Conflicts of Interest
policy
Jan 2015
DRAFT
Chair: Dr Clare Highton
1
Chief Officer: Paul Haigh
Introduction
Transparency is an important value for our CCG, embedded in our constitution and
underpinning how we work.
This policy sets out how we manage conflicts of interest to:
• enable our clinicians and the CCG in our commissioning roles to demonstrate
that we are acting fairly and transparently and in the best interest of our
patients;
• ensure that we operate within the legal framework, but without being
bound by over-prescriptive rules that risk stifling innovation and clinical
leadership;
• safeguard clinically led commissioning, whilst ensuring objective investment
decisions;
• provide the public, providers, Parliament and regulators with confidence in
the probity, integrity and fairness of our decisions; and
• uphold the confidence and trust between patients and GP, in the recognition
that individual commissioners want to behave ethically but may need support
and training to understand when conflicts (whether actual or potential) may
arise and how to manage them if they do.
And outlines:
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the nature of conflicts of interest;
arrangements for declaring interests;
maintaining a register of interests;
keeping a record of the steps taken to manage a conflict;
excluding individuals from decision-making where a conflict arises; and
engagement with a range of potential providers on service design.
What are conflicts of interest?
A conflict of interest occurs where an individual’s ability to exercise judgment, or act in a
role, is or could be impaired or otherwise influenced by his or her involvement in another
role or relationship. The individual does not need to exploit his or her position or obtain
an actual benefit, financial or otherwise, for a conflict of interest to occur.
“For the purposes of Regulation 6 [National Health Service (Procurement, Patient
Choice and Competition) (No.2) Regulations 2013], a conflict will arise where an
individual’s ability to exercise judgment or act in their role in the commissioning
of services is impaired or influenced by their interests in the provision of those
services.”
Monitor - Substantive guidance on the Procurement, Patient Choice
and Competition Regulations (December 2013)
As well as direct financial interests, conflicts can arise from an indirect financial interest
(e.g. payment to a spouse) or a non-financial interest (e.g. reputation). Conflicts of
loyalty may arise (e.g. in respect of an organisation of which the individual is a member
or with which they have an affiliation). Conflicts can arise from personal or professional
Chair: Dr Clare Highton
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Chief Officer: Paul Haigh
relationships with others, e.g. where the role or interest of a family member, friend or
acquaintance may influence an individual’s judgment or actions, or could be perceived to
do so. Depending upon the individual circumstances, these factors can all give rise to
potential or actual conflicts of interest.
Gifts or hospitality offered to you by external bodies and whether this was declined or
accepted in the last twelve months may constitute a conflict.
Interests and gifts will be recorded on the register of interests and register of gifts and
hospitality, which will be maintained by the CCG Business Coordinator on behalf of the
Accountable Officer.
The register will be accessible by the public and inspection of the register of CCG
Board members interests will be encouraged, as appropriate.
For a commissioner, a conflict of interest may therefore arise when their judgment as a
commissioner could be, or be perceived to be, influenced and impaired by their own
concerns and obligations as a provider. In the case of a GP involved in
commissioning, an obvious example is the award of a new contract to a provider in
which the individual GP has a financial stake. However, the same considerations, and
the approaches set out in this guidance, apply when deciding whether to extend a
contract.
What are the principles we use when managing conflicts of interest?
Conflicts of interest can be managed by:
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Doing business appropriately. If we get our needs assessments, consultation
mechanisms, commissioning strategies and procurement procedures right from
the outset, then conflicts of interest become much easier to identify, avoid and/or
manage, because the rationale for all decision-making will be clear and
transparent and should withstand scrutiny;
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Being proactive, not reactive. We will always seek to identify and minimise the
risk of conflicts of interest at the earliest possible opportunity, for instance by:
o considering potential conflicts of interest when electing or selecting
individuals to join our governing body or take on leadership roles;
o ensuring individuals receive proper induction and training so that they
understand their obligations to declare conflicts of interest.
We will establish and maintain registers of interests, and agree in advance how
a range of possible situations and scenarios will be handled, rather than
waiting until they arise;
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Assuming that individuals will seek to act ethically and professionally,
but may not always be sensitive to all conflicts of interest. Rules should
assume people will volunteer information about conflicts and, where
necessary, exclude themselves from decision-making, but there should also
be prompts and checks to reinforce this;
Chair: Dr Clare Highton
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Chief Officer: Paul Haigh
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Being balanced and proportionate. Rules should be clear and robust but
not overly prescriptive or restrictive. They should ensure that decision-making
is transparent and fair, but not constrain people by making it overly complex or
cumbersome;
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Openness. Ensuring early engagement with our patients and public,
clinicians and other stakeholders, including local Healthwatch and Health and
Wellbeing Boards, in relation to proposed commissioning plans and
transacting our business in public and open to scrutiny
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Responsiveness and best practice. Ensuring that commissioning intentions
are based on local health needs and reflect evidence of best practice – securing
‘buy in’ from local stakeholders to the clinical case for change;
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Transparency. Documenting clearly the approach taken at every stage in the
commissioning cycle so that a clear audit trail is evident;
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Securing expert advice. Ensuring that plans take into account advice from
appropriate health and social care professionals, e.g. through clinical senates and
networks, and draw on commissioning support, for instance around formal
consultations and for procurement processes;
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Engaging with providers. Early engagement with both incumbent and potential
new providers over potential changes to the services commissioned for our
population;
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Creating clear and transparent commissioning specifications that reflect the
depth of engagement and set out the basis on which any contract will be awarded
and on which performance will be measured;
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Following proper procurement processes and legal arrangements, including
even-handed approaches to providers;
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Ensuring sound record-keeping, including up to date registers of interests;
and
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A clear, recognised and easily enacted system for dispute resolution.
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Individual responsibility to record conflict - whilst individuals have a
responsibility to register their own conflicts, the CCG expect individuals to
recognise their personal duty of candour in raising any perceived conflicts of other
individuals, in order to ensure transparency and openness is maintained. The
CCG is keen to maintain a culture of openness and support to all colleagues and
stakeholders and as such is keen to uphold a culture where individuals can raise
concerns and believe this supports the overarching requirement that where there
is any doubt about the existence of a conflict, it is better to raise it so a declaration
can be recorded. This supports our whistleblowing policy and constitutional
statements that our ethos of encouraging our staff and members to feel confident
in speaking out over any concerns they may have.
Chair: Dr Clare Highton
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Chief Officer: Paul Haigh
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Retrospective action and potential challenges - whilst we are endeavouring to
ensure that through robust process, any and all conflicts are registered, both at all
appropriate CCG meetings and via an ongoing structure of quarterly updates of
declaration forms, it is recognised that an individual may not appropriately declare
their interests in good time. In this instance the Chair of the relevant committee
would consider, with support from the CCG Chief Officer and/or the Audit
Committee Chair, any perceived impact and the risk involved in not making the
declaration and as such any required corrective action. These would then be
detailed and the next committee meeting in order to maintain openness and
transparency. In the event that we receive a challenge in respect to our
management of conflicts or where it is believed an individual has acted outside of
the guidance held within this policy or our constitution, the CCG Chief Officer
would undertake to investigate the matter and ensure that any wrongdoing is
appropriately managed and highlighted to the CCG Board.
Our register of interests
Our operating model
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We maintain a number of registers of interest for each of our committees and
Board which are all published and available on the CCG website
(http://www.cityandhackneyccg.nhs.uk/ONELCityHackney/Pages/aboutus/register-of-interests.htm).
We ensure that all individuals declare any conflict or potential conflict in relation
to any decision as soon as they become aware of it and we record it.
We require all appointees or office holders to the CCG to complete a register of
interests declaration which we publish and regularly review and update
We require the CCG Board and each of our sub-committees and each
Programme Board to have a register of interests of all members
We specifically exclude from either any clinical lead or formal CCG role or office any
individual who holds an appointment with the City and Hackney GP Confederation
and/or CHUHSE (the local GP Out of Hours provider).
We require all our GPs involved in CCG roles to declare their interests in both the
Confederation and CHUHSE alongside their individual practice interests.
How we operate this
We use the form in Appendix 1 to record all interests as follows;
On appointment:
Applicants for any appointment to an office in the CCG or to our governing body are
asked to declare any relevant interests. When an appointment is made, a formal
declaration of interests will be made and recorded and published on our website and
in the register for all committees of which the individual is a member.
