How are clinical commissioning groups managing conflicts of interest under primary care co-commissioning in England? A qualitative analysis

Abstract

ObjectivesFrom April 2015, NHS England (NHSE) started to devolve responsibility for commissioning primary care services to clinical commissioning groups (CCGs). The aim of this paper is to explore how CCGs are managing potential conflicts of interest associated with groups of GPs commissioning themselves or their practices to provide services.DesignWe carried out two telephone surveys using a sample of CCGs. We also used a qualitative case study approach and collected data using interviews and meeting observations in four sites (CCGs).Setting/participantsWe conducted 57 telephone interviews and 42 face-to-face interviews with general practitioners (GPs) and CCG staff involved in primary care co-commissioning and observed 74 meetings of CCG committees responsible for primary care co-commissioning.ResultsConflicts of interest were seen as an inevitable consequence of CCGs commissioning primary care. Particular problems arose with obtaining unbiased clinical input for new incentive schemes and providing support to GP provider federations. Participants in meetings concerning primary care co-commissioning declared conflicts of interest at the outset of meetings. Different approaches were pursued regarding GPs involvement in subsequent discussions and decisions with inconsistency in the exclusion of GPs from meetings. CCG senior management felt confident that the new governance structures and policies dealt adequately with conflicts of interest, but we found these arrangements face limitations. While the revised NHSE statutory guidance on managing conflicts of interest (2016) was seen as an improvement on the original (2014), there still remained some confusion over various terms and concepts contained therein.ConclusionsDevolving responsibility for primary care co-commissioning to CCGs created a structural conflict of interest. The NHSE statutory guidance should be refined and clarified so that CCGs can properly manage conflicts of interest. Non-clinician members of committees involved in commissioning primary care require training in order to make decisions requiring clinical input in the absence of GPs.

Achieving integrated care through commissioning of primary care services in the English NHS: a qualitative analysis

“…The legislation establishes NHSE as the statutory authority commissioning primary care services. The delegation of this function to CCGs does not remove this statutory responsibility, and introduces significant issues in relation to potential conflicts of interest 18. As a result, structures have been put in place within CCGs to separate the work of commissioning primary care services from the wider work of the CCG in commissioning secondary and community services, with Primary Care Co-Commissioning Committees constituted as separate decision-making bodies which are required to have a non-GP majority.…”

“…The introduction of co-commissioning drew much opposition, especially in terms of overcoming real and perceived conflicts of interest associated with GPs commissioning or contracting themselves 18. The key concerns were around performance management of the core GP contract of CCG members, with powers to issue breach notices and terminate contracts.…”

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“…Co-commissioning has caused increased concerns over conflicts of interest, whereby GPs could commission services that they themselves provide. 23 This has led to GP board members in one of our case study CCGs being asked to leave the room or abstaining from voting when decisions about primary medical services are made. This meant the CCG made clinically related decisions without any clinical input:It was a major contract, which had to be approved by Governing Body, however, all of the GPs there, or themselves, provide minor surgery for our patients, and therefore, we were all directly conflicted.…”

“…Co-commissioning has caused increased concerns over conflicts of interest, whereby GPs could commission services that they themselves provide. 23 This has led to GP board members in one of our case study CCGs being asked to leave the room or abstaining from voting when decisions about primary medical services are made. This meant the CCG made clinically-related decisions without any clinical input:…”

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“…CCGs as the organisational governance arrangements for the delivery of primary care co-commissioning were either not specified exhaustively by NHSE and the government or, when specified, created a ‗structural conflict of interest' that is very hard to manage (Moran et al 2017).…”