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Conflict of Interest policy V 4
08 Fall
This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of the document are not controlled.
Date approved: July 2017
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Approved by Integrated Governance and Performance Committee
Date approved 27 July 2017
Name and title of originator/author Sheetal Mukkamala, Governance and Assurance Manager
Name and title of sponsor Malcolm Hines, Chief Financial Officer
Name of responsible committee/individual
Integrated Governance and Performance Committee/ Risk and Assurance Manager
Review date July 2020, or when new guidance is released.
Policy description (Max 50 words) Conflict of Interest Policy will guide the CCG in managing conflicts of interest in commissioning of services for its population and will enable proactive managing of conflicts.
Target audience As covered in the scope of the policy
Stakeholders engaged in development or review
CCG staff, Governing Body members, Integrated Governance and Performance Committee members.
Version Control
Version number Version 4
Supersedes Version 3
Implementation
Implementation plan in place? Yes
Method and date of dissemination Intranet, Staff newsletter, GP bulletin
Monitoring
Monitoring method Via Integrated Governance and Performance Committee and Audit Committee. Improvement and Assessment Framework
Frequency At least quarterly
Responsibility Chief Financial Officer
Reporting NHS England quarterly self-assessments
Document Review Control Information
Version Date Reviewer Name(s) and Job title
Change/amendment
1.0 June 2013 Governing Body Approved by CCG Governing Body
1.1 2nd September 2013
IGP - New Southwark CCG email address inserted on Page 11
- Minor changes suggested by Asst. Counter-Fraud Manager, London Audit Consortium
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Version Date Reviewer Name(s) and Job title
Change/amendment
regarding references to Bribery Act on pages 19,20 and CoI form declaration pages 27,30
2.0 October 2014
IGP Amendments to insert details of COI Panel, terms of reference and referral mechanism.
3 March 2015
IGP Amendments to reflect new COI guidance re primary care co-commissioning, issued by NHS England in December 2014.
4. October 2016
IGP Amendments to reflect new COI guidance issued by NHS England in June 2016, including:
- Reporting breach and non-compliance
processes
- Annual CoI audit within IA plan
- Annual COI training requirements
5. July 2017 IGP Amendments to reflect new guidance released June 2017, including
- Register of interests publication
amendments
- New care models commissioning
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Contents
1. Background ............................................................................................... 6
2. Introduction, Aims & Objectives ................................................................ 7
3. Scope of the Policy .................................................................................... 8
4. Principles .................................................................................................. 8
5. Definition of ‘Conflict of Interest’ .............................................................. 9
6. Accountability & Responsibilities ............................................................ 11
7. Conduct expected of individuals involved in the CCG ............................... 11
8. Privileged information ............................................................................. 12
9. Declaration of Interests ........................................................................... 13
10. Declaration of Gifts, Hospitality and Sponsorships .................................. 14
11. Maintaining a Register of Interests .......................................................... 14
12. The role of the Governance and Assurance team .................................... 15
13. Procedure to be followed during Governing Body meetings, or Committee/ Sub Committee meetings ............................................................ 16
14. The Role of the Chair of the Governing Body/ Committee/ Sub Committee meeting .......................................................................................................... 17
15. The Role of the Lay Member as Conflict of Interest Guardian .................. 18
16. Outside employment ................................................................................ 19
17. Conflict of Interest and GP Federations/ other provider organisations ... 20
18. Conflict of Interest (CoI) Panel ................................................................ 20
19. Appointment of Governing Body/ Committee Members ......................... 21
20. Identifying and managing conflicts of interest in commissioning new care models ............................................................................................................ 22
21. Designing Services ................................................................................... 23
22. Procurement of Services ......................................................................... 24
23. Declaration of Interests for Bidders/ Contractors .................................... 24
24. Ensuring transparency in Procurement (see Appendix 5) ......................... 25
25. Contract Monitoring: .............................................................................. 26
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26. Data protection ....................................................................................... 26
27. Conflict of Interest Management for Procurement Decisions Related to Primary Care ................................................................................................... 27
28. Raising concerns and Managing breaches: .............................................. 27
29. Monitoring and Compliance:................................................................... 29
30. Policy development and Monitoring ....................................................... 29
31. Training and Raising Awareness .............................................................. 30
32. Equality & Diversity Statement ............................................................... 30
33. Links to other Policies ............................................................................. 30
Appendices ..................................................................................................... 32 APPENDIX 1 – Declaration Form for Member / employee/ governing body member / committee or sub-committee member ........................................ 32 Appendix 2 - Declaration of Interests Form: Bidders/potential contractors/service provider ........................................................................ 34 Appendix 3 Template declarations of interest checklist ................................ 36 Appendix 4 Template for recording minutes ................................................ 38 Appendix 5: Declaration of Interests Form for Bidders/potential contractors/service providers ...................................................................... 40 Appendix 6 - Declaration of Interests Form: Tender Evaluation Panel Members ..................................................................................................... 41 Appendix 7 – Code of Conduct – Procurement ............................................. 43 Appendix 8- Conflict of Interest Panel - Terms of Reference ......................... 45 Appendix 9 – Flowchart for decision-making and managing conflicts of interest ........................................................................................................ 48 Appendix A - Policy checklist for sponsors and authors ................................ 49 Appendix B – Equality Impact Assessment Tool ............................................ 50
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1. Background
1.1. As a public body, the CCG is responsible for the stewardship of significant
public resources when making decisions about the commissioning of health and social care services. In order to ensure and be able to evidence that these decisions secure the best possible services for the population it serves, the CCG must demonstrate accountability to relevant stakeholders (particularly the public), probity and transparency in the decision-making process.
1.2. Effective handling of conflicts of interest is crucial to give confidence to patients, tax payers, healthcare providers and Parliament that CCG
commissioning decisions are robust, fair and transparent and offer value for money. It is also essential in order to protect healthcare professionals and maintain public trust in the NHS. Failure to manage conflicts of interest could lead to legal challenge and even criminal action in the event of fraud, bribery and corruption. If conflicts of interest are not effectively managed, CCGs could face civil challenges to procurement decisions they make that could potentially overturn the award of a contract, lead to damages claims against the CCG, and necessitate a repeat of the procurement process.
1.3. NHS England has recently published revised detailed guidance under sections 14O and 14Z8 of the National Health Service Act 2006 (as amended by the Health and Social Care Act 2012) to support CCGs to manage conflicts of interest. All CCGs are expected to implement this guidance.
1.4. The NHS (Procurement, Patient Choice and Competition) Regulations 2013 also sets out that commissioners must:
manage conflicts and potential conflicts of interests when awarding a
contract by prohibiting the award of a contract where the integrity of the award has been or appears to have been affected by a conflict;
keep appropriate records of how they have managed any conflicts in individual cases.
1.5. All CCGs have statutory requirements1 they must legally comply with regarding
conflict of interest, including make arrangements for declaring conflicts of interests, managing actual and potential conflicts of interests in such a way as to ensure that they do not and do not appear to, affect the integrity of the CCG’s decision-making processes and maintain and publish registers of conflicts of interests and gifts and hospitality.
1.6. Therefore, NHS Southwark CCG recognises the importance of all of its members to be fully aware of the guidance and continuously mindful of conflicts of interest. It has included in its Constitution the Standards of Business Conduct and Managing conflicts of interest, which Member
1 Section 140 of the National Health Service Act 2006, inserted by the Health & Social Care Act 2012
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Practices, members of the Governing Body (and its committees and sub-committees) and employees will at all times comply with and be aware of their responsibilities as outlined in it.
2. Introduction, Aims & Objectives
2 .1 . This policy follows the guidance issued by NHS England Managing Conflicts of Interest: Revised Statutory Guidance for CCGs version 72.
2 .2 . This policy will guide the CCG in ensuring that robust mechanisms for
declaration of interests and managing them are in place thus safeguarding the interests of patients and the public.
2 .3 . It sets out how NHS Southwark CCG will manage any conflicts (or potential conflicts) of interest arising during the course of the CCG’s business. It also sets out the organisation’s commitment to on-going training, raising awareness on conflicts of interest and an induction programme for new members of the CCG.
2 .4 . The policy should be read in conjunction with the following documents (as amended):
NHS England Managing Conflicts of Interest: Revised Statutory Guidance for CCGs version
Standards for members of NHS Boards and Clinical Commissioning Groups (Professional Standards Authority, November 20123)
NHS Clinical Commissioners, Royal College of General Practitioners and British Medical Association – Shared principles on conflicts when CCGs are commissioning from member practices (December 2014) (Annex 1 to the above)
Next steps towards primary co-commissioning (NHS England November 2014)
Towards Establishment: Creating responsive and accountable CCGs Technical appendix 1 (NHS Commissioning Board, October 2012)
Appointments Commission’s Code of Conduct and Code of Accountability, Code of Conduct for NHS Managers 2002
The Healthy NHS Board: Principles for Good Governance (NHS Leadership Academy 2013)
General Medical Council: Good Medical Practice April 2013
2 .5 . In addition, it should be noted that this policy updates and expands upon the provisions contained in the CCG’s constitution.
