Is this a satisfactory ending to the saga? (NHS commissioning & CCGs)

Some weeks ago I posted my last letter to the Chief Officer of the local Clinical Commissioning Group as part of my ongoing correspondence about what I am calling "systemic conflicts of interest". You can read the letter here with links to previous episodes. As you can see, I wrote to Lou Patten on Janury 15. I received her reply a couple of days ago. Here it is:

26 February 2014
Dear Jon

Thank you for your further email, received on 15th January; I write to clarify your outstanding queries.

Firstly, I’m pleased we are agreed that there is tremendous value in engaging with as many stakeholders as possible, including potential providers in the development not only of commissioning plans but also in the service redesign before procurement. Because of this wide engagement there are many stakeholders with financial interest in the outcomes of the process, so we need to adopt a transparent method of dealing with all possible conflicts of interest and to ensure we have a robust process for dealing with them should they arise. This is to us a much better option rather than refusing to engage in the first place, because to co-design without their input would not achieve the integrated services we strive to develop for patients.

We continue to build on our website information; you will see that our ‘how are we doing’ area now includes our performance reports. This is still work in progress; the build of the website was to have these areas set out and a work plan to fill them over time. Whilst this may seem frustrating to the visitor, it was cost effective important to build these areas in at the beginning. Please note these papers can be obtained through our Governing Body Papers section, as we now hold all our monthly meetings in public (this is not mandatory but we are trying to be as open as possible).

Kind regards,
Louise Patten
Chief Officer

I think I have now lost the will to reply as clearly Ms Patten is not going to address my questions about:

• The majority of the members of the CCG's Executive Team having a personal financial interest in the outcomes of commissioning processes
• That there is a non-level playing field by dint of these financial interests
• As we approach the anniversary of the CCG being established, the continuing absence of any accessible information about the interests of key members of the management team on the CCG website (happy to be corrected when such information is made available)
• The lack of any public consultation of these matters

I can imagine that in the intervening weeks since I last wrote, Ms Patten has been diligently checking the law to see if anything being done by the CCG and its staff is illegal. I fully expect that everything is legit within the terms of the legislation that the coalition government has put through. 

But I ask you: are these arrangements acceptable to you? Do you think this is good public governance in action? Is this an ethical way to administer considerable sums of taxpayers' money? Are the citizens of Aylesbury Vale being well served here?

Aylesbury Vale CCG Conflict of Interest (part 4)

Last night I received this reply to my last email from Lou Patten, Chief Office of Aylesbury Vale CCG. (Part three blog below: with my letter to her and links to parts one and two)

Dear Jon

Re: Aylesbury Vale CCG Conflict of Interest

Thank you for our email dated Wednesday 8th January regarding your ongoing queries about our conflict of interest policy and behaviours.

In terms of the Companies House records for Vale Health, I have relayed your comments back to the Company Secretary so that he can contact you directly once the process of updating the annual return has been undertaken.

With reference to your concern about Vale Health Ltd, I write to confirm that Aylesbury Vale CCG is the lead contractor for the Out of Hours service and Minor Injuries & Illness Unit (MIIU) that is contracted through Bucks Urgent Care, of which Vale Health is a partner within a Joint Venture arrangement. It is important to note that the existing contract with Bucks Urgent Care was awarded by the Buckinghamshire Primary Care Trust (not the CCG, as it was before our time) and passed to us as a legacy contract.

In terms of wider commissioning processes, it is our intention to be as open and transparent throughout the whole commissioning cycle, as this gets the best results for our patients. We actively seek to engage our stakeholders in helping us describe what the ‘gold standard’ service looks like. This engagement will include not only our public and patients but also potential providers of those services, as this offers the greatest opportunity for developing innovative and high quality services.

As you state, strategic commissioning is a complicated process to determine the health needs, wants and preferences of our community. Within this large and multi modal process we aim to offer our public, patients and all stakeholders – including potential providers of services – the opportunity to influence not only the shape of our strategy but also how individual services should be commissioned.

