Let’s assume for a moment that the NHS bill passes, and that it leads, as the government want it to, to a competitive environment for care. Every thought how much conflict of interest this would lead to?
Let me say, first of all, that I like doctors, and what follows isn’t meant to be hostile, even if it reads a such.
GPs are the cornerstone of the reforms. They are meant to be getting involved in commissioning as well as acting to make sure patients make the best choices (at least they will be advising patients on choice, at most making the choices for patients if, like me, they don’t think they are qualified to be making choices).
Thing is, most GPs have been asked to consider themselves as independent contractors in the NHS. They get paid on a really complex mix of different kinds of fees, and have increasingly invested in provision in areas of primary care outside of their own surgeries (which they may also part-own as well). If you are regarding yourself as an independent contractor in a non-competitive environment all this is at least moderately sensible (I’d prefer GPs to be salaried myself, buy hey ho).
None of these arrangements, however, are sensible in a market-based environment. Somehow we are going to have to make sure GP commissioners don’t face the situation where they have to choose between providers, some of which they have a financial interest in. That will mean potentially excluding the very large numbers of GPs who have done largely what the government asked them to, and got involved in local healthcare provision, and even then GP commissioners don’t have interests themselves, they will be in a difficult position because of their partners’ and colleagues’ financial interests. Even in advising patients about choices, GPs will have to disclose their financial interests – and what on earth are patients meant to do with this information? If you are in a collaborative environment, not driven by profit, there is greater scope for allowing GPs to refer to organizations in which they have an interest, as this is surely covered by professional ethics. If, however, we are moving to a competitive, for-profit basis, things are getting a lot more fraught. I’m not convinced the government has worked this through.
If the situation for GPs is going to get a lot more complex for hospital consultants. Consultants may work for both the NHS and private sector. In that case, they will be effectively working for organizations that are now expected to compete with one another. Surely that can’t be right? It would be like someone working for both Apple and Microsoft – far too much potential for conflict of interest through seeing information that is commercially confidential. In a competitive environment, I’m afraid, you have to choose whose side you are on, and stick to it. Professional ethics, again, don’t cover this.
Professionalism, as US sociologist Elliot Friedson suggested is a third logic – neither market, nor bureaucracy, but something else. If healthcare is going to be delivered competitively, you can’t depend on professionalism alone to prevent conflict of interest. And if you are depending on professionalism to prevent a creep of non-professional, market-based ethics into relationships, why introduce markets?
There is one more conflict of interest that has sadly become very apparent in recent weeks. Every time the NHS bill has been debated in the Lords, a running commentary on twitter has appeared explaining the financial interest many of those speaking have in relation to private medicine. That hasn’t stopped them, however, from making points entirely in favour of that interest. That is breath-taking – and to think that politicians wonder why we no longer trust them. If we can’t depend on politicians to deal with pretty obvious conflicts of interest, I wonder what the future holds for those that are tasked with implementing their reforms.