2 https://www.england.nhs.uk/wp-content/uploads/2017/06/revised-ccg-coi-guidance-jul-17.pdf 3 http://www.professionalstandards.org.uk/docs/default-source/publications/standards/standards-for-members-of-nhs-boards-and-ccgs-2013.pdf?sfvrsn=2
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3. Scope of the Policy
3.1. This policy applies to:
The members of NHS Southwark CCG (practices), The members of the NHS Southwark CCG Governing Body;
The members NHS Southwark CCG’s committees and sub- committees of
the Governing Body
The members of its advisory panels or groups; and The employees of NHS Southwark CCG including fixed term, temporary
etc. as listed in #5.2
4. Principles
4.1. S tandards of business conduct and managing conflicts of interest are set out in
the CCG’s Constitution (4.4). This policy supports the CCG Constitution. These include:
The Good Governance Standards for Public Services 2004;
Seven Key Principles of the NHS Constitution
UK Corporate Governance Code
Standards for members of NHS boards and CCG governing bodies in England
The Equality Act 2010
The Seven Principles of Public Life promulgated by the Nolan Committee: i. Selflessness ii. Integrity
iii. Objectivity iv. Accountability v. Openness vi. Honesty
vii. Leadership
4.2. This policy reflects the principles of managing conflicts of interest as detailed in the NHS England guidance Managing Conflicts of Interests: Guidance for clinical commissioning groups, March 2013:
(i) Doing business properly: Conflicts of interest become much easier to
identify, avoid and/or manage when the processes for needs assessments, consultation mechanisms, commissioning strategies and procurement procedures are right from the outset, because the rationale for all decision-making will be clear and transparent and should withstand scrutiny;
(ii) Being proactive not reactive: Commissioners should seek to identify and minimise the risk of conflicts of interest at the earliest possible opportunity;
(iii) Being balanced and proportionate: Rules should be clear and robust but not overly prescriptive or restrictive. They should ensure that decision-making is transparent and fair whilst not being overly constraining, complex or cumbersome.
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(iv) Be transparent: Document clearly the approach and decisions taken at every stage in the commissioning cycle so that a clear audit trail is evident.
(v) Create an environment and culture where individuals feel supported and confident in declaring relevant information and raising any concerns.
4.3. In addition, this policy also supports the three main principles of procurement
law: Equal treatment, Non-discrimination and Transparency.
5. Definition of ‘Conflict of Interest’
5.1. A conflict of interest is defined as:
A conflict between the private interests and the official responsibilities of a person in a position of trust;
A set of conditions in which a professional judgement concerning a primary interest [such as patients’ welfare or the validity of research] tends to be unduly influenced by a secondary interest [such as financial gain].
A set of circumstances by which a reasonable person would consider that
an individual’s ability to apply judgment or act, in the context of delivering, commissioning, or assuring taxpayer funded health and care services is, or could be, impaired or influenced by another interest they hold.
5.2. This definition includes:
(i) Financial interests: This is where an individual may get direct financial benefits
from the consequences of a commissioning decision. This could, for example, include being:
A director, including a non-executive director, or senior employee in a
private company or public limited company or other organisation which is
doing, or which is likely, or possibly seeking to do, business with health or
social care organisations. This includes involvement with a potential
provider of a new care model;
A shareholder (or similar owner interests), a partner or owner of a private
or not-for-profit company, business, partnership or consultancy which is
doing, or which is likely, or possibly seeking to do, business with health or
social care organisations.
A management consultant for a provider;
A provider of clinical private practice;
Also includes an individual in -
In employment outside of the CCG;
In receipt of secondary income from a provider;
In receipt of a grant from a provider;
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In receipt of any payments (for example honoraria, one off payments, day
allowances or travel or subsistence) from a provider
In receipt of research funding, including grants that may be received by
the individual or any organisation in which they have an interest or role;
and
Having a pension that is funded by a provider (where the value of this
might be affected by the success or failure of the provider).
(ii) Non-financial professional interests: This is where an individual may obtain a
non-financial professional benefit from the consequences of a commissioning
decision, such as increasing their professional reputation or status or promoting
their professional career. This may, for example, include situations where the
individual is:
An advocate for a particular group of patients;
A GP with special interests e.g., in dermatology, acupuncture etc.
An active member of a particular specialist professional body (although routine GP membership of the RCGP, BMA or a medical defence organisation would not usually by itself amount to an interest which needed to be declared);
An advisor for Care Quality Commission (CQC) or National Institute for Health and Care Excellence (NICE);
Engaged in a research role.
Development and holding of patents and other intellectual property rights which allow staff to protest something they create, preventing unauthorised use of products or the copying of protected ideas, or
GPs and practice manager, who are members of the governing body of committee of the CCG, should declare details of their roles and responsibilities held within their GP practices
(iii) Non-financial personal benefits: This is where an individual may benefit
personally in ways which are not directly linked to their professional career and do not give rise to a direct financial benefit. This could include, for example, where the individual is:
A voluntary sector champion for a provider;
A volunteer for a provider;
A member of a voluntary sector board or has any other position of authority in or connection with a voluntary sector organisation;
Suffering from a particular condition requiring individually funded treatment;
A member of a lobby or pressure groups with an interest in health.
(iv) Indirect interests: This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non-financial personal interest in a commissioning decision (as those categories are described above). For example, this should include:
Spouse / partner;
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Close relative e.g., parent, grandparent, child, grandchild or sibling;
Close friend;
Business partner.
5.2. A declaration of interest for a “business partner” in a GP partnership should include all relevant collective interests of the partnership, and all interests of their fellow GP partners (which could be done by cross referring to the separate declarations made by those GP partners, rather than by repeating the same information verbatim).
5.3. Whether an interest held by another person gives rise to a conflict of interests
will depend upon the nature of the relationship between that person and the individual, and the role of the individual within the CCG.
6. Accountability & Responsibilities
6.1 The Accountable Officer has overall accountability for the CCG’s management
of conflicts of interest. In addition, the CCG’s corporate governance agenda is
supported by the Chief Financial Officer who is also the director responsible for
governance, the Head of Governance and Assurance and the Governance and
Assurance Manager.
6 . 2 . It is the responsibility of all listed below to ensure that they are not placed in a
position which creates a conflict or potential conflict between their private
interests and their NHS Southwark CCG duties.
The members of NHS Southwark CCG (practices), The members of the NHS Southwark CCG Governing Body;
The members NHS Southwark CCG’s committees and sub- committees of
the Governing Body
The members of its advisory panels or groups; and The employees of NHS Southwark CCG including fixed term, temporary
etc.
7. Conduct expected of individuals involved in the CCG
7.1 All members, employees and appointees of NHS Southwark CCG are required to observe principles of good governance in the way the organisation’s business is conducted (as set out in the CCG’s Constitution (4.4)). 7.2. This policy supports a culture of openness and transparency in business
transactions. All employees and appointees of NHS Southwark Clinical Commissioning Group are required to:
ensure that the interests of patients remain paramount at all times be
impartial and honest in the conduct of their official business;
use public funds entrusted to them to the best advantage of the service, always ensuring value for money;
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ensure that they do not abuse their official position for personal gain or to the benefit of their family or friends;
ensure that they do not seek to advantage or further, private or other interests, in the course of their official duties.
7.3. The General Medical Council (GMC) guidance on conflicts of interest4
recommends that:
You must not allow any interests you have to affect the way you prescribe for, treat, refer or commission services for patients.
If you are faced with a conflict of interest, you must be open about the conflict, declaring your interest informally, and you should be prepared to exclude yourself from decision making.
You must not try to influence patients’ choice of healthcare services to
benefit you, someone close to you, or your employer.
If you plan to refer a patient for investigation, treatment or care at an organization in which you have a financial or commercial interest, you must tell the patient about that interest and make a note of this in the patients’ medical records
Where there is an unavoidable conflict of interest about the care of a particular patient, you should record this in the patient’s medical records
You must keep up to date with and follow the guidance and codes of practice that govern the commissioning of services where you work
You must formally declare any financial interest that you or someone close to you, or your employer has in a provider company, in accordance with the governance arrangements in the jurisdiction where you work
You must take steps to manage any conflict between your duties as a doctor and your commissioning responsibilities
NHS Southwark CCG supports the GMC guidance.
7.4. In conclusion, NHS Southwark CCG acknowledges it as important that:
perception of wrong-doing, impaired judgement or undue influence may be as detrimental as it actually occurring;
if there is any doubt, it is better to assume a conflict of interest and act appropriately rather than to ignore it; and
it is not necessary for financial gain to be present for a conflict to exist.
8. Privileged information
8.1. No–one should use confidential information acquired in the pursuit of their role within the CCG to benefit themselves or another connected person, or create the impression of having done so.