For example, we need to take into account the views of local hospital Consultants and GPs when we describe services for patients, as they have significant intelligence about the clinical quality and safety of the services being shaped for procurement. Such discussions therefore include clinicians from several of our local hospital providers, who are arguably part of your ‘systemic’ network of interests, as their hospital could be intending to bid for the service.

Where commissioning and procurement decisions have to be made, our Conflict of Interest policy gives us clear guidance on how to handle actual or perceived conflicts. If our Executive team were conflicted to the point that there were not enough non-conflicted members to be quorate then the decision would be passed to the Governing Body.

We remain of the view that we cannot remove ourselves from the many perceived or actual network of interests across our health and social care commissioners and providers. However, we do not see this as a systemic problem, rather as an opportunity to embrace our stakeholders’ engagement in order to maximise innovation and high quality commissioning in the knowledge that we have a very clear process for handling commissioning decisions in the event of a perceived or actual conflict of interest.

Yours sincerely
Lou Patten
Chief Officer
Aylesbury Vale CCG

__________

Here is my reply to her:

Dear Lou

Thank you for your reply to my last email. Many thanks for ensuring that the Vale Health Secretary will alert me when the process of updating the annual return has been undertaken. Thank you also for the information about Vale Health and the legacy contract that the CCG inherited.

Of course, like you, I see the value in engaging with the widest possible set of people in developing your commissioning plans. However, I fail to understand how this justifies many members of your Executive Team having a personal financial interest in the outcomes of that commissioning process. It seems to me that the current arrangements mean that:

• Other commercial / non-commercial providers are not party to, in the same way, the deliberations of the CCG. In other words, by having such a predominant interest in one commercial provider, the CCG is supporting a non-level playing field for all potential bidders / providers. Is this fair?
• Aside from being transparent about what interests different parties hold (and I note that you have not addressed my concern about the absence of any accessible information on your website) and arrangements to ‘step outside the room’ when a critical decision is being taken, you seem relaxed about all other ways in which the interests of the Executive Team might influence the spending of public money. If this is never an issue, why do members of government have to place their investments in blind trusts? 

Moreover, you do not seem to countenance the possibility that the fact that members of the Executive team have financial interests in a provider (not just Vale Health, but others too for all that I currently know) might possibly have a bearing one day on the provision of publicly funded health services to the extent that commissioning becomes structured more around financial gain than health gain.

Indeed you seem to embrace the advantages of having a majority of your Executive team being shareholders in a local commercial (for-profit) provider “as an opportunity to embrace our stakeholders’ engagement in order to maximise innovation and high quality commissioning”. I am really not sure that the general public would see it in this way. Have you consulted them on this aspect of the CCG? I, for one, see this as a very slippery slope which holds the potential of the NHS being run for financial rather than health interests. It is very simple to solve the potential problem now.

Finally, please will you address the point that I have raised twice about the absence of any performance links working on your website. I am sure you wish the public to support your approach to commissioning as one that is yielding positive health outcomes for the people of Aylesbury Vale. At the moment, the public have little idea as to what is being achieved with our money as your website is providing no easy access to performance data.

Thank you, as before, for your attention to these matters.

Sincerely yours

Jon

CCG & systemic conflicts of interest (part 3)

Warning: this is a long post!

________

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.

________

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

_______

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 

________

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.

Aylesbury Vale CCG: is this what the NHS has come to now?

One of the most controversial changes that the current government has introduced is the top down restructuring of the NHS. It remains controversial because before the 2010 election the Conservatives repeatedly promised “no more top down reorganisations” of the NHS. David Cameron said that "With the Conservatives there will be no more of the tiresome, meddlesome, top-down re-structures that have dominated the last decade of the NHS". (Ref) It continues to be controversial as the very real threat of the NHS being Balkanised into a series of privatised units appears to be slowly but inexorably happening. (See here and here for example)

So here we are now, almost a year into the some of the most radical changes the NHS has ever undergone.

