Fast forward to the present day: have these fears about the improper use of public money been realised? The National Audit Office attempted to answer this question in a report published earlier this month.
On first reading of the report, the simple answer seems to be no. Monitor – which is responsible for ensuring that the NHS follows proper procurement processes – has so far conducted only one investigation into a complaint that involved a potential CCG conflict of interest. In that case (involving a community services contract in Northern, Eastern and Western Devon CCG), Monitor ruled that the CCG’s decisions had not been affected by conflicts of interest. NHS England – which is responsible for the ongoing assurance of CCGs – has also said conflicts have not been a serious cause for concern.
Despite this, I believe there is still reason for unease. As the purchaser–provider split gets fuzzier and NHS finances continue to tighten, there are three points that the NHS and its scrutineers should consider.
First, it’s important to look beyond the awarding of new contracts when identifying and addressing potential problems. Conflicts of interest in awarding contracts may be tangible and relatively easy to identify, but NHS England says few new contracts have been awarded since 2013. However, conflicts of interest could potentially occur at other levels of CCG decision-making:
- allocating funding: what proportion of a CCG’s budget should be spent on acute versus community versus primary care? And within that, what type of services should be commissioned?
- performance managing contracts: are providers performing well and if not, what actions should be taken to improve things?
Second, as (some) CCGs’ new responsibilities for co-commissioning primary care embed and the NHS works to implement the new, more integrated models of care outlined in the NHS five year forward view, the potential for conflicts will grow.
We know from an investigation into GP out-of-hours services last year that CCGs have not always managed conflicts of interest appropriately when commissioning services in primary care. Between now and 2020 we can expect to see more CCGs awarding large capitated contracts to multispecialty community provider (MCP) groups that are likely to be based around a group of local GP practices. It’s possible that the GPs involved in taking those commissioning decisions and managing those contracts will be working for the MCPs. Furthermore, under new contracting models that award a contract to a lead provider who then subcontracts with others, the supply chain may not always be obvious when the contract is signed and the seemingly simple task of identifying whether there is a potential for conflict may be tricky.
Third, after five years of austerity in the NHS budget, the cracks are starting to show in the acute sector and this may push conflicts of interest into the spotlight. As hospitals find it harder and harder to balance their books, they will be increasingly likely to challenge CCG decisions to take money out of acute contracts and shift it into primary care.
All three of these points relate to conflicts that cannot easily be monitored by trawls of meeting minutes and governance documents alone (the main focus of the NAO’s methodology). Although new guidance for co-commissioning has tightened up CCG governance processes, the approach to assurance is still reactive, based on CCG self-certification and investigations by exception.
The NAO points out that NHS England has only a ‘limited understanding’ of how effectively CCGs are monitoring conflicts of interest. But while it is not pragmatic (or desirable) for their local offices to monitor every contract decision made by CCGs, some more in-depth investigation is needed to understand which – if any – of the risks outlined above are affecting patient care. This month, NHS England is conducting an audit of 10 randomly selected CCGs to assess the effectiveness of its new guidance on conflicts of interest for primary care co-commissioners. I hope it will help identify whether and how the approach to managing conflicts should be enhanced in the future.
Underlying all this, transparency is essential to maintaining the trust of both the public and other parts of the health service. If public trust is lost, CCGs might find themselves heading for the scrap heap (as happened with their GP fund-holding predecessors).
I would be interested to hear what’s happening in your local health system. Are conflicts of interest affecting the services patients receive? Or is this inherent feature of clinical commissioning being managed appropriately through common-sense decision-making?