CCG & systemic conflicts of interest (part 3)

Warning: this is a long post!

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Late last night I received a reply to my concerns from Lou Patten, the Chief Officer of the CCG. (I wrote to her last Friday with a bespoke version of my blog post below). I am reprinting her reply in the interests of fairness and transparency, as it addresses many (but not all) of the points I raised with her. And below this letter, I also reprint the email I have just sent back to her.

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7 January

Dear Jon

Thank you for your email, received on 3 January 2014, regarding the interests of Dr Jackson, Dr West and Executive Committee members in Vale Health Ltd. For clarity, I have answered your queries by describing our CCG’s approach to developing a greater level of transparency about our register of interests and I have specifically addressed your query regarding Dr Jackson’s and Dr West’s previous shareholdings.

Aylesbury Vale CCG accepts that as a member organisation (where each GP Practice is a member practice) we are likely to have interests of members that could come into conflict with a commissioning decision. Our attitude to this has been to develop a strategy of gaining as high a level of transparency as possible about our register of interests and a robust method for dealing with conflicts if they arise; this work remains in progress. Whilst I am pleased you have found our updated Conflicts of Interest Policy ‘tighter’, I would like to further detail the work that we aim to complete by the end of March that will offer further transparency about how we register interests and handle any perceived or actual conflicts. This work includes:

• The Governing Body took the decision in July 2013 (minutes attached) to ask all members and employees for declarations of all shareholdings, company interests and partner interests.

• Our Governing Body Register of Interests includes listing where members have previously held shares, so Drs Jackson and West are described as ‘previously shareholders’. We felt this was important in the interests of transparency.

• We are currently in the process of putting the Executive Committee declarations together ready for publication on our website. You have highlighted the need to be as accurate as possible in this information, so it is taking time to check our records. Please note this is additional voluntary information, as CCGs are required only to publish the Governing Body details.

• We have asked for all member practices to declare by exception any interests (in other words, we are only being told about the members of staff who have interests, rather than asking all staff at all member practices to declare no interests).

• All individuals who take part in any CCG business are asked to declare all interests; this covers GPs or other clinical and non- clinical staff who might do some one-off project work.

Dr Jackson and Dr West

In response to your query about the Companies House listing of Dr Jackson and Dr West, I have spoken to the Secretary of Vale Health and clarified that this is indeed a timing issue. For clarity, Drs Jackson and West were officially no longer shareholders from the day they wrote and revoked their shareholdings in April and May 2013 respectively. From that day onwards they did not receive any advantage offered to other Vale Health shareholders. At a later stage they were reimbursed for their shareholdings and the process commenced to apply through the Vale Health Secretary and relevant Accountancy firm to remove their names from the shareholding list and from the Companies House Return. This process has clearly taken some time and I have alerted the Secretary to this issue.

The reason Drs Jackson and West revoked their shareholdings whilst the Executive Committee continue with their shares in Vale Health relates to our policy for managing conflicts of interests. If Vale Health or any related company were successful in any CCG procurement of services, the final sign off would have to be taken not by the Executive Committee (due to their conflict of interests) but by the Governing Body. As the GP members of the Governing Body, Drs Jackson and West no longer have shares in the company so they can participate in that decision – although the final permission for their involvement in the decision is down to our Lay Member (as set out in the policy). Please note that any such decisions would be taken at our Governing Body meeting, all of which are now held in public.

In summary, Aylesbury Vale CCG takes very seriously its role in ensuring a transparent and watertight approach to the governance of our commissioning decision making. Our aim is to be as transparent as possible about all interests held not only by Governing Body members but also by all employees and member practice staff and to ensure that there is a robust policy in place for managing any perceived or real conflicts should they arise. I have found your enquiry very helpful in highlighting areas where this has not been clear and I hope I have been able to rectify this in my response.