Locally, this has meant the Aylesbury Vale Clinical Commissioning Group taking over the role previously held by the Primary Care Trust (broadly speaking). The AVCCG will be buying health care services on behalf of us all. I blogged about their conflicts of interest in some detail 10 months ago. Having taken that blog as a report to the Town Council, we then wrote to the CCG about our concerns. Buckinghamshire County Council also became involved and Louise Patten the Chief Officer of the CCG wrote a long and considered letter on 26 June 2013 to Cllr Lin Hazell (the Town Council was copied in). The quotes below come from that letter.

Ms Patten said that their Conflicts of Interest Policy was “being reviewed as a matter of urgency”. The new policy can be found here and it would appear that this indeed has happened.

In my previous blog I highlighted this particular statement:

If the withdrawal of a CCG member has the effect of rendering the meeting in question inquorate, the chair reserves the right to adjourn and reconvene the meeting when appropriate membership can be ensured.

This has now been strengthened and now reads:

Loss of quorum - If the withdrawal of a CCG member results in the loss of quorum of the meeting, the item cannot be decided upon at that meeting. The meeting should be reconvened when appropriate quorum can be ensured.

There is more of course. But this is certainly tighter than before. This is good.

However, I remain concerned about the overlap of interests between the AVCCG and the ‘for profit’ local supplier called Vale Health (description here). In Ms Patten's letter, she said “Both Dr Jackson and Dr West felt their position as shareholders of Vale Health was not tenable with their position on the Governing Body in terms of conflicted interest and both members resigned their shareholding in April and May 2013 respectively”. She went onto to say “Neither member has any ongoing interest in the company, nor in any other company perceived to be conflicted”.

This is another matter I highlighted in my blog from March last year as well. So that is all OK then…? Well probably but I am confused by the latest document held by Companies House which details the shareholders in Vale Health. The date of return is 18/5/13 and it was filed in electronic format on 1/8/13.

In this document Dr Jackson is listed as owning 4 ordinary shares “held as at the date of this return” and Dr West having 2 “held as at the date of this return” (of a total 496 shares). I appreciate that Dr West’s shares may well have been disposed of in May and just missed the date of return. However, Ms Patten said that Dr West had disposed of his in April which is several weeks earlier. Perhaps this matter could be cleared up?

It is all the more confusing still since the button on the website that would take readers to the list of all declared interests (as at the time of writing: 1600 on 3/1/14) does not work. Perhaps this might be fixed too, given that the CCG has been officially live since April last year. (As an aside, I would also highlight that none of the buttons on the “How are we doing” webpage work either. The website proudly says:

In this section we’ll be keeping our performance reports and other benchmarking material, as well as keeping you abreast of the wider-scale state of the work of the CCG. We will use this information to measure how we are maintaining or improving the health outcomes and service standards delivered for our population

… but try clicking on “Performance Reports” or “National & Local Standards” and nothing happens. Could the public have this data made accessible sometime, perhaps?)

But to return to the issue of conflicts of interest. The AVCCG site lists all the members of their Executive Team. Here is the list:

• Dr. Christine Campling (20s)
• Dr Kevin Suddes (5s)
• Dr Juliet Sutton (11s)
• Dr Stuart Logan (1s)
• Dr Karen West (2s)
• Lesley Munro-Faure (5s) 
• Trevor Boyd (-)
• Dr Malcolm Jones (1s)
• Dr Charles Todd (6s)
• Dr Rodger Dickson (19s)
• Louise Patten (-)
• Jane McVea (-)
• Robert Majilton (-)
• Colin Thompson (-)

You may be wondering about the numbers in brackets. Or of course, you may well have worked out that these Executive Team members are also listed as shareholders of Vale Health on the Companies House document. The numbers are their allotted shares.

