Explainer: NHS Clinical Commissioning Groups’ Conflicts of Interests

What are they, why are they relevant and how should you monitor them?

Source: GoLegal (CC BY-SA 3.0)

Over the past year, the NHS has been at the forefront of managing UK’s response to COVID-19. On a regional level, Clinical Commissioning Groups, or CCGs as they are commonly called, have been one of the major vehicles by which this response was budgeted and balanced against ongoing existing healthcare needs.

For a sense of scale, England’s CCGs were allocated more than £81b during the 2020/21 fiscal year, representing almost 9% of UK’s total budget.

A prime example of COVID time services commissioned by CGGs was and still is vaccination:

Where is the conflict of interests here?

CCGs are generally governed by active medical professionals (GPs, etc), the services of which they commission, directly or indirectly. As part of its assurance, NHS England defines how CCGs should manage this conflict of interests and provide transparency into its possible effects.

In this explainer, we aim to highlight policies and regulation related to this aspect of the NHS, a publicly funded institution. We will also dive into the published conflict of interests statement of a specific CCG and provide tools and resources by which an interested reader might become familiar with the inner-workings of a CCG.

We’ll open up with an overview of what CCGs are and how they are governed.

What are CCGs?

NHS England defines a Clinical Commissioning Group as an entity that commissions “most of the hospital and community NHS services in the local areas” for which it is responsible. It goes on to state that a CCG is part of the process that decides what services are needed for diverse local populations and for making sure that they are indeed provided.

Services CCGs normally commission include a majority of planned hospital care, rehabilitative care, urgent and emergency care (including out-of-hours), community health services, mental health and learning disability services.

CCGs are assured by NHS England, the public body overseeing budget, planning and delivery of day-to-day healthcare commissioning operations, as set out by the NHS Act 2006 and amended by the Health and Social Care Act 2012.

Primary care services, such as GP and dental services, as well as other specialised hospital services are commissioned directly by NHS England. Still, many GPs are also co-commissioned with CCGs.

For a visual presentation of how CCGs fit into the NHS, check out this video:

How many CCGs are there?

Over the past years, the number of CCGs has been dropping, from a peak of 211 in 2013 to 106 currently, as nearby CCGs are being merged into a single entity. Moreover, CCGs are scheduled to be completely replaced by Integrated Care Systems (ICSs) according to a ten year NHS Long Term Plan.

Still resistance to CCG mergers remains considerable, as The Lowdown writes:

The merger of CCGs has been contested locally in many areas, primarily because the loss of more local CCGs further limits the extent to which NHS management can be held accountable or pressed to respond to the health needs of specific communities.

NHS England provides a comprehensive directory of CCGs, while ONS provides an interactive map (last updated April 2020). A map for the 2019 planned mergers was published by HSJ:

How are CCGs governed?

In accordance with the NHS Act, CCGs must adopt a constitution and nominate a governing body and a chair, who will be the accountable officer responsible for all aspects of the group’s operations. Governing body members represent the area’s GP practices and include representatives of social care and public health services, as well several laypeople, as representatives of the public.

The governing body normally meets once a month. Meetings are open to the public and a process for submitting questions is available. During the pandemic, governing bodies’ meetings were held online and access provided only upon request.

Here is a peek into a recent CCG governing body meeting: (NHS Barnsley, 13 May 2021):

How are CCG governors’ conflicts of interests handled?

NHS England, as the assuring body for the CCGs, has published guidance on managing conflicts of interest within the NHS as a whole and specifically for CCGs. In its introduction, NHS states that:

Decisions involving the use of NHS funds should never be influenced by outside interests or expectations of private gain, but we recognise that conflicts of interest are unavoidable in complex systems.

As an illustrative example, a CCG usually determines which trust in an area will be responsible for the care of a people suffering from dementia. A member of the CCG’s governing body might be a medical doctor practicing at that trust. This possible conflict of interests is the kind of situation NHS provides guidance for and that might be of interest to the local community.

NHS England provides specific guidance on how to consistently declare and publish such possible conflicts of interests in a transparent manner.

Local spotlight: Leicester, Leicestershire and Rutland (LLR)

To get a better sense of what CCG conflict of interests are all about, let’s dive into the greater Leicester area and look at the declaration of interests provided by the governing body of its commissioning groups.

Three CCGs serve the Leicester area and operate jointly under the LLR Alliance: Leicester City CCG, East Leicestershire and Rutland CCG and West Leicestershire CCG.

According to NHS data for 2020/21, these CCGs commission services for close to 1.15 million residents with a budget allocation of almost £1.4b. This translates into roughly £1,200 yearly per capita allocation (11.5% below the national average).

Source: NHS

The three CCGs publish an aggregated Register of Interests, which was last updated on 19 May 2021. The register lists the declared interests of their board members and is available here.

LLR register of interests analysis

The register lists the declared interests of members of the governing bodies of each of the three CCGs, as well as members of a shared executive body.

Out of the 45 people listed, 5 women and 21 men are identifying themselves as practicing medical professionals. The rest are either professional executives or lay members of the governing bodies.

Source: Dror Kessler (icons: creative commons)

[note: according 2021 data published by Statista, 46% of UK doctors are women, with a pronounced gender gap among specialists (37%). Amongst GPs, women doctors are a slight majority (56%)]

CCG conflict of interest categories

Interests are declared using four categories (as defined by NHS guidelines): (i) Financial interests, (ii) Non-financial professional interests, (iii) Non-financial personal interests and (iv) Indirect interests.

The number of categories declared by a member can serve as a crude first estimate to the breadth of the interests. Using this metric, analysis of the LLR register shows that medical professional women are reporting 30% more categories of interests than man. For non-medical professionals, the ratio is somewhat reversed.

Anther metric that can be used to gauge the declared interests is the number of family members mentioned by the declaring parties. Again, medical professional women are reporting higher numbers of interests related to family members, this time 140% more than their man counterparts.

Source: Dror Kessler (icons: creative commons)

[note: given the small sample size, these should serve as examples of how a conflict of interests register can be analysed rather than a statement on the behaviour of governing body members in general or of these specific CCGs. It is recommended that the conflict of interests statements be read in full to better gauge the need to question specific decisions]

Additional Reading

To learn more about this subject, an interested reader might:

  • Read the National Audit Office’s report on “Managing conflicts of interest in NHS clinical commissioning groups”. Being from 2015, it is a bit outdated. Nevertheless, still does provide key facts and metrics on the subject.
  • Find the website for your local CCG in the NHS England’s CCG Directory.
  • On your CCG’s website, locate the pages describing governing body members and their declared conflict of interests. Apply the metrics described above (number of reported categories, family members) to the interests’ register.
  • Find out when the next meeting of your CCG’s governing body takes place and try to attend.
  • Ask your GP and other medical professionals whether they are familiar with the local CCG and feel they can contribute to its decision-making process.

Furlough Fraud, Whistleblowing, DarkWeb, Data Journalism, #Birmingham (researcher/journalist)