8.2. Members of NHS Southwark CCG, employees and the Governing Body should take care not to provide any third party with a possible advantage by
4 http://www.gmc-uk.org/static/documents/content/Financial_and_commercial_arrangements_and_conflicts_of_interest.pdf
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sharing privileged, personal or commercial information, or by providing information that may be commercially useful in advance of that information being made available publically (such as by informing a potential supplier of an up and coming procurement in advance of other potential bidders), or any other information that is not otherwise available and in the public domain.
9. Declaration of Interests
9.1. The CCG requires that declaration of interests, as listed in #5.2 above, should
be made by all of the following: All CCG staff including:
all full time and part time staff
any staff on sessional or short term contracts
any students and trainees(including apprentices)
Agency staff
Seconded staff
Self-employed consultants or other individuals working for the CCG under a contract for services, should make a declaration as if they were CCG employees.
All Members of the governing body including:
Co-opted members
Appointed deputies
Any members of committees/ groups from other organisations
Members on any joint committees representing the CCG
Clinical associates
All members of the CCG (i.e. each practice):
GP partners (or where the practice is a company, each director)
Any individual directly involved with the business or decision-making of the CCG).
9.2 Declarations should be made as soon as reasonably practicable and by law within 28 days after the interest arises. The CCG Chief Officer should be informed of any interests requiring registrations within 28 days of a member taking office, or within 28 days of any changes to a member’s existing declarations. Such changes should also be reported to the Governance and Assurance Manager for making changes in the register.
9.3. Applicants for any appointment to the CCG or its Governing Body will be asked to declare any relevant interests. Appointments will be followed by a formal declaration form to be submitted.
9.4. NHS Southwark CCG requires that all staff update their declarations of interests at least annually or make a nil return where no interests or changes to declare.
9.5. All members are required to confirm their declarations as a standing item on
the agenda for every Governing Body meeting, committee and subcommittee meeting. Declarations will be recorded in the minutes of the meeting. Even if an
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interest has been already recorded in the register of interests, it should be declared in meetings where matters relating to that interest are discussed.
9.6. New declarations are required when an individual changes role or responsibility
with NHS Southwark CCG (including the Governing Body), and when an individual’s circumstances change in a way that affects the individual’s interests (e.g. a new role outside the CCG or setting up of a new business or relationship). This could include a conflict of interest ceasing to exist or a new one materialising.
10. Declaration of Gifts, Hospitality and Sponsorships
10.1. Employees, members, committee and sub-committee members of the CCG,
members of the Governing Body (and its committees), individuals contracted to work on behalf of the CCG or otherwise providing services or facilities to the CCG must comply with provisions of the Bribery Act 2010.
10.2. The CCG’s Gifts and Hospitality Policy has been reviewed in light of recent
(June 2017) guidance and provides details on the CCG’s approach to acceptance of gifts, hospitality and sponsored events.
10.3. The CCG also has a ‘Joint Working with Pharmaceutical policy’ which should be
read in conjunction with the Counter fraud and anti- bribery policy, conflict of interest policy and the gifts and hospitality policy.
11. Maintaining a Register of Interests
11.1. Registers of Interests will be maintained for individuals listed in #9.1. The
registers will be maintained and held by the Governance team based at NHS Southwark CCG headquarters.
11.2. The CCG’s Register of Interests will be published on the CCG public website
and updated every quarter. It can be made available on request by writing to:
Governance and Assurance Manager
NHS Southwark Clinical Commissioning Group 1st Floor, Hub 5, PO Box 64529
London SE1P 5LX
Email: [email protected]
11.3. As a minimum, the CCG is required to publish Registers of Interest and Gifts and Hospitality for decision-making staff at least annually and make them available at request. The CCG will therefore, publish registers covering the following individuals:
- All Governing Body members
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- Members of advisory groups which contribute to direct or delegated decision making on the commissioning or provision of taxpayer funded services such as working groups involved in service redesign or stakeholder engagement that will affect future provision of services;
- Members of the Primary Care Commissioning Committee (PCCC);
- Members of other committees of the CCG e.g., audit committee, remuneration committee etc.;
- Members of new care models joint provider / commissioner groups / committees;
- Members of procurement (sub-)committees;
- Those at Agenda for Change band 8d and above;
- Management, administrative and clinical staff who have the power to enter into contracts on behalf of the CCG; and
- Management, administrative and clinical staff involved in decision making concerning the commissioning of services, purchasing of good, medicines, medical devices or equipment, and formulary decisions.
11.4. The Register of Interests will be updated following every Governing Body and committee meeting. Interests will be maintained on the register for a minimum of 6 months after the interest has expired.
11.5 The Register of Interests will be published as part of the CCG’s Annual Report
and Annual Governance Statement.
11.6 The CCG will maintain a register of gifts and hospitality for staff as is required
by the guidance.
12. The role of the Governance and Assurance team
The Governance Manager/ team will:
Receive declarations of interests from all new members and employees of the CCG and Governing Body.
Update the Register of Interests and ensure it is available on the CCG’s public website every quarter
Ensure the Register is made available on request
Ensure declaration of interest is taken as a standing item at every CCG
Governing Body, committee and sub-committee meeting and the signing sheet
is made available at all committee and subcommittee meetings.
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13. Procedure to be followed during Governing Body meetings, or Committee/ Sub Committee meetings
13.1. D e c l a r a t i o n of Interests will be a standing item on the agenda of all
Governing Body meetings, committees and sub-committee meetings, after introductions and apologies (see also Section 16).
13.2 I n a d d i t i o n , the Register of Interests will be circulated to all members for acknowledgement of entries and signatures. Blank forms for declarations will also be made available from the staff member servicing the meeting. The interests of those individuals that are “In attendance” rather than full members, will be captured in the minutes of the meeting only.
13.3. The chair, with members of the board/ committee, should review interests
against each agenda item to determine whether they have any specific (i.e. relevant and material) interests which could potentially conflict with an agenda item. - An interest is specific when it refers directly to the matter under discussion - An interest is non-specific where it does not refer directly to the matter
under discussion
13.4. If any conflicts of interest are declared or otherwise arise in a meeting, the chair, aided by the CoI guardian should advise on the appropriate management action in cases where a conflict is identified and may wish to refer to the table below as a guide:
Type of interest Action
Direct financial Specific Declare and leave the meeting for the item(s) concerned. In exceptional circumstances the chair may rule that they can attend to answer specific questions
Non-specific Declare and participate unless, the chair rules otherwise
Indirect financial Specific Declare and participate unless, the chair rules otherwise
Non-specific Declare and participate unless, the chair rules otherwise
Non-financial Specific Declare: action is then at the discretion of the chair
Non-specific Declare and participate unless, the chair rules otherwise
13.5. Record keeping: The chair must ensure the following information is recorded in the minutes: - who has the interest; - the nature of the interest and why it gives rise to a conflict, including
the magnitude of any interest; - the items on the agenda to which the interest relates; - how the conflict was agreed to be managed; and - evidence that the conflict was managed as intended (for example
recording the points during the meeting when particular individuals left or returned to the meeting).
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A template for recording minutes is provided in Appendix 4 13.6. Where an interest is significant, or when the individual or a connected person
has a direct financial interest in a decision, the individual should not take part in the discussion or vote on the item, but may be allowed to sit with the public, where this is relevant.
13.7. If that exclusion affects the quorum of the meeting, the item should be:
a) postponed to another such time when quorum can be achieved without conflicts, or;
b) referred to the Conflict of Interest Panel in the panel’s ‘recommend’ mode, see 2.2b. of Appendix 6 Conflict of Interest Panel terms of reference.
13.8. If the conflicted member is a specialist/ expert, quorum may be achieved on the
following occasion by inviting an external independent expert from another CCG or trust.
13.9. It is recognised that there may be circumstances where the Chair of the
meeting judges it appropriate for the individual concerned to attend the meeting and contribute in the discussion having declared an interest (waiver), but not to participate in any decision-making resulting from such discussion (i.e. not having a vote in relation to the decision).
13.10. Alternatively, in cases where the declared a conflict of interest is deemed not
significant enough for them to have to withdraw from the discussion, the chair of the meeting can permit them to participate in the discussion but can then refer the outcome of the discussion to the Conflict of interest Panel for it to review in “validate” mode (see paragraph 2.2 a. of the Panel’s terms of reference at Appendix 6).
13.11. If the Chair of the meeting is personally conflicted, the deputy chair will
conduct proceedings, providing they are not also conflicted. If the Chair and Deputy are both conflicted, then a Chair will be appointed by the remainder of the Committee/ Governing Body members. The National Health Service (Clinical Commissioning Groups) Regulations 2012 specify that the Accountable Officer, the Chief Finance Officer, the registered nurse, hospital consultant and the Lay Person who chairs the Audit Committee, are ineligible to be the chair of the CCG Governing Body.
