Should we be worried about CCG conflicts of interest?

Anxiety about conflicts of interest hangs over clinical commissioning groups (CCGs) now as it did GP fund-holders in the past. Worries about the propriety of giving GPs public money to purchase care – potentially from themselves – were raised several times as the Health and Social Care Bill worked its way through parliament four years ago.

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?

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#544933 Mary Elizabeth Hoult
community volunteer

I don't think their is a problem with conflict of interest with CCgs they always seem to the patient at the heart of everything they do.

#544934 John Davies



#544937 Craig Wakeham
Dorset CCG

This seems to be a call for MORE regulation and 'over-sight'. How does this 'square' with the call in Chris Ham's blog for space to innovate? It is my experience (working for a CCG) that the desire to show 'no conflict of interest' had lead to yet more neglect of primary care at a time when everyone recognized that constantly trying to 'fix' the problems in secondary care with more and more money simply doesn't work (remember what Einstein is reputed to have said was the definition of insanity). The solutions are in an effective primary care system, working in an integrated system with community, yes specialist services. Monitor simply doesn't get this...neither do auditors!

#544941 Ruth Robertson
The King's Fund

Thanks for your comment and I certainly agree with your description of what good integrated care needs to look like. I don't want to suggest needless extra bureaucracy, but think a more in-depth look at what's happening in a few CCGs will help NHS England and others work out the best approach to assurance and regulation.

#544950 Professor Maure...
Deputy Chair
Liverpool CCG

But how to choose which CCGs to examine as they are all so different including those whose statistics suggest similarities? Proportionality in risk management is the key to good transparent conflict of interest practices. We should not let Folk Devils scare us into inappropriate responses yet we should be ever vigilant for the small minority of individuals dominated by personal venal interests. Part of the down side of the opportunities afforded by robust and positive clinical leadership is the risk of conflicts of interest. In my opinion the benefits outweigh the risks - at least they do in Liverpool! I also think it is bit harsh to subject NHS and CCGs to a level of scrutiny and standards of probity far beyond that expected or delivered in Banking and other Business and Political sectors.

#544951 John Kapp
Social Enterprise Complementary Thaerapy Company SECTCo

Nobody is actually considering the interests of the patient (despite the rhetoric to the contrary) Paul Farmer's task force review of 20k mental patients found that 52% wanted more access to treatment, 33% wanted more choice of treatment, and 25% wanted more prevention of relapse.
The answer is the mass commissioning of the 8 week Mindfulness Based Cognitive Therapy (MBCT) course, which teaches patients self help. There is enough money (£3.8 bn pa) in the Better Care Fund to give 4 million Rachel (65, depressed in sheltered housing) and Dave (40, alcoholic and homeless) a £1000 course, but nobody is even considering this (except perhaps Devo Manchester) Pooled budgets for housing, health social care, education and criminal justice should be overseen by Health and Wellbeing Boards, but mine (Brighton and Hove) sees themselves as partners with the CCG, rather than above them. See my papers on section 9 of

#544952 Bernie Crean
Managing Director/CHC advocate
Care Review Services Ltd

There could be conflict of interest when a CCG contracts with a Health Trust to manage its CHC budget. I have heard of such contracts whereby the CCG give a set amount of money to meet CHC demands (i.e. £24 million) and the Trust is allowed to keep any surplus from that year. This would build in a financial incentive to make it harder for individuals to obtain CHC funding. It will also place that Trust at risk if they overspent on CHC and had to take money form other funding streams when they overspend on the contract with the CCG. I suspect that this may be occurring in many areas with CHC contracts.

#545246 Mark O'Sullivan
Member, community consultative panel
Bath CCG

Prof. Maure: But it is appropriate for organisations which spend public money to be subject to fuller scrutiny than those which do not.

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