At meetings:
Chair: Dr Clare Highton
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Chief Officer: Paul Haigh
All attendees are asked to declare any interest they have in any agenda item before it
is discussed or as soon as it becomes apparent. Even if an interest is declared in the
register of interests, it should be declared in meetings where matters relating to that
interest are discussed.
The Chair also asks members to ensure their register of interests form is up to date.
Declarations of interest are recorded in minutes of meetings. This applies to the CCG
Board, its sub-committees and the CCG Programme Boards.
Quarterly:
We proactively request all appointees and office holders to review and reconfirm their
interests every quarter – i.e. 1 April; 1 July; 1 October and1 January - and this is
organised by Corporate Services.
On changing role or responsibility:
Where an individual changes role or responsibility within the CCG or our governing
body, any change to the individual’s interests are declared.
On any other change of circumstances:
Wherever an individual’s circumstances change in a way that affects the individual’s
interests (e.g. where an individual takes on a new role outside the CCG or sets up a
new business or relationship), a further declaration should be made to reflect the
change in circumstances. This could involve a conflict of interest ceasing to exist or a
new one materialising.
Conduct of meetings
The up to date register of interests for that meeting is always included in the agenda
papers for each meeting. It is noted as part of the agenda.
We also require at the start of each meeting that members declare any interests relevant
to the business being discussed.
Noting of the register and all interests declared are included in the minutes of the
meeting.
The Chair of any meeting has responsibility for deciding whether there is a conflict of
interest and the appropriate course of corresponding action. In making such decisions,
the Chair may wish to consult the CCG Chief Officer and/or the lay member for
governance.
All decisions, and details of how any conflict of interest issue has been managed, are
recorded in the minutes of the meeting.
Depending on the nature of the conflict, GPs or other practice representatives could
be permitted to join in discussions at the meeting, about the proposed decision, but
should not take part in any vote on the decision.
Chair: Dr Clare Highton
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Chief Officer: Paul Haigh
Our Register of procurement decisions
On our website at
http://www.cityandhackneyccg.nhs.uk/ONELCityHackney/Pages/about-us/tenderscontracts.htm we have a register of our procurement decisions taken. This includes:
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the details of the decision;
who was involved in making the decision (i.e. governing body or committee
members and others with decision-making responsibility); and
a summary of any conflicts of interest in relation to the decision and how
this was managed by the CCG.
The register also includes a link to the meeting where the procurement decision was
taken and the papers used to inform that decision.
Making decisions
Our operating model
Our Programme Boards have responsibility for developing all proposals for new services
and for service improvements which will improve outcomes for our patients. In doing so
they will develop a pathway outlining how any new service or service development fits
within existing services.
We are committed to engaging our patients, our members and relevant providers,
especially clinicians, in confirming that the design of service specifications will meet
the needs of our patients.
Such engagement, done transparently and fairly, is entirely legal. However, conflicts of
interest can occur if we engage selectively with only certain providers (be they
incumbent or potential new providers) in developing a service specification for a
contract for which they may later bid.
We seek, as far as possible, to specify the outcomes that we wish to see delivered
through a new service, rather than the process by which these outcomes are to be
achieved. As well as supporting innovation, this helps prevent bias towards particular
providers in the specification of services.
Our engagement will follow the three main principles of procurement law, namely
equal treatment, non-discrimination and transparency. This includes ensuring that the
same information is given to all.
Other steps include:
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We are explicit that a service design/re-design exercise is taking place
and invite participation from our patients, stakeholders and any
potential providers and other interested parties (ensuring a record is
kept of all interactions);
Chair: Dr Clare Highton
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Chief Officer: Paul Haigh
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as the service design develops, we engage with a wide range of
providers on an ongoing basis to seek comments on the proposed
design, e.g. via the work of the Programme Board and via workshops
with interested parties;
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we use our engagement to help shape the requirement to meet our
patients’ needs but take care not to gear the requirement in favour of
any particular provider(s);
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we engage the advice of the CCG’s Independent GP Adviser, as well as
an independent specialist clinical adviser, on the design of services;
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we are completely transparent about our procedures;
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we ensure at all stages that potential providers are aware of how the
service will be commissioned; and
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we maintain commercial confidentiality of information received from providers
where appropriate but do not allow commercial confidentiality to restrict what
we debate and transact in public.
When engaging our providers on service design, we recognise that we - the CCG - have
ultimate responsibility for service design and for selecting the provider of services.
The most obvious area in which conflicts could arise is where we commission (or
continue to commission by contract extension) healthcare services, including GP
services, in which a member of the CCG has a financial or other interest. This may
most often arise in the context of co-commissioning of primary care, particularly with
regard to delegated arrangements, but it also needs to be considered in respect of any
commissioning issue where GPs are current or possible providers.
The process
Where a Programme Board is considering a new service to be commissioned from GPs
as providers/the GP Confederation/CHUHSE or where GPs/the GP
Confederation/CHUHSE may be a potential bidder, the Programme Board will go
through the following steps:
1. Programme Board develops idea for a new service to be commissioned from
practices.
2. Initial consultation about the idea with members via CCF/Consortia/Clinical
Executive Committee.
Outline direction of travel to GP Confederation if a list based service.
Share plan with Primary Care Quality Board.
3. Develop service specification using following frame: What outcomes do we want delivered?
 What is the basis of the CCG contract?
Chair: Dr Clare Highton
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Chief Officer: Paul Haigh
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How will we measure whether the service has been delivered?
How will we pay for delivery?
Programme Board to co-develop the specification by actively engaging with:
 Mike Fitchett, Independent GP Advisor on specification and outcomes;
 Anna Bennett re contractual framework;
 Anna Garner on outcomes and metrics;
 Jenny Singleton on quality;
 PPI representative – either via Programme Board or PPI Committee.
4. Test with CSU if procurement is needed or can contract with the GP
Confederation under single tender action as it’s a list-based service.
Their guidance to your Board to be submitted to Primary Care Committee.
5. Consult on final version of specification with members, LMC and GP
Confederation.
Consider comments and finalise specification, confirming back how comments
have been incorporated.
6. Finalise service specification and formally sign off at the Programme Board
Complete Code of Conduct form.
Submit to Primary Care Committee (and PCQB for information).
We have appointed an independent GP Advisor. This is a GP who does not practice
within City and Hackney nor has any interest in delivering services to our patients. S/he
has the following roles:
• to provide independent clinical advice to the Programme Board in the
development of the service specification for any service;
• to ensure that there is independent clinical advice available to the Programme
Board when local clinical leaders have a conflict of interest;
• to attend the CCG’s Primary Care Committee and provide independent clinical
and GP advice to the Committee on the proposed service specifications and
outcomes. A copy of the job description for this role is in Appendix 4.
Where any new service proposal needs additional funding for implementation, the
Programme Board is responsible for developing a project initiation proposal which, along
with the service specification, is considered by the CCG’s Prioritisation and Investment
Sub-committee.
For all proposed contracts with practices/the GP Confederation/CHUHSE:
• the Programme Board must submit their service specification and the signed
code of conduct form in Appendix 2 to the CCG’s Primary Care Committee;
• the key considerations for the Primary Care Committee when considering the
proposal are:
o Are we clear about the service, outcomes, measurement and payment
which will form the basis of the contract?
o How has the Programme Board engaged with patients in co-developing the
specification and how have they reflected patient feedback and comments
Chair: Dr Clare Highton
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Chief Officer: Paul Haigh
o Does the funding represent VFM compared to other services
commissioned from practices/the Confederation/CHUHSE and other
providers?
o How does the contract align with other provider contracts?
o How has the Programme Board mitigated against conflicts of interest from
GPs as providers in developing the model?
The code of conduct form in Appendix 2 has been designed to publicly demonstrate
how the Programme Board has developed its service specification and how it has
managed and mitigated the conflicts of interest which are inherent in clinical
commissioning.
The service specification and code of conduct form are published on the register of
procurement decisions once the Primary Care Committee has confirmed its decision.
This is to ensure that the public can see both the details of the service and how the
Programme Board managed the conflicts of interest.
In developing their proposals each Programme Board is required to take formal advice
from NELCSU on:
• whether the service specification outlines a list based service which can only be
provided by practices (and would therefore be commissioned under single tender
action from the GP Confederation/practices);
• whether the service should be procured and who are the potential providers.
The Programme Board is required to submit this advice and their proposed contractual
arrangements along with the specification and code of conduct form to the Primary Care
Committee.