13.12. If there is any doubt as to whether an interest should be declared, a declaration
should be made and advice sought from the Lay Member with responsibility as the Guardian for Conflict of Interests (see Section 17).
14. The Role of the Chair of the Governing Body/ Committee/ Sub Committee meeting
14.1. The chair of a meeting of the CCG’s governing body or any of its committees,
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sub-committees or groups has ultimate responsibility for deciding whether there is a conflict of interest and for taking the appropriate course of action in order to manage the conflict of interest.
14.2. In the event that the chair of a meeting has a conflict of interest, the vice chair
is responsible for deciding the appropriate course of action in order to manage the conflict of interest. If the vice chair is also conflicted then the remaining non-conflicted voting members of the meeting should agree between themselves how to manage the conflict(s).
14.3 In making such decisions, the chair (or vice chair or remaining non-conflicted
members as above) may wish to consult with the Conflicts of Interest Guardian (see paragraph 67) or another member of the governing body.
14.3. In advance of Governing Body/ committee and sub-committee meetings, the Chair of the meeting will review agenda for any conflicts of interests. If any conflicts are identified, the Chair will ensure that the process outlined in section 13 onwards will be followed.
14.4. The Chair of the meeting will decide on the course of action regarding how to
proceed should conflicts of interest arise within the meeting, and whether a matter needs to be referred to the Conflict of Interest (CoI) Panel. In making such decisions, the Chair may wish to consult the Conflict of Interest Guardian for advice. All decisions should be recorded in the minutes of the meeting.
15. The Role of the Lay Member as Conflict of Interest Guardian
15.1. NHS Southwark CCG Governing Body has appointed one of the Lay Members
(with a lead role in Governance) to act as “Conflict of Interest (CoI) Guardian”. The lay member who is the Audit Chair is the COI Guardian for the CCG.
15.2. The Lay Member should have no provider interest, is not a medical doctor or a
healthcare provider and is therefore independent and impartial with regard to decisions related to commissioning of services.
15.3. The Lay Member will:
- act as a conduit for GP practice staff, members of the public and healthcare professionals who have any concerns in regard to Conflicts of Interest. Members of the public will be able to contact the Lay Member regarding concerns via the NHS Southwark CCG website.
- Be a safe point of contact for employees or workers of the CCG to raise any concerns in relation to this policy
- Advise on how to minimise risks of conflicts of interest; - act as Guardian for conflict of interest and decide if a matter needs to be
referred to the COI panel; - Be responsible for ensuring that the CCG applies conflict of interest
principles and policies rigorously and provides the CCG with independent
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advice and judgment where there is any doubt about how to apply them to individual cases.
- The Lay Member will have a lead role in ensuring that the Governing Body and the wider CCG behaves with the utmost probity at all times and be able to give an independent view on possible internal conflicts of interest.
- Be the Vice Chair of the Joint Committee for Primary care Co-Commissioning while the Lay member for PPI will be the Chair. The COI guardian in his role as the audit chair cannot be the Chair of the Primary Care Commissioning Joint Committee. There will always be a lay and executive majority on the Committee. Details on the conflict of interest management in co-commissioning decision are listed in section 25.
15.4. The Conflict of Interest Guardian operates:
reactively, when the Chair of a meeting, individual Governing Body member, or Southwark CCG as a whole or seek advice on a specific issue,
pro-actively, when a potential Conflict of Interest risk is identified and acts on it. The Conflict of Interest Guardian is a voting member of the Governing Body and is familiar with the work of the organisation and the roles of Clinical Leads. The Conflict of Interest Guardian is, therefore, in an informed position to identify such risks when they arise.
In either mode the Conflict of Interest Guardian will discuss the issue with those involved (and any other relevant party) and issue written advice or judgement for the Governing Body. The members of the Governing Body, its committees and sub-committees have agreed that they will accept the advice or judgement of the Conflict of Interest Guardian in such cases.
15.5 All issues raised to the Lay Member for Conflict of Interest will be logged with
the Southwark CCG Governance team, under the COI Guardian log.
15.6 The Governance Team & Lay Member with responsibility as Guardian for Conflict of Interest will review Register of Interest entries on a regular basis and take any action necessary highlighted by the review. All actions taken will be reported to the Integrated Governance & Performance Committee.
16. Outside employment
16.1. This refers to employment and other engagements, outside of formal
employment arrangements. 16.2. This policy requires that CCG employees, committee members, contractors and
others engaged under contract with the CCG, should declare if they are employed or engaged in, or wish to be employed or engaged in, any employment or consultancy work in addition to their work with the CCG, as soon as it arises.
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16.3. The purpose of this is to ensure that the CCG is aware of any potential conflict of interest. Examples of work which might conflict with the business of the CCG, including part-time, temporary and fixed term contract work, include:
Employment with another NHS body;
Employment with another organisation which might be in a position to supply goods/services to the CCG including paid advisory positions and paid honorariums which relate to bodies likely to do business with the CCG;
Directorships e.g. of a GP federation or non-executive roles;
Self-employment, including private practice, charitable trustee roles, political roles and consultancy work, in a capacity which might conflict with the work of the CCG or which might be in a position to supply goods/services to the CCG.
17. Conflict of Interest and GP Federations/ other provider organisations
17.1. All committee members should update their declaration of interests to include
stating if the practice where they do most work is member of a GP Federation and its name e.g. Quay Health Solutions or Improving Health Solutions.
17.2. All committee members should update their declaration of interests to include
management roles at provider organisations e.g. Director of Quay Health Solutions.
17.3. Any committee members who have a management role at provider
organisations which may bid for certain work will be seen as having a conflict regarding discussion of that work
17.4. Any committee members who work at practices who are part of provider
organisations bidding for work will not automatically be seen as conflicted unless they are in management roles at the provider organisations, or personally declare themselves conflicted due to extensive involvement.
17.5. Anyone who does not declare a conflict which is later deemed to be such does
put their organisation at risk of being excluded from bidding to provide those services. Advice can be sought from the Conflict of Interest policy, Conflict of Interest Guardian, or the Governance Team.
18. Conflict of Interest (CoI) Panel
18.1. The COI Panel is an advisory body to the Governing Body – decisions made by
the Governing Body are sovereign. The terms of reference for the COI Panel are attached in Appendix 6
18.2. The Conflict of Interest Panel will provide neutrality in the evaluation process
and will have the following membership in unconflicted roles:
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GB Lay member, normally lay member with CoI guardian responsibility (See
Section 17)
The Chief Officer
Chief Financial Officer
Secondary Care Consultant
Registered nurse
Lambeth and Southwark Director of Public Health or a suitable deputy
Plus co-opted clinical or procurement expertise if necessary, at the discretion of the Chief Officer.
18.3 In exceptional circumstances, lay members from other CCGs or experts from
the field e.g. primary care commissioners from NHS England, GPs from other CCGs, procurement/ legal specialists may be invited to join the Panel to provide necessary expertise or advice.
18.4 The panel will operate in two principal modes – validate mode and recommend mode. More details are available in the COI Panel terms of reference in Appendix 6.
18.5 A flowchart to explain how referrals will be received by the COI Panel can be
found in Appendix 9.
18.6. The Panel’s consideration and recommendation will be fully minuted and
attached to the relevant Governing Body meeting papers.
18.7. A CoI Panel will be held approximately 4 weeks, or as necessary, to allow
adequate amount of time for referrals to be made to the Panel from the source committees.
18.8 The Governing Body meeting will receive and consider the Panel’s
recommendations.
19. Appointment of Governing Body/ Committee Members
19.1. The appointment process for Governing Body members is fully
documented in the NHS Southwark CCG Constitution.
19.2. Any individual who has an interest in an organisation which provides or is likely to provide substantial business to a CCG (either as a provider of healthcare or commissioning support services) should not be appointed as a member of the Governing Body. Appointments will be considered on a case by case basis. In making appointments, the CCG will consider materiality of the interest, the extent and nature of the interest.
19.3. The Secondary Care Doctor on the Governing Body should have no conflicts
of interest i.e. they should not be employed by any organisation from which the CCG secures any significant volume of provision.
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19.4. The Registered Nurse on the Governing Body should have no conflicts of
interest i.e. they should not be employed by any organisation from which the CCG secures any significant volume of provision.
19.5. CCG employees, committee members, contractors and others engaged in a
contract with the CCG should inform the CCG of any secondary employment undertaken in addition to their work with/for the CCG. The purpose of this is to ensure that he CCG is aware of any potential conflict of interest. Examples of work which might conflict with the CCG’s business, including part-time, temporary and fixed term contract, include:
- Employment with another NHS body, - Employment with another organisation which might be in a position to
supply goods and services to the CCG - Directorship of a GP federation - Self-employment, including private practice, in a capacity which might
conflict with the work of the CCG or which might be a position to supply goods/ services to the CCG.
