GP conflicts of interest must be managed and be seen to be managed
It makes sense for CCGs to have a bigger role in commissioning but they will need the oversight of NHS England to reassure the public on the conflicts of interest question.
Inherent within CCGs is a tension between the role of GPs as commissioners of services and the role of the same GPs as providers of services. All CCGs are currently responsible for commissioning some of the services that GPs provide.
Wikipedia defines a conflict of interest as, ‘a situation occurring when an individual or organization is involved in multiple interests, one of which could possibly corrupt the motivation’, and goes on to say, ‘a conflict of interest can be discovered and voluntarily defused before any corruption occurs.’
So, as is evident from the definition, it is not a long journey from conflict of interest to corruption. Now, CCGs have robust governance procedures in place to ensure that GPs themselves are not involved in any decisions where they may have a personal conflict of interest, and a key part of the CCG authorisation process was testing of these procedures and their consistent application.
But if concern develops amongst the general public that there may be corruption in the way that GPs use NHS resources, I think we could quickly end up in a situation where there is a loss of confidence in CCGs as a whole. Clearly, then, this is not an issue that should be taken lightly.
Throw into the mix the co-commissioning of primary care by NHS England and CCGs (which I have previously discussed (What is co-commissioning), and we are taking the potential for a conflict of interest to a whole new level. This is because co-commissioning potentially gives decision making responsibility to CCGs for the commissioning of the whole range of GP services.
So is it worth it? Why would Simon Stephens, as the new Chief Executive of NHS England, take such a risk on the reputation (and potential future) of CCGs? Why would he put every GP involved in CCGs in a position where their integrity can be questioned, because of the inevitable and unavoidable conflict of interest that co-commissioning puts GPs under?
General practice, as has been widely reported by the Royal College of General Practitioners and many others, is in crisis. There is a staffing crisis as GPs leave at a much faster rate than they can be recruited, and a premises crisis which we touched on (Rationalising notional rent essential to solving GP shortage). As businesses, an increasing number are getting into serious financial difficulty. GPs are working harder and longer just to keep things going and to be able to meet the ever increasing demand. Something has to change.
The new (post April 2013) system, where the commissioning of general practice is carried out by remote area teams of NHS England, is not able to deliver this change. Those involved in general practice are the ones who understand it best, and are the ones most likely to be able to identify the changes that could be made to tackle the issues that general practice faces.
Equally, general practice is an integral part of the local delivery of care outside of hospital. Commissioning it in isolation from the other out of hospital services (which are commissioned by CCGs) does not make any sense. Giving CCGs a bigger role in the commissioning of general practice is a logical, and many would argue necessary, step.
But that brings us right back to conflicts of interest. GPs may well be the experts on general practice, but how on earth can GPs commission their own business? How can this be done in a way that will maintain public confidence in CCGs?
There are two possible ways. The first is to put extra tests and rigour on the way that CCGs manage conflicts of interest to ensure that no GP is involved in any decision making about services that they provide. The second is to build joint committees between CCGs and NHS England, whereby NHS England retains overall responsibility and ultimate decision making, but CCGs provide input and direct influence so that workable solutions can be identified.
My view is that, however robust the quality of governance within a CCG controlling the conflict of interest, the average man on the street is never going to be convinced that it is ok. The second option feels to me to be much more palatable, and one that retains the input from GPs whilst leaving the final say at sufficient distance from them.
However the risks around conflict of interest are managed, concerns will never disappear completely because it is a conflict that sits at the heart of clinical commissioning. What co-commissioning will require is the rapid delivery of real and demonstrable results, as evidence that these additional risks were ones worth taking.
The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of The Information Daily, its parent company or any associated businesses.
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