General practice commissioning: in whose interests?

Conflicts are inevitable

CCGs and NHS England acknowledged that conflicts of interest were inevitable in a system that made GPs both purchasers and providers of services but insisted that all decisions were backed by strong governance processes and probity.

But this investigation identified wide variations in how CCGs handled conflicts of interest and their willingness to provide information on how conflicts were handled when awarding contracts. Some CCGs asked board members to leave the room when a conflict occurred, while others permitted conflicted members to participate in discussions but not vote. Often the course of action was at the discretion of the CCG chair (box).

Doctors’ leaders, patient representatives, and MPs all expressed concern at the variation and said CCGs needed to be fully accountable for the money they are spending as public bodies, particularly when large sums of money are involved.

One CCG to award large sums of money to organisations in which their board members declared an interest was NHS Birmingham South Central CCG, which gave contracts worth £1.7m to South Doc Services, a GP owned company that provides services such as community pulmonary rehabilitation, anticoagulation management and audiology over two years. Four members of the CCG’s governing body have declared an interest in the company, including one of the company’s directors, Naresh Chauhan, who stepped down from the CCG board in October 2014.

A CCG spokesperson said that Chauhan had “fully complied” with the organisation’s conflict of interest rules when a board member. These rules require declarations to be made at any meeting, and members that declare an interest to abstain from taking part in any decision.

Chauhan said, “I declared any conflict, and if there were any meetings that discussed anything which may have an impact on the contracts, I declared the interest and left the meetings.”

When questioned on the how the money South Doc Services had received was used, Chauhan said, “We’re a non-profit making organisation, we don’t give dividends. I can’t discuss [what the money is used for] because it’s commercially sensitive.” In a follow-up letter to The Times, Chauhan said the company, “reinvests all funds back into patient care.”

The investigation also highlighted 15 contracts worth £2.2m awarded by NHS Newham CCG to organisations in which some members had apparent conflicts of interest (box). This included an out of hours contract worth £577 047 awarded to the Newham GP Cooperative, of which CCG board member Jim Lawrie is chair and CCG deputy chair, and Ashwin Shah, is a board member. Shah’s interest was not declared when he attended a meeting of the CCG’s procurement committee in March 2015 during which the CCG board was told of a decision to extend the out of hours contract until a wider procurement took place in 2016.

In response, a spokesperson for Newham CCG said, “We acknowledge that in the March 2015 procurement committee meeting, a conflict of interest should have been declared and recorded at the time. It is important to note that the item in question was a brief update to the meeting and not an extensive paper requiring any decisions to be made from those present and so no decision was influenced in this case.”

Other notable conflicts occurred in contracts awarded to the GP led social enterprise Patient First to provide musculoskeletal and physiotherapy services worth £439 520 and minor surgery, dermatology, and gynaecology services (value unknown). Newham CCG board member Bhupinder Kohli declared an interest as director and chair of Patient First, and Lawrie declared an interest as clinical governance director of Patient First.

The spokesperson added, “Newham CCG takes its responsibilities around managing conflicts of interests seriously and it is an area that we continuously look to strengthen.”

Other CCGs where conflicts were identified included NHS Bedfordshire, NHS North Durham, and NHS Canterbury and Coastal, the last of which awarded £1.9m worth of contracts to Whitstable Medical Practice—where CCG board member John Ribchester is a partner.

Ribchester said the CCG had a very robust process for dealing with conflicts of interest. “As a GP … you might be involved in designing the pathway [but] at that point your involvement as a GP would end. Then it would go out to the procurement team of the CCG. It would be very wrong if you were involved in the procurement if you were also a potential provider. We certainly don’t do that.”

But Ribchester added, “I think a bit of trust in the system would be quite nice … try to trust that there are some of us out here trying to do the right thing for patients.”

An NHS England spokesperson said, “Robust statutory guidance on managing conflicts of interest for CCGs has been published with input from the National Audit Office and other regulators. A national audit is underway to look at how these arrangements are working in practice.”

Better scrutiny

But Katherine Murphy, chief executive of the Patients Association, said current governance processes were inadequate and needed more scrutiny.

“I don’t think this is anywhere near the transparency we need,” she said.

“It’s very easy to tick a box and say we won’t participate in that part of the conversation, but what about the influence you have on your colleagues on the board who can speak up on your behalf?”

Meg Hillier, the new chair of the House of Commons Public Accounts committee—which produced a report last year demanding action on the “significant” conflicts of interest in general practice out of hours care3—said MPs may re-examine the wider issue in light of the latest findings.

“It’s about not just transparency and accountability but the appearance of those things. We want to look at that. There is definitely a governance issue. There needs to be the same level of standards for CCGs as there are for charities,” she said.

Hillier added that it was “ridiculous” for GPs to claim that their provider companies’ use of money is commercially sensitive.

“This is taxpayers’ money. There should be nothing to hide,” she said.

Clare Gerada, a GP in Lambeth and former chair of the Royal College of GPs, said there was a real danger that the current system would erode the trust and relationship between GPs and patients.

“You’re beginning to wonder whether things are being done in your best interest or in the interests of profit. We’ve got to be careful that it’s the patient’s pulse we’re feeling not the patient’s purse,” said Gerada.

Chaand Nagpaul, chair of the BMA’s GP committee, said that GPs who are directors of provider organisations should not hold a board position on a CCG which could commission that provider. “There should be a clear line,” he said.

Nagpaul added that even if CCGs are operating within the rules, the NHS should hold itself to higher standards than other industries.

“[The NHS is] a service rooted in very strong values and principles that the public expect of it,” he said. “I don’t think we should be judging ourselves on the way the commercial world may operate.”

To bolster governance, the BMA has also advised that each CCG should have a separate scrutiny committee of non-conflicted members to commission services from local general practices, which could include GPs coopted from neighbouring areas.

Nagpaul added that NHS England’s guidance may need to be revised as it is currently “too permissive” and leaves “enormous scope for variation between CCGs.”

Amanda Doyle, cochair of NHS Clinical Commissioners and chief operating officer at NHS Blackpool CCG, said CCGs acknowledged potential conflicts of interest but insisted that “they are manageable.”

“As long as CCGs … have the recommended checks and balances in place when they procure services, then the rationale for what and how they are commissioning from member practices will withstand scrutiny,” she said.