I don’t know about you, but this does not leave me feeling particularly comfortable. Nine out of fourteen members of the commissioning body’s executive team have a financial interest in one of the agencies that they could be commissioning in the future.

• Does this situation need to change?
• Is this an example of good governance?
• Or are you quite relaxed about this state of affairs?

____________

UPDATE 1216 | 080114: I turned this blog into a letter to the CCG. You can read the reply from the Chief Officer above. 

A systemic conflict of interest? (CCGs)

On April 1st, all around England, the new Clinical Commissioning Groups (CCGs) will formally come into being and will henceforth be spending millions of pounds of public money on health care services. This role was fulfilled by Primary Care Trusts before. CCGs are a big part of the Government's NHS reforms. The stated purpose of the CCGs is to put General Practitioners in the driving seat of shaping health services to meet the health care needs and wishes of local people and patients.

However, a recent article (Many GPs have interests in private firms in PublicService.co.uk) begins with this paragraph:

Marketisation' and privatisation of the NHS are back in the spotlight after a study has claimed to have revealed potential conflicts of interest because 36 per cent of GPs running clinical commissioning groups (CCGs) have connections with private companies.

And so I got to wondering what the situation was in my locality...

In our locality, this role will be fulfilled by the Aylesbury Vale CCG, details of which can be found here: www.aylesburyvaleccg.nhs.uk/unitedcomm. Eight members of the Board of this new body have declared interests in a variety of other organisations and property. Two of these eight people (Dr Karen West, Executive Clinical Lead and Dr Graham Jackson, Chairman of the CCG) have declared that they have shareholdings in a company called Vale Health.

What is Vale Health? On the website of Vale Health (www.valehealth.co.uk), it states that "Vale Health Limited was established in 2006 as a for-profit, limited company to exploit the very real, significant and arguably unique business opportunity created by practice based commissioning conferring great advantage on general practice" and "since 2007 Vale Health Limited has been providing a range of NHS clinical services for the people of Buckinghamshire".

The website also goes onto say that "Vale Health intends to work with the General Practice Commissioners and position itself at the heart of the effort to change the way services have hitherto been delivered"

I have added some highlighting there.

So, two main board members of the new NHS commissioning body for our area have shareholdings in a profit making company that will (almost certainly) be bidding for contracts from the same body.

Now, there are published arrangements around handling conflicts of interest: there is a 14 page policy accessible here. This policy states, for example:

At meetings – at the start of each meeting, all attendees will be 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 has already been declared in the Register of Interests, it should be declared in meetings where matters relating to that interest are discussed. Declarations of interest will be recorded in the minutes of the meeting as well as being included on the register. If the withdrawal of a CCG member has the effect of rendering the meeting in question inquorate, the chair reserves the right to adjourn and reconvene the meeting when appropriate membership can be ensured.

If 'the chair reserves the right...' (and I have already established that the Chairman has a shareholding in what could be a key bidder in a procurement process) will the Chair always exercise this right? I would contend that the policy should say "If the withdrawal of a CCG member has the effect of rendering the meeting in question inquorate, the chair must adjourn and reconvene the meeting when appropriate membership can be ensured and quorum established"

The policy goes on:

7. Declaration of Interests in relation to procurement

Where a relevant and material interest or position of influence exists in the context of the specification for, or award of, a contract the Committee member will be expected to:

• Declare the interest;
• Ensure that the interest is recorded in the register;
• Withdraw from all discussion on the specification or award;
• Not have a vote in relation to the specification or award.

Members will be expected to declare any interest early in any procurement process if they are to be a potential bidder in that process. Failure to do this could result in the procurement process being declared invalid and possible suspension of the relevant member from the CCG.

So it would seem that two of the eight main board members may well have to absent themselves from all discussions (assuming that is what 'withdraw from all discussion' means rather than just stay quietly in the room) in many of the procurement processes (which is huge part of the work of CCGs, I would add).

