 


The Department of Health acknowledged in its response to its consultation “Securing the Best Value for Patients” that concerns about conflicts needed to be answered, and it pledged to strengthen the power of the healthcare regulator Monitor to act where conflicts “may affect the integrity of a commissioner’s decision.”

According to the department this would mean “the Monitor is able to take action where conflicts have not been managed appropriately in awarding a contract, and not only where Monitor is able to establish that the decision to award a contract was the result of an interest in the provider—which may have set the bar too high to allow action to be taken.”

In other words we are really waiting for the horse to bolt before locking the stable door. 

The General Secretary of the General Medical Council, the doctor's governing body, said  "This is all about honesty and integrity—we expect doctors to be open about any financial and commercial interests linked to their work.”

We certainly expect that; but then we expect that in all professions, but often conflict of interest becomes difficult to unravel. 


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