The rationale for the CCG to contract with the GP Confederation under single tender
action for list based services is to ensure 100% population coverage – i.e. that all
commissioned services are available and accessible to all patients registered with City
and Hackney practices and the onus is on the Confederation as part of the CCG
contract to put in place a delivery model which will provide this.
Mobilising the contract
Once a decision has been made to enter into a contract:
• If procurement is not required, once the service specification has been agreed by
the Primary Care Committee and any funding agreed by the Prioritisation SubCommittee, the specification should be issued;
• This will be done by the CCG Head of Contracts and Programme Board jointly,
inviting the provider to respond and agree mobilisation;
• This is not an opportunity for the provider or practices to re-negotiate the service
specification – the service specification is agreed by the Primary Care Committee
as the definitive version;
• Once mobilisation etc. is agreed, the CCG Head of Contracts will liaise with the
provider to issue the formal contractual agreement.
Making payments
Chair: Dr Clare Highton
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Chief Officer: Paul Haigh
We are committed to total transparency in all payments to practices/the
Confederation/CHUHSE and our process is as follows:
• Each Programme Board is responsible for measuring whether the provider has
delivered the contractual requirements in line with the service specification;
• In doing so they will require information from the provider on performance and
how this has been evaluated and how there has been independent and objective
assessment of delivery;
• When contracting with the Confederation they will also be required to outline how
the contractual funding has been used in an open book way – i.e. how contract
income has been used by the Confederation vs. by practices and what it has
funded to support the delivery of the contract;
• Each Programme Board is required to complete the form in Appendix 3 which
outlines how they have assessed contractual performance and this should be
accompanied by a proposed payment schedule which has been countersigned by
the CCG Deputy CFO.
• The completed pro-forma and schedule is submitted to the Primary Care
Committee who will scrutinise the work of the Programme Board and confirm
whether they are satisfied that payment should be made.
• The completed pro-forma and payment schedule is published by the CCG as part
of the papers for the Primary Care Committee on the CCG website and therefore
all payments and the rationale for these is in the public domain.
Role of Primary Care Committee
We have established a Primary Care Committee which takes delegated responsibility
from the CCG Board for:
• Management of the core GP contract;
• Managing practice vacancies;
• Scrutiny, award and management of any additional services to be contracted from
the Confederation, CHUHSE or practices;
• Any contract where practices/Confederation/CHUHSE is a potential provider;
• Any procurement where practices/the Confederation/CHUHSE may be a potential
bidder;
• Approval of all non-core payments to practices/the Confederation/CHUHSE,
These functions recognise our plans to take delegated responsibility for primary care
commissioning from NHSE in 2015.
The terms of reference for this Sub-committee are in Appendix 5
This Committee plays a critical role in how we manage conflicts of interest and how we
ensure transparency and objectivity in our decision making.
The Committee:
• meets in public and its papers are all published on the CCG website at - Link
• has an independent Chair who is a non-voting associate lay member of the CCG
Board and its other formal members are:
o representatives of London Borough of Hackney and City of London
Healthwatches;
o CCG Board secondary care consultant;
Chair: Dr Clare Highton
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Chief Officer: Paul Haigh
CCG Board Nurse
CCG Board lay member (Governance);
CCG Board lay member (PPI & Conflicts)
CCG Board associate lay member
Chief Officer;
Chief Finance Officer;
also has in attendance (i.e. participating but not voting):
o the London Borough of Hackney/City of London Director of Public Health;
o the CCG’s independent GP advisor;
o and the Chairs of the London Borough of Hackney and City of London
HWBBs have a standing invite to attend the meetings.
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The terms of reference outline the arrangements for the conduct of business by the
Committee and details of quoracy and decision making.
The Committee reports on its work to the CCG Board, and thus to stakeholders and
members, each quarter.
The Committee meets with the Audit Committee at least annually to review its operating
processes and how it has assessed proposals from Programme Boards and met its
objectives. The Audit Committee will ask the CCG’s internal auditors to include the
operation of the Committee and its operating policies within its annual work plan and
may ask the internal auditors to conduct an independent "deep dive" into any particular
exercise or decision and report the outcome to the Audit Committee.
Scrutiny of the work of the Primary Care Committee by the CCG Audit Committee and
internal auditors provides an important assurance role to the CCG Board for the risk and
assurance/governance frameworks.
The CCG Board decision making
Although the Primary Care Committee has delegated responsibility from the CCG Board
for the areas outlined in its terms of reference, there are times when the CCG Board will
be considering and making a decision where the GP members have a conflict of
interest.
Like all committees the CCG Board maintains a register of interest which goes to each
meeting for noting and is proactively updated each quarter. At the start of each meeting
the Board members are asked to declare any conflicts of interest in any item of business
and these are recorded in the minutes.
Where the GP Board members have a conflict of interest our constitution in section
8.2.10, makes the following provision for decision making;
The Chair of the CCG Board meeting has responsibility for deciding whether there is a
conflict of interest and the appropriate course of corresponding action. In making such
decisions, the Chair may wish to consult the CCG Chief Officer and/or the lay member
for governance.
All decisions, and details of how any conflict of interest issue has been managed, are
Chair: Dr Clare Highton
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Chief Officer: Paul Haigh
recorded in the minutes of the meeting.
Depending on the nature of the conflict, GPs or other practice representatives could
be permitted to join in discussions at the meeting, about the proposed decision, but
should not take part in any vote on the decision.
Transparency of GP earnings
In line with NHSE commitments on transparency of GP earnings, there will be a new
contractual requirement for GP practices to publish on their practice website by 31
March 2016, the mean net earnings of GPs in their practice (to include contractor and
salaried GPs) relating to 2014/15 financial year. Alongside the mean figure, practices
must publish the number of full and part time GPs associated with the published figure.
The figure will include earnings from NHS England, CCGs and local authorities for the
provision of GP services that relate to the contract and which would have previously
been commissioned by PCTs. Costs relating to premises will not be included. Fuller
details will be included in the implementation guidance for the 2015/16 GP contract,
due to be published in February 2015. This is an interim solution until arrangements
are finalised for publishing individual GP net earnings in 2016/17.
Additional Guidance
The CCG have also attached as Appendix 6, the following guidance for additional
reference – ‘NHS Clinical Commissioners, Royal College of General Practitioners and
British Medical Association - Shared principles on conflicts of interest when CCGs are
commissioning from member practices’
Review
This policy will be reviewed in January of each year and also reviewed in the light of any
new guidance and the work of the CCG.
We will undertake collective organisational development sessions to ensure that we
embed the principles and operating model outlined in this policy in our everyday practice
and all Committee and Board members will participate in our annual appraisal and
review processes to reflect any learning points or areas for development and review in
how we conduct our business.
Chair: Dr Clare Highton
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Chief Officer: Paul Haigh
Appendix 1 - Declaration of
interests for members/employees
template
NHS City & Hackney Clinical Commissioning Group
Member / employee/ governing body member / committee or sub-committee
member (including committees and sub-committees of the governing body)
[delete as appropriate] declaration form: financial and other interests
This form is required to be completed in accordance with the CCG’s Constitution and
section 14O of The National Health Service Act 2006, the NHS (Procurement, Patient
Choice and Competition) regulations 2013 and the Substantive guidance on the
Procurement, Patient Choice and Competition Regulations
Notes:
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Each CCG must make arrangements to ensure that the persons mentioned
above declare any interest which may lead to a conflict with the interests of the
CCG and/or NHS England and the public for whom they commission services in
relation to a decision to be made by the CCG and/or NHS England or which may
affect or appear to affect the integrity of the award of any contract by the CCG
and/or NHS England.
A declaration must be made of any interest likely to lead to a conflict or potential
conflict as soon as the individual becomes aware of it, and within 28 days.
If any assistance is required in order to complete this form, then the individual
should contact the CCG Business Coordinator, Matthew Knell
([email protected]).
The completed form should be sent by both email and signed hard copy to the
CCG Business Coordinator, Matthew Knell ([email protected]).
Any changes to interests declared must also be registered within 28 days by
completing and submitting a new declaration form.
The register will be published on the CCG website and can be found via the
following link - Register of interests
Any individual – and in particular members and employees of the CCG and/or NHS
England- must provide sufficient detail of the interest, and the potential for conflict
with the interests of the CCG and/or NHS England and the public for whom they
commission services, to enable a lay person to understand the implications and
why the interest needs to be registered.
If there is any doubt as to whether or not a conflict of interests could arise, a
declaration of the interest must be made.