Is that good governance when a quarter of your decision making capacity, including the Chairman has, to 'step outside the room' on a regular basis? Since agendas may not be that linear, I can also imagine some meetings of the board involving people hopping in and out of the meeting on several occasions and chairing of the discussions swapping back and forward. I do not envy the minute taker!

The policy goes onto to cite extracts from Guidance within the GMC’s core guidance Good Medical Practice (2006) and reiterated in its document Conflicts of Interest (2008) Indicates, in such cases, that:

• “You must act in your patients best interests when making referrals and when providing or arranging treatment of care. You must not ask for or accept any inducement, gift or hospitality which may affect or be seen to affect the way you prescribe, treat or refer patients. You must not offer such inducements to colleagues. 
• if you have financial or commercial interest in organisations providing healthcare or in pharmaceutical or other biomedical companies, these interests must not affect the way you prescribe for, treat or refer patients.
• if you have a financial or commercial interest in an organisation to which you plan to refer a patient for treatment or investigation, you must also tell the patient about your interest. When treating NHS patients you must also tell the healthcare provider.”

The GMC also provides the following general guidance:

• you may wish to note on the patient’s record when an unavoidable conflict of interest arises; and
• if you have a financial interest in an institution and are working under an NHS employers’ policy you should satisfy yourself, or seek other assurance from your employing or contracting body, that systems are in place to ensure transparency and to avoid, or minimise the effects of, conflicts interest. You must follow the procedures governing the schemes.

This is all very well, but it does not mention commissioning as such. This General Medical Council guidance relates to the specific treatment of individual patients. The broader role of commissioning which includes market making, slicing & dicing services to create tendering opportunities, deciding on overall priorities and strategic plans (as well as the practice of procurement itself) is not really covered by this GMC Guidance, I would argue. 

Within the new NHS commissioning arrangements, the commercial suppliers who will succeed and make healthy profits will be the ones who understand the market place in detail and/or may have had influence over the shape of that market place. The published policy on conflicts of interest for AVCCG covers mostly arrangements for declaring interests and withdrawing from specific discussions within CCG meetings where there is a conflict of interest. I do not see anything in this policy paper which relates to the passing of information / intelligence / insight out to other bodies, or the setting up of blind trusts (such as happens with Government ministers where their financial interests could be seen to be in conflict), or indeed the creation of robust firewalls between the CCG and potential providers. 

Now (for the sake of loud public record), I am not, of course accusing any of the CCG board members of any impropriety, corruption or exploitation of interests. Nor am I suggesting that Vale Health have done anything unethical or illegal.

The policy states (with added emphasis from me) "All CCG members are required to declare any relevant and material personal or business interests and any relevant and material personal or business interests of their spouse; civil partner; cohabite; family member or any other relationship which may influence or may be perceived to influence their judgement" and that the "principles and aims of the policy" are to "avoid potential conflicts of interest, manage conflicts of interest where unavoidable, ensure equity, support openness and transparency, [and] adopt appropriate and proportionate safeguards".

• Is the fact that two members of main board have financial interests in a likely local supplier an 'avoidable' conflict of interest? (They could easily sell their shareholdings, for example.) 

• Given the current circumstances, might the people of Aylesbury Vale 'perceive' an influential conflict of interest?

• Are the current arrangements, which only really cover decision making within CCG meetings and the declaration of interests, adequately providing 'appropriate and proportionate safeguards'?

• Are there any systemic conflicts of interest here? (By systemic I mean inherent in the current system no matter what mitigating procedures are put in place.)

• Given that the policy says that declarations of interest should include "Any role or relationship which the public could perceive would impair or otherwise influence the individual’s judgement or actions in their role within the CCG", the highly political nature of these new arrangements are there any memberships or relationships which might have been overlooked (political parties, professional associations, free masonry etc)?

• What do you think should happen now?