Yours sincerely
Lou Patten
Chief Officer
Aylesbury Vale CCG

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Here is my reply:

Dear Lou

Many thanks for your detailed letter that I received late last night. I am most grateful for the speed of your reply to the many of the points I raised in my email to you last Friday.

I note your investigation into the share holdings of Dr Jackson and Dr West. I am comforted by your statement that the Companies House records are merely out of date. You say that the “process has clearly taken some time and I have alerted the [Vale Health] Secretary to this issue”. Please can you ask the Secretary to let me know when the process has been completed so that I can update my records? Thank you.

However, I remain very concerned about conflicts of interest. Please allow me to explain why: whilst transparency & absenting oneself from moments of critical decision making are two key ingredients in avoiding such conflicts, the fact that there is such an overlap between their commissioning role and the financial interests of the majority (still) of your executive team in Vale Health raises many questions about good public governance.

Please forgive me if this is a misinterpretation of the points you make: you appear to be saying that you and I should only be concerned about the shareholdings of Drs Jackson & West because only they, as Board members, will be making the critical decisions around commissioning contracts. With regard to members of the Executive Team, so long as everyone is transparent about their financial interests & clears the room at any point when (perhaps) preliminary decisions on commissioning are made, then everything is fine.

I fundamentally disagree.

The reason I disagree is that strategic commissioning is (as I am sure you know) a defined as a process not a set of final procurement decisions. The CCG is involved in a complicated and strategic process to determine the health needs, wants and preferences of the Vale community and produce a commissioning plan and procurement strategy that meets those, in the most efficacious and efficient way possible. Within this large and multi modal process there are ample opportunities to influence the direction in favour of the kinds of provision available from Vale Health. Equally, as this process rolls forward there are ample opportunities for Vale Health to adjust its strategy to be more in line with the emerging CCG strategy giving itself a commercial advantage over other suppliers. If people have a concern on both sides, there is, I would say, a systemic conflict of interest. (And there is, of course, the over-arching concern for the health and well-being of the community / patients as well.)

Now to be very clear, all of what I have said is speculation. I have absolutely no evidence that any such exchange of strategic intelligence across the boundary between the CCG and Vale Health has ever occurred or will ever occur. But despite all members of the CCG being signed and 100% committed to the Nolan principles (I assume), exchanges of such information could occur. And since it could, I ask you, what does this look like to the public? I would contend that good governance (like justice) has to be done and be seen to be done.

I find it difficult to believe that if such strategic commercial exchanges of intelligence were to happen that these could be regulated / investigated / uncovered in any kind of reliable way. Therefore my solution is very simple: no one advising or working as part of the CCG should have any financial interests (directly or indirectly) in providers who may well benefit down the line from commercial contracts. The government has created a commercial commissioning framework that mixes financial and public interests. I think it is behoving upon all players to have very crisp demarcations of such interests.

I am not the only person raising these concerns with the new NHS structure: Managing conflicts of interest in clinical commissioning groups | RCGP/ NHS Confederation (although I expect that you have seen this before. Scenario 1 on page 3 is of interest I feel.)

I am interested in how your current policy on managing conflicts of interest handles the systemic concerns that I am raising. I look forward to your thoughts.

Furthermore, while I note the care you are taking in producing a comprehensive statement about the interests of all members and employees of the CCG, I am surprised there is nothing on the website about even the Board at this stage (with a holding statement about everyone else). Your CCG has been operational since April last year and was in existence as a shadow body for some months before then. Is there not something that you can add to your link now?

Finally, although I did mention it as an aside in my earlier email, I am concerned that there are no working links on your ‘how are we doing’ pages. Please can you let me know by when you will have web based accessible public information on the performance of the CCG? Thank you.

Thank you once again for your attention to all these matters

Very best wishes

Jon 

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I will be interested in her reply. I will keep you posted. For the record: my thanks to @Bill_Russell3 for the link to the RCGP / NHS Confederation document

UPDATE 1150|150114: My letter has had a reply from Lou Patten. You can read it here.