19.6. It is advised that individuals should obtain prior permission to engage in
secondary employment, and the CCG reserves the right to refuse permission where it believes a conflict will arise which cannot be effectively managed.
20. Identifying and managing conflicts of interest in commissioning new care models
20.1. The CCG recognises that conflicts of interest can arise throughout the whole
commissioning cycle from needs assessment, to procurement exercises, to contract monitoring.
20.2. In the case of new care models5, it is perhaps likely that there will be individuals
with roles in both the CCG and new care model provider/potential provider. These conflicts of interest should be identified as soon as possible, and appropriately managed. The position should also be reviewed whenever an individual’s role, responsibility or circumstances change in a way that affects the individual’s interests. For example, where an individual takes on a new role outside the CCG, or enters into a new business or relationship, these new interests should be promptly declared and appropriately managed in accordance with the statutory guidance.
5 In the guidance, ‘new care models’ refers to any Multi-speciality Community
Provider (MCP), Primary and Acute Care Systems (PACS) or other arrangements of a similar scale or scope that (directly or indirectly) includes primary medical services.
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20.3. On occasions where the conflict of interest is profound and acute, such as where an individual has a direct financial interest which gives rise to a conflict, e.g., secondary employment or involvement with an organisation which benefits financially from contracts for the supply of goods and services to a CCG or aspires to be a new care model provider), the CCG will consider whether, practically, such an interest is manageable at all. This can arise in relation to both clinical and nonclinical members/roles.
20.4. If an interest is not manageable, the CCG may require an individual to step
down from a particular role and/or move to another role within the CCG and may require the CCG to take action to terminate an appointment if the individual refuses to step down.
20.5. Where a member of CCG staff participating in a meeting has dual roles, for
example a role with the CCG and a role with a new care model provider organisation, but it is not considered necessary to exclude them from the whole or any part of a CCG meeting, he or she should ensure that the capacity in which they continue to participate in the discussions is made clear and correctly recorded in the meeting minutes, but where it is appropriate for them to participate in decisions they must only do so if they are acting in their CCG role.
20.6. CCGs should identify as soon as possible where staff might be affected by the
outcome of a procurement exercise, e.g., they may transfer to a provider (or their role may materially change) following the award of a contract. This should be treated as a relevant interest, and CCGs should ensure they manage the potential conflict. This conflict of interest arises as soon as individuals are able to identify that their role may be personally affected.
20.7. Similarly, CCGs should identify and manage potential conflicts of interest where
staff are involved in both the contract management of existing contracts, and involved in procurement of related new contracts.
20.8. Decisions related to commissioning and contracting of any new care models
involving primary care should be referred to Primary Care Commissioning Committee, as this committee has executive and lay majority and includes a requirement to invite Local Authority and Healthwatch representative.
21. Designing Services
21.1. In the course of new or existing service designs NHS Southwark CCG will
engage with relevant providers, especially clinicians, to confirm service specifications and such engagement when done transparently and fairly, is entirely legal and not contrary to competition law.
21.2 NHS Southwark CCG will take all necessary steps and ensure safeguards are
in place to avoid and manage conflicts of interest arising from such engagement towards service redesign by following the three main principles of procurement law, namely, equal treatment, non-discrimination and
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transparency. This includes ensuring that the same information is made available to all.
22. Procurement of Services
22.1 NHS (Procurement, Patient Choice and Competition) Regulations 2013 set out
that all commissioners must:
manage conflicts and potential conflicts of interests when awarding a
contract by prohibiting the award of a contract where the integrity of the award has been or appears to have been affected by a conflict, and,
keep appropriate records of how they have managed any conflicts in individual cases
22.2 Under section 78 of the Health and Social Care Act 2012, Monitor will guidance
on compliance with any requirements imposed by the regulations made under section 75, and how it intends to exercise the powers conferred on it by these regulations.
22.3. NHS Southwark CCG will implement and adhere to any such guidance from
Monitor/ NHS England.
23. Declaration of Interests for Bidders/ Contractors
23.1 NHS Southwark CCG recognises that Conflict of Interests may vary according
to the route that a service is commissioned. Examples of different options include:
Competitive tender: Where a CCG is commissioning a service through
competitive tender (i.e. seeking to identify the best provider or set of providers for a service), a conflict could arise where GP practices or other providers in which CCG members have an interest are amongst those bidding.
Any Qualified Provider: Where a CCG wants patients to be able to
choose from a range of possible providers and is therefore commissioning a service through Any Qualified Provider, a conflict could arise where one or more GP practices (or other providers in which CCG members have an interest) are amongst the qualified providers from which patients can choose. In these circumstances, there are a number of options for demonstrating that GP practices have offered fully informed choice at the point of referral and for auditing and publishing referral patterns. These will build on well-established procedures for declaring interests when GPs or other clinicians make a referral.
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Single tender: Where the CCG is procuring services from a GP practice
where there are no other capable providers, i.e. this is the appropriate procurement route and the proposed service goes beyond the scope of the services provided by GP practices under their GP contract.
23.2. The conflicted person is expected to declare any interest early in any procurement process if they are to be a potential bidder in that process. Failure to do so could result in the procurement process being declared invalid and possible suspension of the relevant member from the CCG.
23.3 Where a relevant and material interest or position of influence exists in the
context of the specification for, or award of a contract, the conflicted person will be expected to:
Declare the interest using the Declaration of Interests for bidders / contractors template (Appendix 2)
Ensure that the interest is recorded in the CCG’s Register of Interests
Withdraw from all discussion on the specification or award
Not have a vote in relation to the specification or award, or any formal role in the procurement process.
23.4. Conflicts and potential conflicts need to declared for all types of procurement
routes including Competitive Tender, Any Qualified Provider or Single Tender. The “Code of Conduct” templates at Appendix 4& 5 set out factors on which CCGs are advised to assure themselves and their Audit Committee – and be ready to assure local communities, Health and Wellbeing Boards and auditors – when commissioning services that may potentially be provided by GP practices.
24. Ensuring transparency in Procurement (see Appendix 5)
24.1 NHS Southwark CCG Procurement Strategy (available on the CCG’s website),
approved by its Governing Body, ensures that:
a) all relevant clinicians and potential providers, together with local members of the public, are engaged in the decision-making processes used to procure services, and;
b) service redesign and procurement processes are conducted in an open, transparent, non- discriminatory and fair way
24.2 NHS Southwark CCG will aim to publish details of all contracts, including the
value of contracts, as soon as possible after they are agreed, on the CCG website.
24.3 Panel members of tender evaluation should also complete a declaration of
interest which shall form part of the procurement evaluation report. This form is attached in Appendix 3.
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24.4 Soliciting, offering or accepting a bribe will be held to be an offence under the Bribery Act 2010. In addition, the Act introduced a new corporate offence – resulting in a wider spectrum of potential defendants, meaning, company’s, as well as individuals, may find themselves in breach of the Act. Thus, it is important that we are all aware and remain compliant with the Act; maintaining a robust corporate and employee code of practice. Any suspected instances of bribery will be taken seriously and dealt with thoroughly the CCG, and appropriate action will be taken where necessary.
24.5 In compliance with the Bribery Act 2010; all stakeholders are required to familiarise themselves with the CCG’s Anti-Bribery Policy which provides clear guidance on the ethical behaviour expected of all persons who are involved or undertaking business on behalf of the organisation.
25. Contract Monitoring:
25.1 Contract monitoring meetings should also follow the protocol for declaration of
interests for CCG meetings. This also applies where a contract is held jointly with another organisation.
25.2. The individuals involved in the monitoring of a contract should not have any
direct or indirect financial, professional or personal interest in the incumbent provider or in any other provider that could prevent them, or be perceived to prevent them, from carrying out their role in an impartial, fair and transparent manner.
25.3. The CCG should be mindful of any potential conflicts of interest when
disseminating any contract or performance information/reports on providers, and manage the risks appropriately.
26. Data protection
26.1. The information in the Declaration of Interest Register will be processed in
accordance with data protection principles as set out in the Data Protection Act 1998.
26.2. Data will be processed only to ensure that the conflicted person act in the best
interests of the group and the public and patients the group was established to serve. The information provided will not be used for any other purpose, unless otherwise stated within statutory legislation. Signing the declaration form will also signify consent to the data being processed for the purposes set out in this policy.
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27. Conflict of Interest Management for Procurement Decisions Related to Primary Care
27.1 The CCG has elected to co-commission primary care services with NHS
England. It will do this via a Joint Committee with NHS England which will jointly oversee any procurement decisions related to primary care. This is a separate committee of the CCG Governing Body. The Joint Committee is led by the Lay Member for Patient and Public Involvement and will have a majority of lay and executive members as well as representation from NHS England.
