NAO Report – Conflicts of Interest in Health Commissioning

We’re glad to see that the National Audit Office has issued a report that picks up on the issue of conflicts of interest in healthcare commissioning. We’ve been going on about this ever since the new structure of Clinical Commissioning Groups (CCGs) was put in place some years back. CCG often have GPs (‘family doctors’) as members, yet also commission (buy) services that the same GPs may be offering themselves.

The NAO found that the issue is, if anything, bigger than we would have expected. No less than 41% of CCG members are also GPs, who may potentially have these conflicts of interest. And matters may get worse (or potentially worse) in the future, as the report points out.

From April 2015, CCGs could choose to take an enhanced role in GP service commissioning. This included an option to take on fully delegated responsibility from NHS England for commissioning primary medical services. NHS England believes that those CCGs who opted to do so will be able to commission care for their patients and populations in more coherent and joined-up ways — but they also expose themselves to a greater risk of conflicts of interest, both real and perceived”.

It is the duty of the CCGs to manage the conflicts, but what is clear from the report is that no-one is really keeping a close eye on this. NHS England and Monitor (the system regulator) are in the frame for this, but don’t seem to be stepping up to the mark.

NHS England has a limited understanding of how effectively CCGs are managing conflicts of interest or whether they are complying with requirements, which will hamper its ability to respond promptly to the likely increase in conflicts” says the report.

And as for Monitor; “Our analysis, to June 2015, found Monitor had only undertaken one formal investigation that included a concern about conflicts of interest in a CCG”.

Now that may mean that problems just aren’t arising. Or it may be that no-one is worrying too much about these issues, given the greater focus on huge systemic problems the NHS is facing (infinite demand, not enough funding, staff shortages etc).

The NAO did find that most CCGs have put in place key elements of a process to manage conflicts of interest. But it was hard to assess from publicly available information what has actually happened in their operations. Transparent information, that would support local accountability and scrutiny, was lacking. So here are the NAO’s recommendations; all good stuff, although maybe lacking a little in terms of really specific outcomes, outputs or deliverables!

To promote this confidence:

- the Department will need to be clear that it has assurance that conflicts of interest are being managed in a way that is sufficient to meet its needs as steward of the health system;

- NHS England will need to be satisfied that it has sufficient and timely information to assure itself that CCGs are managing conflicts promptly and effectively. This will include needing to be satisfied that CCGs have implemented the strengthened assurance measures in its new statutory guidance, and that these measures are operating as intended and that they are effective;

- Monitor will need to be confident that it could respond to an increased number of complaints about conflicts at appropriate scale and pace; and

- CCGs will need to ensure transparency at the local level when making commissioning decisions and when handling of conflicts of interest, to promote accountability.

We suspect it will need a nice juicy scandal before anyone gets really exercised by this. But at least the parties involved know that NAO has some interest in the issue now.

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