NHS reforms

Final crackdown on conflicts of interest with tightened rules on gifts and hospitality

From 1 June this year, senior NHS staff will have to declare any gift over £50, refuse any hospitality more expensive than £75, seek prior permission to engage in outside employment, and make clear any shares they might hold in companies which do business with their organisation – amongst a series of other obligations.

These obligations form part of the final guidance on tackling conflicts of interest, published in papers last week as part of NHS England’s board meeting. The guidance, written by a task and finish group led by Sir Malcolm Grant, was concluded after consideration of around 250 submissions from a September 2016 public consultation.

In a bid to “protect taxpayers and the use of the NHS pound” by ensuring public money is spent “free from undue influence”, the group sought to “bring greater clarity and consistency” to the rules of conflicts of interest. This was largely done to complement existing management guidelines, such as NHS England’s statutory guidance released in 2015 for commissioners.

Amongst other measures, listed in full here, the guidance particularly tightens the rules around gifts, hospitality and shareholdings. Staff will now have to decline any gifts from suppliers or contractors and only accept gifts of over £50 in value on behalf of their organisation – and declare them.

They can accept hospitality up to £25, but anything between £25 and £75 must be declared, whilst any hospitality more expensive than that must be refused altogether. This particular part of the guidance follows health secretary Jeremy Hunt’s decision to tighten the rules around gifts after a 2015 Telegraph investigation found “disturbing” evidence of senior medical managers taking “lavish” trips and being paid thousands of pounds by firms wanting their drugs prescribed.

To crack down on conflicts of interest, particularly the widely-reported issues within CCGs, Sir Malcolm’s team decided that staff must declare any shareholdings and ownership interests in companies which might do business with their own organisation. In late 2015, for example, an investigation found that CCGs in England have awarded nearly 500 contracts worth at least £2.4bn to providers in which one or more of their board members had a financial interest – a problem that NHS England has been keen on exterminating ever since.

“The public rightly expects NHS staff to behave appropriately and use the healthcare budget to achieve the best outcomes for patients. While behaviour is exemplary in virtually all instances, there are times when more could have been done to prevent standards slipping,” said Sir Malcolm, who is also chair of NHS England.

“We have invited comment from the public, patients, NHS staff and other stakeholders on our proposals and have acted on what they have told us. This new guidance will bring a consistent approach to conflicts of interest and ensure that the public can have faith in the integrity of the NHS.”

The task and finish group’s public consultation also found “widespread agreement” that programmed NHS commitments should take precedence over private work, as well as support for the principle of declaring that private practice does that place.

Similarly, there was strong opposition to declaring the earnings from royal colleges, professional bodies, NHS organisations and clinicians – this being the area that attracted most comment from respondents and dominated media coverage of the proposals.

“The group listened carefully to this feedback, and has amended its proposals,” board papers said. “The issue of equity of treatment is an important one. In our proposals on outside employment for all groups of staff, we ask them to declare what their outside interests are, who they are with, and what time they spend involved in them.

“We believe that applying the same requirements to clinicians is just and equitable. Rather than asking for additional information on earnings we are asking for sessional activity to be published as that should already exist via job plans and appraisals.”

However, Sir Malcolm’s team nevertheless acknowledged that this area is “complex and controversial” and could best be tackled systemically through the terms and conditions of NHS employment. It therefore recommended that the Department of Health and NHS Employers should reflect this revised proposal as part of contract negotiations, and consider whether further safeguards are needed to manage conflicts of interest between NHS practice and private practice.

Chris Hopson, the CEO of NHS Providers, welcomed the guidelines, recognising the need to “bring greater coherence and consistency to how the health service handles conflicts”, whilst Professor Helen Stokes-Lampard, chair of the Royal College of GPs, argued it’s important to preserve the relationship between doctors and patients.

“GPs are well aware of the importance of transparency when they receive gifts from patients or organisations, and already follow robust guidance to ensure potential conflicts of interest are properly managed,” added Prof Stokes-Lampard. “But further information so that GPs and our teams are absolutely clear about what is appropriate will be useful.”

Who the guidance will apply to

With regards to who the guidance will affect, the group decided that it should apply to NHS bodies (CCGs, trusts and foundation trusts), although it “invited” the boards/governing bodies of independent and private sector organisations, GP practices, social enterprises, community pharmacies and local authorities to “consider the guidance as good practice”.

“Should significant material concerns emerge in relation to the handling of conflicts of interest by non-NHS organisations, NHS England will review options for seeking wider application and compliance,” the board papers read.

Rather than applying to “senior staff” as previously suggested, the group clarified that the guidance will now apply to “decision-making staff” – including as a minimum band 8DS and above, rather than band 7 and above.

Sir Malcolm’s team also acknowledged the fact that NHS employees are “working hard under conditions of unprecedented demand”, and the “last thing they need is additional and unnecessary burdens”. The guidance has therefore been developed with “consistent and practical definitions” of conflicts of interest, with supporting information and templates to explain these terms.

Before June, NHS England will also be releasing a ‘model conflict of interest policy’ which organisations can use in whole or in part to update their current policies, as well as issue short guides for different groups of staff to help them understand what the guidance will mean for them.

Evaluation of the guidance will take place in early 2018-19.