27.2 The Joint Committee remit includes areas such as:
Planning (carrying out needs assessments) primary medical care services for the geographical area in question;
Undertaking service reviews as appropriate;
Co-ordinating a common approach to primary care commissioning as appropriate;
Managing relevant budgets. 27.3 In dealing with conflicts of interest, the CCG’s policy for Conflict of interest
management i.e. this policy will be followed. 27.4. When the CCG makes a procurement decision relating to the commissioning of
services from general practices, it must complete a template (Appendix 4) to ensure that there is a detailed record of why the service was commissioned in this way. The template will assist the CCG in assuring its Governing Body, NHS England, Monitor, and the general public that its commissioning decisions are both effective and transparent.
27.5. The CCG’s Procurement Register will record details of any procurement decisions made, details of who was involved in the decision-making and a summary of how any conflicts that arose in the context of the decision have been managed. Information regarding procurement decisions shall be provided to the Head of Finance.
27.6. The CCG will at all times adhere to NHS England guidance on conflict of interest management for co-commissioning.
28. Raising concerns and Managing breaches:
28.1 Reporting:
28.1.1. In order to report any breaches, employees, governing body members, committee/ sub-committee members, GP practice members should follow the CCG’s whistleblowing policy. The different types of conflicts of interests covered in this policy are listed in section 5 of the policy.
As a guide:
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CCG employees – should report to their line manager who in turn may refer
to the CoI Guardian for Guardian. If the employees are unable to report to
their line managers e.g. if line managers are suspected of breach, then they
may contact the COI Guardian directly.
committee members who are not CCG employees and GB members -
should report direct to the CoI Guardian
GP Practice members – should report any concerns to the Chief Officer and
Chief Financial Officer.
28.1.2. Where the breach is reported by an employee or worker of another
organisation, the individual should follow their organisation’s policies for whistleblowing.
28.1.3. The CCG’s COI guardian is best placed to address any concerns and advise on COI matters and should be contacted in the first instance.
28.1.4. All such notifications will be treated with appropriate confidentiality and in accordance with the CCG’s policies and relevant laws.
28.2. Investigating:
28.2.1. It must be ensured that the Chief Officer/ Chief Financial Officer are kept
informed of any suspected breaches.
28.2.2. Once reported, the CoI Guardian should investigate the report of the
suspected breach with the help of the Risk and Assurance manager.
28.2.3. The aims would be to determine if a material breach has occurred and if so
to identify the reasons and propose remedial action (e.g. training issues,
lack of clarity in policy or culpable non-compliance by one or more
individuals)
28.2.4. The conclusions of the investigation will be reported to the GB.
28.2.5. Failure to comply with this policy or failure to make a declaration, or making
a false declaration could result in an investigation by the Local Counter
Fraud Specialist which could result in a disciplinary, and/or criminal/civil
action if fraud or bribery is discovered.
28.3. Remedying and Redressing:
28.3.1. CoI Guardian’s investigation should recommend remedial action which
might range from clarifying the policy, augmenting the training or
disciplinary action of the types set out in your black text from the current
policy.
28.3.2. If relevant, the appropriate professional body will be notified of the breach.
28.3.3. The following CCG policies (as amended) will apply to breaches of this
policy where appropriate:
Whistleblowing Policy
Disciplinary Policy
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28.4. Publicising:
28.4.1. As required by NHS England, the CCG will publish anonymised details of
confirmed breaches, including remedial action on our website for the
purpose of learning and development.
29. Monitoring and Compliance:
29.1. External: NHS England’s Improvement and Assessment Framework for CCGs includes a conflict of interest indicator which the CCG will be required to confirm compliance against through self-certification. Submission guidelines for this indicator are as follows:
Annually - CCG has a clear policy for management of COI and robust process for managing breaches - CCG has a minimum of 3 lay members - CCG audit chair is in the role of the COI guardian - Declaration of level of compliance with mandatory online training for COI management
Quarterly - CCG has processes in place to declare interests and has up-to date registers on interests, procurement decisions and gifts and hospitality - Registers are available on its website - Whether the CCG is aware of any breaches of its policies and procedures in relation to management of COI - Audit Committee will be presented the quarterly self-certifications for assurance.
29.2. Internal:
As per guidance, NHS Southwark CCG will include conflict of interest
management as part of annual internal audit plans in order to provide further
assurance about the degree of compliance on management of conflicts. The
results of this audit will be reflected in the CCG’s annual governance
statement.
30. Policy development and Monitoring
30.1. This policy was developed by the shadow CCG for submission of its
authorisation documents. It was drafted in consultation with the shadow governing body and relevant NHS Commissioning Board and best practice guidance- see policy development document control panel Appendix A.
30.2. This policy will be reviewed annually by the Integrated Governance and
Performance Committee and recommended to the Audit Committee.
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31. Training and Raising Awareness
31.1. N H S Southwark CCG will ensure that all members and employees are aware
of this policy. The following steps will be taken to raise awareness:
Policy will be introduced to new starters (employees and members) and will be included within the induction material and as part of development programme for new Governing Body members
Offer NHS England’s annual online CoI training for Governing Body members and employees, members of CCG committees and sub-committees
Annual reminders of the policy via internal communication methods and publication on the NHS Southwark CCG public website and intranet
Regular reminders sent to all members to update declaration forms
Where appropriate the CCG will support its lay members in participating in any governance training programmes offered by NHS England.
31.2. Staff and members should also refer to their respective professional codes of
conduct relating to the declaration of conflicts of interest.
32. Equality & Diversity Statement
32.1. NHS Southwark CCG is committed to equality of opportunity for its employees and members and does not unlawfully discriminate on the basis of their “protected characteristics” as defined in the Equality Act 2010 - age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation. An Equality Impact Assessment has been completed for this policy in Appendix B.
32.2. If members or employees have any concerns or issues with the contents of this
policy or have difficulty understanding how this policy relates you’re their role they are advised to contact the Governance Team on 020 7525 0014/ 0207 525 5250.
33. Links to other Policies
33.1 The policy draws upon national guidance which sets out generic guidelines,
principles and responsibilities for NHS organisations and General Practitioners in relation to conflicts of interests. This policy should be read in conjunction with:
CCG Counter Fraud and Anti-Bribery Policy
Procurement Policy
Gifts and Hospitality policy
Whistleblowing Policy
CCG’s Confidentiality policies
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CCG Integrated Risk Management Framework
Joint Working with the Pharmaceutical Industry Policy Constitution including Standing Orders, Reservation and Delegation of
Powers and Standing Financial Instructions
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Appendices
APPENDIX 1 – Declaration Form for Member / employee/ governing body member / committee or sub-committee member
NHS SOUTHWARK CLINICAL COMMISSIONING GROUP
DECLARATION OF INTERESTS FORM
Name:
Position within or relationship with CCG
Interests
Type of Interest Description of Interest (including for indirect Interests, details of the relationship with the person who has the interest)
Date interest relates
From & To
Actions to be taken to mitigate risk (to be agreed with line manager or a CCG senior manager)
Financial
(see overleaf)
Please insert this suggested wording for this column where any applicable-
CCG conflict of interest policy and procedures will be followed to ensure interests do not influence CCG’s commissioning/ procurement decisions.
Non-Financial Professional
(see overleaf)
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I understand that this form follows NHS England’s guidance on interests’ declaration for CCGs. The information submitted will be held by the CCG for personnel or other reasons specified on this form and to comply with the organisation’s policies. This information may be held in both manual and electronic form in accordance with the Data Protection Act 1998. Information may be disclosed to third parties in accordance with the Freedom of Information Act 2000 and published in registers that the CCG holds.
I confirm that the information provided above is complete and correct. I acknowledge that any changes in these declarations must be notified to the CCG as soon as practicable as and no later than 28 days after the interest arises. I am aware that if I do not make full, accurate and timely declarations then civil, criminal, professional regulatory or internal disciplinary action may result.
To the best of my knowledge and belief, the above information is complete and correct. I have read the Conflict of Interest policy for the CCG and undertake to update as necessary the information provided and to review the accuracy of the information provided regularly and no longer than annually. I give my consent for the information to be used for the purposes described in the NHS Southwark CCG Constitution and published accordingly.
Signed:
(please sign not print)
Dated:
Non-Financial Personal
(see overleaf)
Indirect Interests
(see overleaf)
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Appendix 2 - Declaration of Interests Form: Bidders/potential contractors/service provider
This form is required to be completed in accordance with the CCG’s Constitution.
Notes:
All potential bidders/contractors/service providers, including sub- contractors,
members of a consortium, advisers or other associated parties (Relevant Organisation) are required to identify any potential conflicts of interest that could arise if the Relevant Organisation were to take part in any procurement process and/or provide services under, or otherwise enter into any contract with, the CCG.
If any assistance is required in order to complete this form, then the
Relevant Organisation should contact Sheetal Mukkamala, Corporate Governance Manager email: [email protected]
The completed form should be sent to:
Sheetal Mukkamala,
Corporate Governance Manager, NHS Southwark CCG, 1st Floor, Hub 5, PO Box 64529 London SE1P 5LX
Any changes to interests declared either during the procurement process or
during the term of any contract subsequently entered into by the Relevant Organisation and the CCG must notified to the CCG by completing a new declaration form and submitting it to [specify].