Interests that must be declared (whether such interests are those of the individual
themselves or of a family member, close friend or other acquaintance of the
individual) include:
 roles and responsibilities held within member practices;
Chair: Dr Clare Highton
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Chief Officer: Paul Haigh
 directorships, including non-executive directorships, held in private companies or
PLCs;
 ownership or part-ownership of private companies, businesses or consultancies
likely or possibly seeking to do business with the CCG and /or with NHS England
 shareholdings (more than 5%) of companies in the field of health and social care;
 a position of authority in an organisation (e.g. charity or voluntary organisation) in
the field of health and social care;
 any connection with a voluntary or other organisation (public or private) contracting
for NHS services;
 research funding/grants that may be received by the individual or any organisation
in which they have an interest or role;
 any other role or relationship which the public could perceive would impair or
otherwise influence the individual’s judgment or actions in their role within the CCG.
We would also ask you to record your interests in the following orgnaisations as it
is important we capture all involvement;
 CHUHSE
o Individual member (GP, Community, Staff)
 Working for a practice contracting with CHUHSE/GP Confederation
o Working for a practice who is a shareholder of the GP
Confederation
o You may also need to indicate other associations with these
organisations as described above for example employed as a GP,
Board member, clinical lead etc. Undertaking any paid sessions for
CHUHSE
 As we ask for LMC involvement in our commissioning, please indicate if you are
member of the local LMC.
If there is any doubt as to whether or not an interest is relevant, a declaration of the
interest must be made.
Declaration:
Name:
Position within or
relationship with,
the CCG or NHS
England:
Interests
Type of Interest
Details
Chair: Dr Clare Highton
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Personal interest or
that of a family
member, close friend
or other
acquaintance?
Chief Officer: Paul Haigh
Roles and
responsibilities
held within
member practices,
CHUHSE, GP
CONFEDERATION
Directorships,
including nonexecutive
directorships, held
in private
companies or PLCs
Ownership or partownership of
private companies,
businesses or
consultancies
likely or possibly
seeking to do
business with the
CCG and/or with
NHS England
Shareholdings
(more than 5%) of
companies in the
field of health and
social care
Positions of
authority in an
organisation (e.g.
charity or voluntary
organisation) in the
field of health and
social care
Any connection
with a voluntary or
other organisation
contracting for
NHS services.
Research
funding/grants that
may be received by
the individual or
any organisation
they have an
interest or role in
Membership of
CHUHSE (GP,
Community, Staff)
Chair: Dr Clare Highton
16
Chief Officer: Paul Haigh
Working for a
practice who is a
shareholder in the
GP Confederation
Membership of LMC
Other specific
interests?
Any other role or
relationship which
the public could
perceive would
impair or otherwise
influence the
individual’s
judgment or actions
in their role within
the CCG and/or with
NHS England.
To the best of my knowledge and belief, the above information is complete and
correct. I undertake to update as necessary the information provided and to review
the accuracy of the information provided regularly and no longer than annually. I give
my consent for the information to be used for the purposes described in the CCG’s
Constitution and published accordingly.
Signed:
Date:
Chair: Dr Clare Highton
17
Chief Officer: Paul Haigh
Chair: Dr Clare Highton
18
Chief Officer: Paul Haigh
Appendix 2: Code of Conduct Template
Service:
Programme Board:
Question
Comment/Evidence
Part A - Developing the service specification
Please provide a brief description of the service:
Outline the benefits to patients if this service is
commissioned:
How will this service support the delivery of the Programme
Board’s commissioning intentions:
Describe how will this service will improve CCG outcomes
and service quality:
How does the proposal support the priorities in the HWBBs’
health and wellbeing strategies)?
Chair: Dr Clare Highton
19
Chief Officer: Paul Haigh
Outline how you have involved patients in the decision to
commission this service and then in the development of the
specification. Who has been involved?
What changes were made following consultation?
Describe the range of CCG clinicians involved in designing
this proposed service and their input to the service
specification:
When and how have you consulted member practices
about commissioning this service:
What changes were made following consultation:
How will this proposed contract align with other contracts
commissioned by the CCG and promote integrated service
delivery across providers
Part B – Managing conflicts of interest
Outline from who you have obtained an independent
clinical perspective / external advice on the specification
and the KPIs/contract:
What changes were made as a result of their comments?
Chair: Dr Clare Highton
20
Chief Officer: Paul Haigh
Describe how all conflicts and potential conflicts of interests
have been declared in the development and agreement of
the service specification:
Can you confirm how conflicts have been recorded and
provide a link to these declarations?
Describe how you have mitigated the conflicts of interest
declared?
Part C – Proposed contract
What is the annual value of this contract?
How have you determined that this represents value for
money and developed the price for this service?
What will be the basis of the contract – on what
performance and / or outcomes will payments be made?
Describe how you will assess the achievement of these
outcomes in recommending payments?
How will you monitor the quality of the service
commissioned?
What systems will there be to monitor and publish data on
referral patterns?
Chair: Dr Clare Highton
21
Chief Officer: Paul Haigh
PART D – List based service only
Outline why this is a list based service and the advice you
have received to confirm this? (i.e. can only be provided by
City and Hackney GP practices)
Please attach the advice that this is a list based service
What steps have you taken to demonstrate that there are
no other providers that could deliver this service?
In what ways does the proposed service go above and
beyond what GP practices should be expected to provide
under the GP contract?
What assurances will there be that a GP practice is
providing high-quality services under the GP contract
before it has the opportunity to provide any new services?
Describe how you will evaluate the contract delivery
proposals:
Describe:

Who will be involved?

How you will obtain independent clinical advice?

How will you ensure there are no conflicts of
interest?
Chair: Dr Clare Highton
22
Chief Officer: Paul Haigh
What additional external involvement will there be in
scrutinising the proposals?
How will you ensure that patients are aware of the full
range of qualified providers from whom they can choose if
appropriate?
Part E – if you are proposing procurement and practices/GP Confederation are potential bidders
Please outline the procurement process and timescale –
attach the advice about this procurement process
Chair: Dr Clare Highton
23
Chief Officer: Paul Haigh
Describe the process you will use for evaluating the bids:
Describe:

Who will be involved?

How you will obtain independent clinical advice?

How will you ensure there are no conflicts of
interest?
Please attach the proposed service specification
Signed by Programme Board Director:
Date:
Signed by PB Chair:
Date:
Chair: Dr Clare Highton
24
Chief Officer: Paul Haigh
APPENDIX 3: RECOMMENDING PAYMENTS PROFORMA
CCG MEMBER PRACTICES/CONFEDERATION
RECOMMENDING PAYMENTS PRO-FORMA
PROGRAMME BOARD:
CONTRACT/SERVICE:
QUESTION
Provide a brief description of the service
under this contract:
What are the benefits of this service for our
patients?
How has your Programme Board assessed
the performance to make your
recommendations? e.g.
 What data did you use?
 How did you assess it?
 How did you measure against the
service specification?
How have you mitigated the conflicts of
interest in reviewing the performance of the
Programme Board Chair's practice and of
other practices of Programme Board GP
members?
EVIDENCE
Chair: Dr Clare Highton
25
Chief Officer: Paul Haigh
Did you identify any concerns or queries?
How have you addressed these?
How are you assured of the quality of the
service being provided?
What are the contractual payment
arrangements to practices for this service?
When did your Programme Board debate
these recommendations?
What issues were raised and debated at the
Board?
What members were in attendance at the
PB meeting (names and designation?
What is the total value of the payment you
are recommending?
How does this compare to the budget for this
period?
PLEASE ATTACH A SCHEDULE INDICATING THE RECOMMENDED PAYMENTS
Chair: Dr Clare Highton
26
Chief Officer: Paul Haigh
Signed by:
Payment schedule supported by Finance
Designation
Date
Programme Board Director
Date
Programme Board Chair
Date
Corporate Services use
CCG Contracts Committee
Considered and recommended for payment at the meeting on (add date)
CCG Board
Presented to the CCG Board for payments authorisation on (add date)
Chair: Dr Clare Highton
27
Chief Officer: Paul Haigh
Appendix 4:- GP Advisor to City and
Hackney CCG
Job description
Sessional commitment: 2-3 per month (session is 3.5 hours)
Responsible to: CCG Chief Officer
Accountable to: CCG Chair
Role summary
The post holder will provide a perspective across the governance of the CCG on issues
relating to commissioned services where local GP Leads have a conflict of interest. The
CCG commissions its out of hours service from a local social enterprise which is run by
local GPs and of which CCG practices are members; similarly the GPs as providers are
creating a GP Federation that the CCG will contract with for the provision of CCG
commissioned primary care services.
