Tuesday, 27 September 2016
Here we are again. Every six months the local CCG writes asking me to complete a Conflict of Interest form, and every six months I find myself not entirely sure what to include. To be fair, I’m an inveterate Form Ditherer, capable of spending whole afternoons staring at a simple binary box tick wondering which one most truly represents the complex nature of my individual human experience, before agreeing that, yes, I am male.
The Conflict of Interest form however represents a particularly challenging dilemma. This is not for want of advice – there is a lovely explanatory page, spelling out the difference between financial interests, non-financial professional interests, non-financial personal interests and indirect interests – though this could probably have been shortened to “just tell us everything basically”.
It’s how much detail to divulge in this “tell us everything” approach that vexes me, because despite our best efforts the NHS is bathed in Conflicts of Interest.
Don’t get me wrong, we’ve tried. We keep a studious record of our Christmas gifts and Drug Reps have been largely expunged from lives. (The odd mug bearing a company logo in the kitchen may still linger as a sort of nostalgic anachronism.) Our local Target afternoons – once a hive of promotional activity – are now entirely free of corporate influence. (They are now also tragically free of cake.) Meanwhile, those educational events that do still carry sponsorship are usually careful to ensure, and reassure, that those sponsors are allowed no say in the content.
The problem is that the chief corrupting influence in General Practice, in fact in the whole NHS, is not from the pharmaceutical industry, or private providers. It’s from Whitehall.
The concept of a Clinical Commissioning Group is, in itself, a conflict of interests. A group of clinicians being paid to determine the funding provided to the rest of the health system, is a contrivance that practically invites corruption. That’s before you introduce “Co-commissioning” and the ability for those same clinicians to start paying themselves too. The irony being of course that many CCGs - being occupied by what are ultimately good, decent people - end up piling the pressure on General Practice instead, for fear of being perceived as favouring their own.
It’s that word, “perception” that is particularly key here. How many patients, I wonder, would feel entirely unperturbed by the fact that my CCG sends me monthly reports indicating my referral levels, invariably highlighted in red, which implore me to refer less people? Already, when I tell my patients that I think referral isn’t necessarily appropriate, I am met with the accusation that I’m simply trying to save money. And the problem is, it’s difficult to categorically deny that. If biros with the word “Viagra” on the side of them were considered such an influential force that they needed to be systematically driven from Primary Care, then surely regular critical reports screaming “Do Less!” are worse?
Now, I know the counter argument – that the point of those letters is to influence me, to make me think twice, to make sure I’m using the resources available to me in the most appropriate manner. I understand that. But that’s a conflict of interest right there. Do what’s best for the NHS, or do what’s best for the patient in front of you.
I suspect I would feel that particular challenge less conflicting were it not for the knowledge that “doing the best for the NHS” increasingly means “spend less money no matter what” – a dictum that helps no-one other than the Chancellor.
Thus we have an insidious influence that has worked its way into medicine largely unchecked, and un-commented upon. What’s more it has had the curious effect of mis-direction. Clinical leaders are now so gloriously pre-occupied with identifying efficiencies, and underlining in red pen any perceived over spending, that they seem to have entirely forgotten to highlight and protest the real issue, namely of underfunding. (We’ve rehearsed this many times before, but for the benefit of anyone who’s forgotten, NHS funding increases will drop to 1.4% next year, and 0.3% in 2018 despite the fact that hospital admissions are up by 6%.)
So in these times of ethical conflict, who can we look to for guidance? Traditionally the answer would be the GMC, but they seem pre-occupied with conflicts of their own at present. Their intervention to suppress the Junior Doctors Strike whilst simultaneously hiring Charlie Massey – Director General at the Department of Health and thus arguably an architect of the very contract that triggered the strike in the first place – does rather suggest that they haven’t wholly grasped how the whole “Conflict of Interest” thing works themselves. (I’m sure they would protest this, to which I would reiterate that it’s not just about being clean, it’s about being perceived to be.) In fairness one could at least argue that the GMC is giving a clear demonstration that it won’t be influenced by financial incentives – after all the medical profession gives it vast sums of money in membership fees, and there’s little evidence that it listens to doctors at all.
So how should I fill in my form? Well, if the GMC example tells us anything, it’s that it doesn’t really matter. Nobody seems to really care. You can appoint whoever you like, with whatever shady connections you wish. As long as you’ve written it down, it seems to get little more than a shrug. “Cause a doctors strike? Have a job at the GMC! Boss of a disgraced NHS Trust? Have a nebulous ill-defined job for the same salary so that you can quit without actually quitting! Used to run the Mafia? You have just the managerial experience we’re looking for!” (OK, I made the last one up, but you get the point.)
I can only conclude that no-one’s bothered about conflicts of interest per se – it’s just that somebody, somewhere just really likes knowing all about us. What else to make of the latest demand - that NHS consultants divulge how much they earn from private work? After all, beyond basic jealousy I don’t really care what my consultant colleagues earn – I care whether that work affects their ability to do their job. But the latest proposals appear to have little interest in addressing the latter, whilst being largely pre-occupied in the nations prurient interest in the former.
Perhaps I should just write “NHS Doctor” in every box in the Conflict of Interest form and leave it at that. Any informed reader will know that means I’m both horribly conflicted and utterly unable to do anything about it.