Relevant Organisations completing this declaration form must provide sufficient
detail of each interest so that a member of the public would be able to understand clearly the sort of financial or other interest the person concerned has and the circumstances in which a conflict of interest with the business or running of the CCG might arise.
If in doubt as to whether a conflict of interests could arise, a declaration of the
interests should be made. Interests that must be declared (whether such interests are those of the Relevant Person themselves or of a family member, close friend or other acquaintance of the Relevant Person), include the following:
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the Relevant Organisation or any person employed or engaged by or
otherwise connected with a Relevant Organisation (Relevant Person) has provided or is providing services or other work for the CCG;
a Relevant Organisation or Relevant Person is providing services or other
work for any other potential bidder in respect of this project or procurement process;
the Relevant Organisation or any Relevant Person has any other
connection with the CCG, whether personal or professional, which the public could perceive may impair or otherwise influence the CCG’s or any of its members’ or employees’ judgments, decisions or actions.
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Appendix 3 Template declarations of interest checklist
Under the Health and Social Care Act 2012, there is a legal obligation to manage conflicts of interest appropriately. It is essential that declarations of interest and actions arising from the declarations are recorded formally and consistently across all CCG governing body, committee and sub-committee meetings. This checklist has been developed with the intention of providing support in conflicts of interest management to the Chair of the meeting- prior to, during and following the meeting. It does not cover the requirements for declaring interests outside of the committee process. Ti
In advance of the meeting
1. The agenda to include a standing item on declaration of interests to enable individuals to raise any issues and/or make a declaration at the meeting.
2. A definition of conflicts of interest should also be accompanied with each agenda to provide clarity for all recipients.
26. Agenda to be circulated to enable attendees (including visitors) to identify any interests relating specifically to the agenda items being considered.
27. Members should contact the Chair as soon as an actual or potential conflict is identified.
5. Chair to review a summary report from preceding meetings i.e., subcommittee, working group, etc., detailing any conflicts of interest declared and how this was managed.
6. A copy of the members’ declared interests is checked to establish any actual or potential conflicts of interest that may occur during the meeting.
Meeting Chair and
secretariat
Meeting Chair and
secretariat
Meeting Chair and
secretariat
Meeting members
Meeting Chair
Meeting Chair
During the meeting
7. Check and declare the meeting is quorate and ensure that this is noted in the minutes of the meeting.
8. Chair requests members to declare any interests in agenda items- which have not already been declared, including the nature of the conflict.
9. Chair makes a decision as to how to manage each interest which has been declared, including whether /
to what extent the individual member should continue to participate in the meeting, on a case-by-case basis, and this decision is recorded.
10. As minimum requirement, the
following should be recorded in the minutes of the meeting:
Individual declaring the interest;
At what point the interest was declared;
Meeting Chair
Meeting Chair
Meeting Chair and
secretariat
Secretariat
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The nature of the interest;
The Chair’s decision and resulting action taken;
The point during the meeting at which any individuals retired from and returned to the meeting - even if an interest has not been declared.
Visitors in attendance who participate in the meeting must also follow the meeting protocol and declare any interests in a timely manner.
A template for recording any interests during meetings is detailed below.
After the meeting
11. All new interests declared at the meeting should be promptly updated onto the declaration of interest form;
12. All new completed declarations of interest should be transferred onto the register of interests.
Individual(s)
declaring interest(s)
Designated person
responsible for
registers of interest
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Appendix 4 Template for recording minutes
XXXX Clinical Commissioning Group Primary Care Commissioning Committee Meeting Date: 16 June 2017 Time: 2pm to 4pm Location: Room B, XXXX CCG Attendees: Name Initials Role Sarah Kent SK XXX CCG Governing Body Lay Member (Chair) Andy Booth AB XXX CCG Audit Chair Lay Member Julie Hollings JH XXX CCG PPI Lay Member Carl Hodd CH Assistant Head of Finance Mina Patel MP Interim Head of Localities Dr Myra Nara MN Secondary Care Doctor Dr Maria Stewart MS Chief Clinical Officer Jon Rhodes JR Chief Executive – Local Healthwatch In attendance from 2.35pm Neil Ford NF Primary Care Development Director
Item No.
Agenda Item Actions
1
Chairs welcome
2
Apologies for absence
<apologies to be noted>
3. Declarations of interest
SK reminded committee members of their obligation to
declare any interest they may have on any issues arising at
committee meetings which might conflict with the business
of XXX clinical commissioning group.
Declarations made by members of the Primary Care
Commissioning Committee are listed in the CCG’s Register
of Interests. The Register is available either via the
secretary to the governing body or the CCG’s website at the
following link: http://xxxccg.nhs.uk/about-xxx-ccg/who-weare/
our -governing-body/
Declarations of interest from sub committees.
None declared
Declarations of interest from today’s meeting
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The following update was received at the meeting:
With reference to business to be discussed at this
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meeting, MS declared that he is a shareholder in
XXX Care Ltd.
SK declared that the meeting is quorate and that MS would
not be included in any discussions on agenda item X due to
a direct conflict of interest which could potentially lead to
financial gain for MS.
SK and MS discussed the conflict of interest, which is
recorded on the register of interest, before the meeting and
MS agreed to remove himself from the table and not be
involved in the discussion around agenda item X.
4. Minutes of the last meeting <date to be inserted> and
matters arising
5. Agenda Item <Note the agenda item>
MS left the meeting, excluding himself from the discussion
regarding xx.
<conclude decision has been made>
<Note the agenda item xx>
MS was brought back into the meeting.
6. Any other business
7. Date and time of the next meeting
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Appendix 5: Declaration of Interests Form for Bidders/potential contractors/service providers
Name of Relevant Person (Individual or Company)
[complete for all Relevant Persons]
Interests
Type of Interest Details Personal interest or that of a family member, close friend or other acquaintance
Provision of services or other work for the CCG
Provision of services or other work for any other potential bidder
in respect of this project or procurement process
Any other connection with the CCG, whether personal or professional, which the public could perceive may impair or otherwise influence the CCG’s or any of its members’ or employees’ judgments, decisions or actions
To the best of my knowledge and belief, the above information is complete and correct. I have read the CCG’s Conflict of Interest policy and I undertake to update as necessary the information.
Signed: Date
On behalf of:
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Appendix 6 - Declaration of Interests Form: Tender Evaluation Panel Members
Declaration of Interests Form: Tender Evaluation Panel Members
Name To be completed by the Evaluator
Job Title/ Relationship to the CCG
Name of service being tendered
Details of Interests
Type of Interest Personal Interest Interest of a family member, close friend or other acquaintance
Provision of services or other work for the CCG
Provision of services or other work for any of the potential bidders in respect of this project or procurement process
Any other interests, whether personal or professional, which the public could perceive may impair or otherwise influence the CCG’s or any of its members’ or employees’ judgments, decisions or actions.
To the best of my knowledge and belief, the above information is complete and correct. I have read the Conflict of Interest policy for the CCG and undertake to
update as necessary the information provided. I give my consent for the information to be used for the purposes described in the NHS Southwark CCG Conflict of Interest and Procurement Policy.
Signed: Date:
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Notes:
1. This form is required to be completed in accordance with Procurement, Patient Choice and Competition Regulations 2013 and the CCG’s Constitution.
2. Interests that must be declared (whether such interests are those of the Relevant Person themselves or that of a family member, close friend or other acquaintance), include the following: - Those that the Relevant Person or any person employed or engaged by or
otherwise connected with a Relevant Person (or Relevant Organisation) has provided or is providing services or other work for the CCG;
- a Relevant Organisation or Relevant Person is providing services or other work for any other potential bidder in respect of this project or procurement process;
- the Relevant Organisation or any Relevant Person has any other connection with the CCG, whether personal or professional, which the public could perceive may impair or otherwise influence the CCG’s or any of its members’ or employees’ judgments, decisions or actions.
3. The declaration form must be completed and signed by the evaluator themselves.
4. Sufficient detail of each interest must be provided so that a member of the public would be able to understand clearly the sort of financial or other interest the person concerned has and the circumstances in which a conflict of interest with the business or running of the CCG might arise.
5. If in doubt as to whether a conflict of interests could arise, a declaration of the interests should be made.
6. If any assistance is required in order to complete this form, then the Relevant Person/Organisation should contact Sheetal Mukkamala, Corporate Governance Manager email: [email protected]
7. A copy of the signed declaration must be submitted with the tender evaluation papers and another copy to be submitted to the Corporate Governance Manager.
8. Any changes to interests declared either during the procurement process or during the term of any contract subsequently entered into by the Relevant Organisation and the CCG must notified to the CCG by completing a new declaration form and submitting it to the Corporate Governance Manager.