Main responsibilities








To review and provide an independent clinical perspective on all service specifications
developed by CCG Programme Boards where the potential provider is practices as
providers/the GP Federation;
To ensure that the specification for any new service is robust, will deliver
improvements for local residents and that there are clear KPIs for monitoring of the
quality of the service being delivered;
To support the CCG to develop a framework for evaluating all proposals from
practices as providers to deliver services and provide clinical input to the
development of decision making arrangements and contractual arrangements;
To provide clinical input to the contract monitoring process and arrangements,
attending contract monitoring meetings as required and ensuring that the CCG can be
assured of the capacity and capability of its primary care commissioned services to
improve outcomes and quality;
To provide support to the Programme Directors to evaluate performance information
and recommend whether contractual terms have been delivered and payment should
be recommended;
To attend the CCG Governing Body Board meetings as required for specific items
To attend the CCG Audit Committee as required and provide an independent clinical
perspective to the deliberations of the Audit Committee in their role of providing
assurance to the CCG Board around contracting with local practices
To be a member of the CCG Remuneration Committee and provide an independent
clinical perspective on remuneration of CCG Clinical Leads and the terms of their
engagement.
April 2014
Chair: Dr Clare Highton
Chief Officer: Paul Haigh
PERSON SPECIFICATION
Job Title:
GP Advisor
Band:
Sessional rate
This is a specification of the qualifications, knowledge, experience, skills and abilities that
are required to carry out effectively the responsibilities of the post (as outlined in the role
description) and is the basis for selecting a candidate.
REQUIREMENTS
ESSENTIAL
DESIRABLE
EDUCATION AND
QUALIFICATIONS
GMC Registration/ Medical
licence
Postgraduate qualifications/
diploma.
Not practicing in any practice
which is part of City and
Hackney CCG
Postgraduate Teaching
qualification.
Currently included on Medical
Performers List.
MRCGP or appropriate (over 5
years) GP experience.
KNOWLEDGE
Relevant knowledge gained
through previous employment,
training or by other means.
Knowledge of the context in
which primary care operates in
City and Hackney and the local
health challenges of inner
cities.
Knowledge of policy and
developments in primary care
and of primary care
contracting.
Knowledge of developing and
evaluating quality standards
and outcomes.
Chair: Dr Clare Highton
Chief Officer: Paul Haigh
EXPERIENCE
Experience of giving
GP/Primary care Clinical
Advice.
Primary care teaching/ GP
Trainer or education.
Delivery of primary care
services and of the potential
contribution that primary care
provision can make to service
development.
SKILLS, ABILITIES and
PERSONAL QUALITIES
Ability to develop and maintain
communication with people on
complex matters, issues and
ideas and/or in complex
situations, anticipating barriers
and taking action to improve
communication as necessary.
Able to build constructive and
supportive relationships with
colleagues.
Able to develop and utilise
professional and other
networks. For example,
identifying opportunities for
partnership working in the local
healthcare system, and
manage stakeholder
relationships in the long-term,
and be a source of expertise
for others.
Ability to analyse and take
decisions in relation to difficult
and contentious facts where
there may be a number of
possible courses of action.
Ability to shape new policies
and set long-term objectives
aligned to wider NHS and
strategic objectives.
Ability to formulate long-term
strategies and plans in an
uncertain environment and to
work in partnership with others
to develop, take forward and
evaluate service
Chair: Dr Clare Highton
Chief Officer: Paul Haigh
improvements.
Ability to lead on, carry out,
and act upon the results of
equality impact assessment
and contribute to the
development of good and best
practice in the area of equality,
diversity and inclusion.
APPENDIX 5 - CCG Primary Care Committee
Terms of Reference
January 2015
Introduction
The CCGs Primary Care Committee has delegated responsibility from the CCG Board for ensuring
the delivery of the CCGs clinical strategy through robust contractual arrangements with general
practices, the GP Confederation and the GP OOH provider, and ensuring this is transacted in a
robust way to manage conflicts of interests
Objectives
1. The CCG Primary Care Committee (CCG PCC) has been established to oversee
the planning and development of primary care provision, to deliver the CCG
strategy under delegated commissioning responsibilities from NHSE and to
consider, review and agree the associated service specifications and contractual
arrangements and in particular those where;
• we are potentially contracting with City and Hackney GP practices directly or
through the local confederation of City and Hackney GP practices for list based
services or extended primary care/out of hospital services
• we are contracting with the GP social enterprise providing our Out of Hours
Service (CHUHSE)
• we are undertaking expanded primary medical care commissioning functions
under delegated responsibilities from NHSE
• where practices, the GP Confederation, CHUHSE is a potential provider under
any CCG procurement exercise
2. In accordance with its statutory powers under section 13Z of the National Health
Service Act 2006 (as amended), NHS England has delegated the exercise of the
functions specified in Schedule 2 to these Terms of Reference to City and
Hackney CCG. The delegation is set out in Schedule 1.
3. The CCG has established the CCG Primary Care Commissioning Committee
(“Committee”). The Committee will function as a corporate decision-making body
Chair: Dr Clare Highton
Chief Officer: Paul Haigh
on behalf of the CCG Board for the management of the delegated functions and
the exercise of the delegated powers.
4. It is a committee comprising representatives of the following organisations:
•
City and Hackney CCG
•
Healthwatch City of London
•
Healthwatch London Borough of Hackney
In addition to voting members being represented by the above, the following
organisations are also invited as non-voting members;
•
Health and Wellbeing Board – City of London
•
Health and Wellbeing Board – London Borough of Hackney
•
Public Health representative
Statutory Framework
5. NHS England has delegated to the CCG authority to exercise the primary care
commissioning functions set out in Schedule 2 in accordance with section 13Z of
the NHS Act.
6. Arrangements made under section 13Z may be on such terms and conditions
(including terms as to payment) as may be agreed between the Board and the
CCG.
7. Arrangements made under section 13Z do not affect the liability of NHS England
for the exercise of any of its functions. However, the CCG acknowledges that in
exercising its functions (including those delegated to it), it must comply with the
statutory duties set out in Chapter A2 of the NHS Act and including:
(a) Management of conflicts of interest (section 14O);
(b) Duty to promote the NHS Constitution (section 14P);
(c) Duty to exercise its functions effectively, efficiently and economically
(section 14Q);
(d) Duty as to improvement in quality of services (section 14R);
Chair: Dr Clare Highton
Chief Officer: Paul Haigh
(e) Duty in relation to quality of primary medical services (section 14S);
(f) Duties as to reducing inequalities (section 14T);
(g) Duty to promote the involvement of each patient (section 14U);
(h) Duty as to patient choice (section 14V);
(i) Duty as to promoting integration (section 14Z1);
(j) Public involvement and consultation (section 14Z2).
8. The CCG will also need to specifically, in respect of the delegated functions from
NHS England, exercise those set out below:
•
Duty to have regard to impact on services in certain areas (section 13O);
•
Duty as respects variation in provision of health services (section 13P).
9. The Committee is established as a committee of the CCG Governing Body in
accordance with Schedule 1A of the “NHS Act”.
10. The members acknowledge that the Committee is subject to any directions made
by NHS England or by the Secretary of State.
Primary Care Commissioning Role of the Committee
11. The Committee has been established in accordance with the above statutory
provisions to enable the members to make collective decisions on the review,
planning and procurement of primary care services in City and Hackney, under
delegated authority from NHS England
12. Primary care services in City and Hackney as part of the CCGs statutory
commissioning responsibilities.
13. In performing its role the Committee will exercise its management of the functions
in accordance with the agreement entered into between NHS England and City
and Hackney CCG, which will sit alongside the delegation and terms of reference
and in accordance with its constitution.
14. The functions of the Committee are undertaken in the context of a desire to
promote increased co-commissioning to increase quality, efficiency, productivity
and value for money and to remove administrative barriers.
Chair: Dr Clare Highton
Chief Officer: Paul Haigh
15. The role of the Committee shall be to carry out the functions relating to the
commissioning of primary medical services under section 83 of the NHS Act.
16. This includes the following:
•
•
•
•
•
•
•
GMS, PMS and APMS contracts (including the design of PMS and APMS
contracts, monitoring of contracts, taking contractual action such as issuing
branch/remedial notices, and removing a contract);
Newly designed enhanced services (“Local Enhanced Services” and “Directed
Enhanced Services”);
Design of local incentive schemes as an alternative to the Quality Outcomes
Framework (QOF);
Decision making on whether to establish new GP practices in an area;
Handling of practice vacancies arising from death, retirement, resignation or
any other reason;
Approving practice mergers; and
Making decisions on ‘discretionary’ payment (e.g., returner/retainer schemes).
17. The CCG will also carry out the following activities:
•
•
•
•
To plan, including needs assessment, primary [medical] care services in the
City and Hackney;
To undertake reviews of primary [medical] care services in City and Hackney;
To co-ordinate a common approach to the commissioning of primary care
services across the CCG;
To manage the budget for commissioning of primary [medical] care services in
City and Hackney.
Additional Remit and Responsibilities
18. The Committee has the following role on behalf of the CCG Board:
•
•
•
•
To review service specifications and contractual proposals for all CCG
commissioned services from primary care providers (either directly or via the
GP Confederation)
To ensure that the contractual proposals will achieve health improvement and
represents value for money
To ensure that in developing service specifications and contract proposals all
conflicts of interest have been mitigated in line with the CCG conflicts of
interest policy
To review the contracting route for the proposals
Chair: Dr Clare Highton
Chief Officer: Paul Haigh
•
•
•
•
•
•
•
In respect of procurement activities, review proposals from Programme Boards
around process, documentation,(including service specifications and evaluation
criteria) and membership to help assure conflicts of interest have been
mitigated in order for them to make recommendations to the Board
To review procurement process after completion and ensure process was
followed and endorse the recommendation to award a contract
Take advice from audit committee and follow any framework they suggest for
initiatives and/or procurement
review and assess any key performance indicators (KPIs) and contractual
metrics and the basis on which contractual payments would be made and
provider performance assessed
Consider any supporting legal advice obtained in respect to contracting matters
and may request specific advise taken where the committee feels this would
help their recommendations
The Board requires the Committee to review and authorise requests for
payments to be made under the GP contracts that have been entered into by
the CCG. The Committee review whether the control processes (established by
the CCG to ensure that services have been properly delivered by the GPs
under these contracts) have been followed in practice and authorise payment.
All decisions relating to contracting with and investment in CHUHSE (the OOH
provider) will be reviewed by this committee once a recommendation has been
received by our Urgent Care Board/ System Resilience Group.
Geographical Coverage
19. The Committee will cover the City and Hackney CCG locality.
Membership
20. The committee shall consist of the following voting members;
•
•
•
•
•
•
•
•
•
•
•
CCG Board Associate Lay Member - (Currently Jaime Bishop) Independent
Chair
CCG Board Lay Member (Governance)
CCG Board Lay Member (PPI and Conflicts)
CCG Board Associate Lay member
Secondary Care consultant CCG Board Member
Nurse CCG Board member
Healthwatch - City of London
Healthwatch - LBH
Chief Officer
Chief Financial Officer
Schedule 3 details individual members
Attenance (without voting rights)
Chair: Dr Clare Highton
Chief Officer: Paul Haigh
•
•
•
•
•
Representatives from the following organisations will be in attendance although
not voting members;
Chair of the Health and Wellbeing Board – City of London
Chair of the Health and Wellbeing Board – London Borough of Hackney
Director of Public Health representing the CCG locality
Independent GP adviser to the CCG
21. Other representatives may be invited by the Chair in order to maintain a balance of
representation.
22. The clinical chairs of the CCG Programme Boards (and other CCG staff) will be
invited to attend meetings of the committee to outline their proposals and clinical
strategy. However they will not be present when the committee debates the plans
or makes its decisions
Chair
The Committee is chaired by the Associate Lay member, Jaime Bishop as his role
does not require him to attend the Audit Committee.
In his absence, the role of Chair can be covered by the other Associate Lay member
or the Lay Member PPI and Conflicts.
Meetings and Voting
23. The Committee will operate in accordance with the CCG’s Standing Orders.
24. The Secretary to the Committee will be responsible for giving notice of meetings.
This will be accompanied by an agenda and supporting papers and sent to each
member no later than 7 days before the date of the meeting. When the Chair of the
Committee deems it necessary in light of the urgent circumstances to call a
meeting at short notice, the notice period shall be such as s/he shall specify.
25. Notification of meetings and meeting papers will be published on the CCG website.
26. Each voting member of the Committee shall have one vote. The Committee shall
reach decisions by a simple majority of members present, but with the Chair
having a second and deciding vote, if necessary. However, the aim of the
Committee will be to achieve consensus decision-making wherever possible
Secretary
Chair: Dr Clare Highton
Chief Officer: Paul Haigh
27. Administrative support to the PCC will be provided by the CCGs Business Coordinator who also manages the CCGs business cycle.
Quorum
28. The quorum needed for the transaction of business is:
•
•
•
•
1 CCG Board Lay Member (can include Associate Lay Member)
1 of either the secondary care consultant Board Member or Nurse Board
Member
1 Healthwatch representative
1 CCG Officer
Frequency of meetings
29. The CCG Primary Care Committee will meet bi-monthly during the calendar year
and more regularly if required however will be stood down if there is no business
to transact.
Transparency
30. Meetings of the committee shall:
a) be held in public, subject to the application of 23(b);
b) the Committee may resolve to exclude the public from a meeting that is open to
the public (whether during the whole or part of the proceedings) whenever
publicity would be prejudicial to the public interest by reason of the confidential
nature of the business to be transacted or for other special reasons stated in the
resolution and arising from the nature of that business or of the proceedings or for
any other reason permitted by the Public Bodies (Admission to Meetings) Act
1960 as amended or succeeded from time to time.
31. Members of the Committee have a collective responsibility for the operation of the
Committee. They will participate in discussion, review evidence and provide
objective expert input to the best of their knowledge and ability, and endeavor to
reach a collective view.
32. The Committee may delegate tasks to such individuals, sub-committees or
individual members as it shall see fit, provided that any such delegations are
consistent with the parties’ relevant governance arrangements, are recorded in a
Chair: Dr Clare Highton
Chief Officer: Paul Haigh
scheme of delegation, are governed by terms of reference as appropriate and
reflect appropriate arrangements for the management of conflicts of interest.
33. Members of the Committee shall respect confidentiality requirements as set out in
the CCG’s constitution.
34. The Committee will present its minutes to London area team of NHS England and
the governing body of City and Hackney CCG after each meeting for information,
including the minutes of any sub-committees to which responsibilities are
delegated under paragraph 29 above.
35. The CCG will also comply with any reporting requirements set out in its
constitution.
36. The committee meeting dates will be communicated well in advance of the
meeting date and the arrangements for public attendance clear and transparent.
Conflicts of Interest
37. Where a member has an interest, or becomes aware of an interest which could
lead to a conflict of interest in the event of the CCG considering an action or
decision in relation to that interest, that must be considered as a potential conflict,
and is subject to the provisions of this Constitution and the CCG’s Conflicts of
Interest policy.
38. The Chair will, at the beginning of all committee meetings, ask for members to
highlight any conflicts of interest as well as reminding members to ensure their
register of interests is up to date.
39. A register of interests will be completed by all members and is updated at least
quarterly and is available on our website for public scrutiny.
40. The register of interests will be available at each meeting.
Review
41. It is envisaged that these Terms of Reference will be reviewed from time to time,
reflecting experience of the Committee in fulfilling its functions. NHS England may
also issue revised model terms of reference from time to time.
Chair: Dr Clare Highton
Chief Officer: Paul Haigh
Accountability of the Committee
42. The constitution and standing orders have been amended to reflect that the
committee has received delegated responsibility to make decisions on behalf of
the Governing Body. Standing Financial Instructions will be amended to reflect
this.
Procurement of Agreed Services
43. The detailed arrangements regarding procurement will be set out in the delegation
agreement which will be attached under schedule 1 & 2.
Decisions
44. The Committee will make decisions within the bounds of its remit.
45. The decisions of the Committee shall be binding on NHS England and City and
Hackney CCG.
46. The Committee will produce an executive summary report which will be presented
to the London regional team of NHS England and the governing body of City and
Hackney CCG after each meeting for information.