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Appendix 7 – Code of Conduct – Procurement
[To be used when commissioning services from organisations in which CCG Governing Body members/ committee members have a financial interest, including GP practices and provider consortia]
Service:
Question Comment/ Evidence
Questions for all three procurement routes (see section 21.1 of the policy)
How does the proposal deliver good or improved outcomes and value for money – what are the estimated costs and the estimated benefits? How does it reflect the CCG’s proposed commissioning priorities?
How have you involved the public in the decision to commission this service?
What range of health professionals have been involved in designing the proposed service?
What range of potential providers have been involved in considering the proposals?
How have you involved your Health and Wellbeing Board(s)? How does the proposal support the priorities in the relevant joint health and wellbeing strategy (or strategies)?
What are the proposals for monitoring the quality of the service?
What systems will there be to monitor and publish data
on referral patterns?
Have all conflicts and potential conflicts of interests been appropriately declared and entered in registers which are publicly available?
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Why have you chosen this procurement route?10
What additional external involvement will there be in scrutinising the proposed decisions?
How will the CCG make its final commissioning decision in ways that preserve the integrity of the decision-making process?
Additional question for AQP or single tender (for services where national tariffs do not apply)
How have you determined a fair price for the service?
Additional questions for AQP only (where GP practices are likely to be qualified providers)
How will you ensure that patients are aware of the full range of qualified providers from whom they can choose?
Additional questions for single tenders from GP providers
What steps have been taken to demonstrate that there are no other providers that could deliver this service?
In what ways does the proposed service go above and beyond what GP practices should be expected to provide under the GP contract?
What assurances will there be that a GP practice is providing high-quality services under the GP contract before it has the opportunity to provide any new services?
10Taking into account all relevant regulations (e.g. the NHS (Procurement, patient choice and competition) regulations 2013 and guidance (e.g. that of Monitor).
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Appendix 8- Conflict of Interest Panel - Terms of Reference
1. Introduction 1.1 The Conflict of Interest (CoI) Panel is established in accordance with NHS
Southwark Clinical Commissioning Group’s Constitution (section 15) to consider issues related to the identification and management of conflicts of interests in the course of business of the CCG.
1.2 These terms of reference set out the membership, remit, conduct,
responsibilities and reporting arrangements of the panel as incorporated in the CCG’s constitution and standing orders.
1.3 The CoI Panel not a committee but an advisory body to the Governing Body –
the Governing Body makes the final decision and is sovereign.
2. Remit and responsibilities of the panel
2.1 The key responsibility of the CoI Panel is to ensure that any actual or perceived conflicts of interest to the business of the organisation are managed effectively in an open and transparent way.
2.2 It is envisaged that the panel will receive referrals predominantly from the Commissioning Strategy Committee (CSC) for commissioning and procurement decisions in the following scenarios: a. to validate commissioning decisions taken by Governing Body committees
ensuring proper management of conflicts of interests has taken place or, b. to make a recommendation in cases where the referring committee was
unable to take a decision or even formulate a recommendation because of actual or perceived conflicts of interest declared by committee members and/or the committee being inquorate,
c. to validate decisions taken by tender evaluation panels in the awarding of contracts.
These scenarios are depicted in more detail in the chart of Appendix 9.
2.3 The decision about the referral route to the COI Panel for the scenarios above will be taken normally at the referring GB Committee i.e. the CSC (for clinical procurement) or SMT (for non-clinical procurement).
2.4 In formulating its recommendations the Panel will seek to ensure that commissioning decisions are based upon objective appraisal of options against criteria consistent with Competition regulations, particularly the criteria listed in Appendix 10. It is envisaged that the CSC or other referring committee will seek to formulate their recommendations on the same basis.
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2.5 Where a challenge or issue relating to the probity of a commissioning decision has been called into question, the panel will consider all relevant papers. The panel can call/ invite any of the following to assist the panel’s assessment on a case-by-case basis:
- any officer/employees of the CCG - any relevant officer at the South London Commissioning Support Unit
that assists with procurement function for the CCG or - others involved or relevant to the review.
2.6 The Chief Officer or Chair may also ask the CoI Panel to review complex or
difficult decision making arrangements that may arise on which scrutiny would be helpful prior to finalising arrangements for commissioning/ procurement decisions.
2.7 The CoI Panel will make recommendations to the Governing Body on its decisions. The results of such a panel will be reported to the CCG Governing Body and ratified there.
3 Membership 3.1 The Panel will consist of the following core members:
- Governing Body Lay Member (Chair of the Panel), - Chief Officer, - Chief Financial Officer, - Director of Public Health or a Public Health Consultant nominated by the
Director. - Governing Body Secondary Care Consultant - Governing Body Registered Nurse
3.2 In exceptional circumstances, lay members from other CCGs or experts from
the field e.g. primary care commissioners from NHS England, GPs from other CCGs, procurement/ legal specialists may be invited to join the Panel to provide necessary expertise or advice.
4 Quorum 4.1 At least three of the following core members must be present for the panel to be
quorate, including one lay member (Chair), Chief Officer/ CFO and any one of the other core members.
5 Conduct of the Panel: 5.1 The CoI Panel will follow all national guidance related to Conflict of Interest
management and procurement of healthcare services in its work, and will refer to the CCG’s Procurement policy to assess procurement proposals.
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5.2 All members and invitees will be required follow the Code of Business Conduct and Nolan Principles as articulated in the CCG Constitution, in managing the affairs of the panel.
5.3 The panel will need to declare their own interests to the business of each
meeting well in advance of the meeting, in order to ensure substitution at the beginning of each panel to confirm that no conflicts exist with the business to be discussed.
6 Administration: 6.1 The CoI Panel will meet as necessitated by referrals and at least three times a
year to review the overall management of Conflicts of Interest, the governance arrangements and its compliance with the Constitution.
6.2 Meetings may need to be called at short notice to scrutinise the decision-making process in response to challenges or issues that have been raised. However, it must be ensured that members must have plenty of time to read all of the relevant papers.
6.3 It would be an expectation that papers for regular meetings would be sent at least seven days in advance and that papers for urgent meetings are sent at least three working days’ in advance.
6.4 The Panel will be supported by the Governance Manager who will collate all papers for the Panel, ensure minutes of meetings are taken, and track and provide reports on actions arising from meetings.
6.5 The minutes for the panel will be taken by a member of the CCG admin team.
7 Reporting:
7.1 The outcome of the CoI panel for individual referrals will be communicated back
to the referring Governing Body Committee with the result and rationale for
decision, using the template in Appendix 11.
7.2 The recommendations of the CoI Panel will be made available to the next
Governing Body as part of the Chief Officer’s report and minutes of the meeting
will be appended as part of the Governing Body papers.
8. Review:
8.1 The terms of reference for the panel will be reviewed at least annually and any appropriate changes will be reflected in the CCG Constitution.
Dated: August 2014
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Appendix 9 – Flowchart for decision-making and managing conflicts of interest
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Appendix A - Policy checklist for sponsors and authors
Yes No
Policy register
Have you informed the Corporate Governance Manager about your policy in development?
He/She will send you the latest policies format and ensure your policy/procedural document is included in the CCG-wide policy register and database.
√
Rationale: Is the policy/procedural document needed? √
Legislation and national best practice
Does the policy/procedural document follow:
legislation
national guidance
national policy
best available evidence / best practice?
√
√
√
√
Consultation with stakeholders
Have all relevant stakeholders been consulted as part of the development of the policy/procedural document, including any relevant Programme Board?
√
Document format
Is the policy/procedural document in the CCG standard policies format?
This will ensure all relevant information is included such as version control, review dates, ratification committee etc.
Does the style and format follow the CCG standard style guidance?
√
√
Dissemination and implementation
What plans are there in place to disseminate and implement the policy/procedural document? Suggestions include:
Staff and members zone (mandatory)
Email to SMT/relevant group
Staff newsletter (contact: [email protected])
Presentation at all staff meeting or directorate meetings
Training programme (if needed)
Reference the policy in the induction checklist (contact: Clinical Governance Manager)
√
√
√
√
√
Monitoring How will the policy be monitored to ensure it is effective and fit for purpose?
NHS Southwark CCG – Insert name of Policy here
This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of the document are not controlled.
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Appendix B – Equality Impact Assessment Tool
Equality Impact Assessment Tool Appendix B
Yes/No Comments
1. Does the policy/guidance affect one group less or more favourably than another on the basis of:
• Age N
• Disability N
• Gender Reassignment N
• Marriage and Civil Partnership N
• Pregnancy and Maternity N
• Race N
• Religion or Belief N
• Sex N
• Sexual Orientation
N
2. Is there any evidence that some groups are affected differently?
N
3. If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable?
NA
4. Is the impact of the policy/guidance likely to be negative?
NA
5. If so can the impact be avoided? NA
6. What alternative is there to achieving the policy/guidance without the impact?
NA
7. Can we reduce the impact by taking different action?
NA