Schedule 1 – Delegation-to be added when final arrangements confirmed
Schedule 2 – Delegated functions-to be added when final arrangements confirmed
Schedule 3 - List of Members
Members
• CCG Board Associate Lay Member - Jaime Bishop (Independent Chair)
• CCG Board Associate Lay Member - Honor Rhodes
• CCG Board Lay Member (PPI and Conflicts) - Catherine Macadam
• CCG board Lay Member (Governance) – Mariette Davis
• Consultant Board Member - Christine Blanshard
• Nurse Board Member – Siobhan Clarke
• Healthwatch City of London – Invitation sent asking for nomination
• Healthwatch LBH – Invitation sent asking for nomination
• Chief Officer – Paul Haigh
• Chief Financial Officer – Philippa Lowe
In attendance
• Health and Wellbeing Chair, LBH – Councilor Jonathan McShane
• Health and Wellbeing Chair, City of London – Reverend Martin Dudley
• Public Health Director, LBH & CoL – Penny Bevan
• Independent GP advisor – Mike Fitchett
Chair: Dr Clare Highton
Chief Officer: Paul Haigh
January 2015
Appendix 6:
NHS Clinical Commissioners, Royal
College of General Practitioners and
British Medical Association Shared principles on conflicts of
interest when CCGs are
commissioning from member
practices
December 2014
1. Introduction
The ability for CCGs to become involved in co-commissioning General Practice and primary
care services has the potential to bring many benefits but it also brings with it the potential
for perceived and actual conflicts of interest.
NHS Clinical Commissioners (NHSCC), the Royal College of General Practitioners
(RCGP) and the British Medical Association (BMA) have decided to collectively outline
their high level starting principles in managing conflicts of interest when CCGs commission
from member practices. In large part this has brought together principles articulated in
previous lines/guidance/steer from the above organisations and NHS England.
Our principles are applicable to each of the three primary care commissioning models
open to CCGs and should not be seen as being directive or be interpreted to mean that
we prefer one model over another. These decisions need to remain a local, professionally
led, decision.
In developing these shared principles we would like them to sit alongside NHS England’s
Chair: Dr Clare Highton
Chief Officer: Paul Haigh
updated guidance on Managing Conflicts of Interest (December 2014). We are on a
journey regarding the co-commissioning of primary care and we will review these
principles when needed and as CCGs work through the guidance.
It should be noted that this paper is not designed to address the issue of perceived or
actual conflicts of interest in CCGs holding and performance managing GP contracts
under co-commissioning arrangements.
2. Our headline shared principles around conflicts of interest
We collectively agree the following in relation to managing conflicts of interest when
CCGs commission from member practices:
• If CCGs are doing business properly (needs assessments, consultation
mechanisms, commissioning strategies and procurement procedures), then the
rationale for what and how they are commissioning is clearer and easier to
withstand scrutiny. Decisions regarding resource allocation should be evidencebased, and there should be robust mechanisms to ensure open and transparent
decision making.
• CCGs must have robust governance plans in place to maintain confidence in the
probity of their own commissioning, and maintain confidence in the integrity of
clinicians.
• CCGs should assume that those making commissioning decisions will behave
ethically, but individuals may not realise that they are conflicted, or lack
awareness of rules and procedures. To mitigate against this, CCGs should
ensure that formal prompts, training and checks are implemented to make sure
people are complying with the rules. As a rule of thumb, ‘if in doubt, disclose’
• CCGs should anticipate many possible conflicts when electing/selecting
individuals to commissioning roles, and where necessary provide
commissioners with training to ensure individuals understand and agree in
advance how different scenarios will be dealt with.
• It is important to be balanced and proportionate – the purpose of these tools is
not to constrain decision-making to be complex or slow.
3. Addressing perceived as well as actual conflicts of interest
Conflicts of interest in the NHS are not new and they are not always avoidable. The
documents we reviewed to produce this paper were all clear that the existence of a
conflict is not the same as impropriety and focus on how to avoid potential or perceived
wrongdoing. Most importantly all acknowledge that perceived wrongdoing can be as
detrimental as actual wrongdoing, and risks losing confidence in the probity of CCGs and
the integrity of wider clinicians such as GPs in networks/federations, individual practices
and partners.
The RCGP/NHS Confederation also notes evidence from the BMJ that people think they
aren’t biased by potential conflicts but often are so the common theme is - if in any doubt
Chair: Dr Clare Highton
Chief Officer: Paul Haigh
it’s important to disclose.
The RCGP/NHS Confederation and NHS England Guidance identify four types of potential
conflict of interest:
• direct financial;
• indirect financial (for example a spouse has a financial interest in a provider);
• non-financial (i.e. reputation) and;
• loyalty (i.e., to professional bodies).
The BMA recognises that for CCGs there will be situations where the best decision for
the population and taxpayers is not in the best interest of individual patients (for whom
GPs are required to advocate) and that this can create a perceived conflict. The
RCGP/NHS Confederation paper acknowledges this but in terms of the governance
when commissioning services.
4. Planning for populations
CCGs must always demonstrate that their commissioned services meet the needs of their
local populations, as such CCGs will need to work with their Health and Wellbeing Board’s
or other local strategic bodies to ensure there is alignment to local strategic plans.
What is clear from all the existing guidance is that CCGs will need to identify the
situations where they are involving their governing body clinicians to strategically plan for
their population, and situations where their governing body clinicians need to be
separated from procurement, planning and decision-making processes. In the former it is
critically important to secure clinical expertise. In the latter, the CCG will need to manage
risks around perceived and actual conflicts in relation to the tendering of services.
The BMA outlines that decisions regarding resource allocation should be evidence
based, and there should be robust mechanisms to ensure open and transparent
decision making. As such, GP involvement must be agreed at each stage of the
commissioning and procurement process so that potential risks of conflicts are
appropriately defined and mitigated early on.
5. Good practice – for CCGs
All the guidance suggests CCGs must have robust governance plans in place to
maintain confidence in the probity of their own commissioning, and maintain confidence
in the integrity of clinicians.
The RCGP/NHS Confederation suggests using existing NHS guidance as a starting point:
• Identify potential conflicts
• Declare interests in a register
Exclude individuals from discussion or decision making if financial interest exceeds 1%
equity in the provider organisation - depending on the nature of the discussion (we would
Chair: Dr Clare Highton
Chief Officer: Paul Haigh
also add that includes considering the share of the contract value to make sure there are
no loopholes, this might also apply to practices with profit sharing arrangements).
• Continue to manage conflicts post-decision i.e. contract managing (carefully
separating overall strategy development for populations from individual
procurement processes. The former will be important for CCG lay involvement will
be important and include secondary care clinicians and non-executive Board
nurses, the latter can be managed by managers).
NHS England guidance also says that an individual with a ‘material interest’ in an
organisation which provides or is likely to provide significant business should not be
member of CCG governing body. The BMA suggests anything above 5% equity is a
material interest. The RCGP/NHS Confederation reference this threshold but also say
that something lower than a 1% stake could also be a material interest (if the size of the
bid is significant).
Clearly these thresholds need to be considered in relation to individual practices and GP
partners once co-commissioning is in place. The perceived risks must be recognised early
on and we feel some worked case study examples would be helpful for CCGs as they
work through the updated guidance. NHSCC, the RCGP and the BMA are planning to
work with NHS England and Monitor to identify these examples.
NHSCC believe that CCG lay members, secondary care doctors and nurses on governing
bodies play a vital role in both the design, implementation, leadership and monitoring of
conflicts of interest systems and processes. They can provide robust challenge and
ultimately a protection for GPs working in both the commissioning and provision of health
care. Enabling them to carry out their roles in this regard is vital.
CCGs should also be proactive in their approach when considering conflicts when
electing/selecting people, doing a proper induction (i.e. include continuous training and
review at both Governing Body and membership (assembly level) and ensuring
understanding from individuals, and agree in advance how different scenarios will be dealt
with. The CCG should ensure individuals are prompted to declare an interest but not
absolved from their responsibility to declare as well. Again, CCG lay members, secondary
care doctors and nurse members of the governing body have a critical role in this process,
as an independent arbiter and as those providing appropriate scrutiny and oversight.
NHS England’s Code of Conduct guidance specifically explores when CCGs are
commissioning services from their own GP member practices. When CCGs are
commissioning from federations of practices, the same guidance should apply.
As practical support NHS England have also produced an updated code of conduct
template for use when drawing up local plans (see their updated guidance). The template
asks a series of questions to provide assurance to Health and Wellbeing Boards that the
service meets local needs, and to the Audit Committee or external auditors that robust
process was used to commission the service, select the appropriate procurement route
and address potential conflicts of interest.
Chair: Dr Clare Highton
Chief Officer: Paul Haigh
6. Good practice - for individuals
The current guidance suggests that individuals making decisions in CCGs do so with the
Nolan principles of public life in mind: selflessness, integrity, objectivity, accountability,
openness, honesty, and leadership.
They also refer to the guidance the General Medical Council (GMC) has produced for
doctors including:
• You must not allow any interests you have to affect the way you prescribe for,
treat, refer or commission services for patients.
• If you are faced with a conflict of interest, you must be open about the conflict,
declaring your interest informally, and you should be prepared to exclude yourself
from decision making.
• You must not try to influence patients’ choice of healthcare services to benefit you,
someone close to you, or your employer. If you plan to refer a patient for
investigation, treatment or care at an organization in.
NHS England guidance indicates that individuals must declare an interest as soon as they
come aware of it, and within 28 days. More informally, the RCGP/NHS Confederation also
suggested the simple ‘Paxman test’ - whether explaining the situation to an investigative
reporter/journalist like Jeremy Paxman would cause embarrassment. We think it would be
helpful to develop this type of text into a tool for CCGs to use locally.
NHS England guidance indicates that individuals must declare an interest as soon as they
come aware of it, and within 28 days.
Finally, the BMA suggested that commissioner doctors:
• Declare all interests, even if they are potential conflicts or the individual is
unsure whether it counts as a conflict, as soon as possible.
• Update a register of interests every three months.
• Doctors must be familiar with their organisation’s formal guidance.
• If individual doctors have any questions, they should seek advice from
colleagues, err on the side of being open about conflicts of interest, or seek
external advice from professional or regulatory bodies.
In addition to the above, the RCGP suggests there should also be a requirement to
update the register of interests if a material difference arises in the circumstances of an
individual at any point.
7. Procurement processes – CCGs and member practices
According to the BMA guidance, when CCGs are procuring community level services,
these contracts are often below threshold requiring a competitive tender process.
There are a number of procurement options for CCGs in this situation – for example a few
may include:
1. Competitive tender where GP practices are likely to bid
Chair: Dr Clare Highton
Chief Officer: Paul Haigh
2. AQP where GP providers are likely to be among the qualified providers
3. Single tender from GP practices
From the guidance that exists, different questions arise around conflicts of interest when
the above procurement processes are used. For example:
• Identifying whether approaches such as AQP are being used with the safeguards
to ensure that patients are aware of the choices available to them.
• If single tender is the route used, CCGs will need to demonstrate a few things
depending on the nature of the procurement. For example that there are no other
capable providers, why the successful bid was preferred to the others and the
impact of disproportionate tendering costs. (Monitor’s procurement guidance
provides many useful steers on what CCGs will need to demonstrate)
For primary care co-commissioning, NHSCC believes one of the elements to include on
procurement processes are the issues around standing financial orders and schemes of
delegation which should not allow CCGs to divide primary care budgets into smaller
budgets to circumvent the procurement process. NHSCC’s lay member network will have
examples/steer on the correct wording to use from previous local experiences.
Regardless of what the local application is the most important part of this process is
transparency. NHS England says to set out the details, including the value of all contracts
on the CCG website. If they are using AQP, the types and prices of services they are
commissioning should be on the website. All of this information should also be in the
CCG’s annual report.
When making procurement decisions, the current guidance suggests that anyone with a
perceived or material conflict should be excluded from decision making, either both
excluded from voting or from discussion and voting. What is not clear in the guidance is
how far back this rule goes – i.e. to the planning stage or just the development of the
specification and procurement. CCGs will need to agree that line locally.
According to the reviewed guidance if all GPs and practice representatives due to make
a decision are conflicted, then the CCG should be:
• Referring decisions to the governing body, so that lay members / the nurse / the
secondary care doctor can make the final decision. However this may weaken
GP clinical input into decision making.
• Co-opting individuals from the HWB or another CCG onto the governing body, or
invite the HWB / another CCG to review proposal to provide additional scrutiny
(these individuals would only be able to participate in decision making if this was
set out in the CCG constitution)
• Ensure that quoracy rules enable decisions to be made in this circumstance
• Plan ahead to ensure that agreed processes are followed.
• Use an appropriately constituted arms-length external scrutiny committee to
ensure probity (recommended by the BMA)
CCGs can use commissioning support services (CSS) to reduce potential conflicts, for
Chair: Dr Clare Highton
Chief Officer: Paul Haigh
example a CSS can help select the best procurement route and prepare bids etc.
However, this cannot completely eliminate the conflict as CCGs are responsible for
signing off specification and evaluation criteria, signing off which providers to invite to
tender, and making the final decision on the selection of the provider. The CCG is
responsible for ensuring that their CSS or other third parties are compliant with regulations
in the same way that the CCG must be.
NHS England also suggest any questions about the service going beyond the scope of the
GP contract should be discussed with NHS England area teams, clearly that would need
review in light of new delegated co-commissioning arrangements.
Networks and Federations
We note that the increasing number of GP networks and federations could potentially
present an added complication to local procurement processes. If most or all CCG
member practices are part of the local federation, then this could mean that a practice not
part of the federation/excluded from a federation may not have the opportunity to win
contracts through competitive tender – because the process is more suited to federated
organisations. One way to mitigate this would be for the CCG to always design and
procure service specifications according to best practice (with openness and
transparency), thereby supporting all practices to bid. One area to be careful about is
when all the GPs on a governing body have a declared interest in local federations – this
makes decision making and accountability complex and the CCG will need to work that
through carefully with the input of its lay members and wider clinicians on the governing
body. Again, an external scrutiny committee with non-conflicted clinicians such as from a
neighbouring CCG may be helpful.
8. Local engagement
Separately, the BMA suggests that LMCs should be involved in CCGs either by formal
consultation, a non-voting seat on governing body, or as an observer on governing
body. They indicate that a non-voting governing body seat would be the best option.
Neither of the other two papers we reviewed address this.
9. Other conflicts of interest issues for consideration
Personal conflict
The RCGP/NHS Confederation highlight that in CCG governing bodies a personal conflict
can arise because CCG leaders are elected by their constituent GP members. There
could be a perception that CCG governing bodies are favouring the most vocal or
influential of their GP practice members. Related to this is the potential indirect interest for
elected GPs to build a constituency of supporters within their CCG.
The CCG is responsible for ensuring that their CSS or other third parties are compliant
with regulations in the same way that the CCG must be.
NHS England guidance suggests that in the case of every GP governing body member
being conflicted, the lay members, registered nurse and secondary care doctor make the
Chair: Dr Clare Highton
Chief Officer: Paul Haigh
decision (and that the constitution is written so that this is quorate). This could however
mean that decisions would be taken without a GP perspective. Alternatively, CCGs may
bring in members of the Health and Wellbeing Board or another CCG to provide oversight,
or as the BMA suggests use an external scrutiny committee to make decisions.
Use of primary care incentive schemes
In its guidance, the BMA highlights its concerns about the professional and ethical
implications of CCGs applying incentive schemes to reduce referral or prescribing activity.
The BMA urges any doctor, whether commissioner or provider, to consider the schemes
carefully and ensure that scheme is based on clinical evidence. NHSCC suggests that one
solution is to ensure the expertise of secondary care clinicians and nurses on governing
bodies plays an important part in providing clinical input and lay members can scrutinize
commercial/ financial and performance data.
The RCGP acknowledge that it is not ethical to under-treat or under-refer for financial
gain, but is not unethical to ‘review and reflect’ on variations in referral/prescribing rates
and try to reduce referrals in line with evidence or best practice.
Note to the reader:
This paper has been developed from a review of three guidance documents and brings
together previous lines/guidance from NHSCC, NHS England, the RCGP and the BMA.
10.
BMA ‘Conflicts of interest in the new commissioning system: Doctors in
commissioning roles’ April 2013
11.
RCGP/NHS Confederation ‘Managing conflicts of interest in clinical
commissioning groups’ September 2011
12.
NHS England ‘Managing conflicts of interest: guidance for clinical
commissioning groups.’ March 2013 (includes Commissioning Board Document that
precedes it). We have also read across the paper to the new version of this document
published December 2014.
NHSCC have also supplemented the principles raised in this paper with some points for
steer that have been raised by members of its lay member network.
Chair: Dr Clare Highton
Chief Officer: Paul Haigh