On Conflicts of interest - For Doctors

September 2008

1. In our core guidance for doctors, Good Medical Practice we advise that:
72. You must be honest and open in any financial arrangements with patients. In particular:
a. You must inform patients about your fees and charges, wherever possible before asking for their consent to treatment.
b. You must not exploit patients' vulnerability or lack of medical knowledge when making charges for treatment or services.
c. You must not encourage patients to give, lend or bequeath money or gifts that will directly or indirectly benefit you.
d. You must not put pressure on patients or their families to make donations to other people or organisations.
e. You must not put pressure on patients to accept private treatment.
f. If you charge fees, you must tell patients if any part of the fee goes to another healthcare professional
73. You must be honest in financial and commercial dealings with employers, insurers and other organisations or individuals. In particular:
a. Before taking part in discussions about buying or selling goods or services, you must declare any relevant financial or commercial interest that you or your family might have in the transaction.
b. If you manage finances, you must make sure the funds are used for the purpose for which they were intended and are kept in a separate account from your personal finances.
74. You must act in your patients' best interests when making referrals and when providing or arranging treatment or care. You must not ask for or accept any inducement, gift or hospitality which may affect or be seen to affect the way you prescribe for, treat, or refer patients. You must not offer such inducements to colleagues.1
75. If you have financial or commercial interests in organisations providing healthcare or in pharmaceutical or other biomedical companies, these interests must not affect the way you prescribe for, treat or refer patients.2
76. If you have a financial or commercial interest in an organisation to which you plan to refer a patient for treatment or investigation, you must tell the patient about your interest. When treating NHS patients you must also tell the healthcare purchaser.
2. Good Medical Practice makes it clear that trust between you and your patients is essential to successful professional relationships. Trust may be damaged by situations in which your financial or other personal interests affect, or are seen to affect, your professional judgement. Such conflicts of interest may arise in a variety of circumstances.
3. The guidance that follows identifies some such areas additional to those covered in Good Medical Practice where conflicts of interest may arise, but it is not intended to be exhaustive. You should always review new arrangements and use your professional judgement to determine if there is a conflict of interest and how best to address it. If you are not sure what to do, contact your defence body, a professional organisation or the GMC Standards and Ethics team for advice.
Financial interests in institutions providing care or treatment
4. Some doctors or members of their immediate family own or have financial interests in care homes, nursing homes or other institutions providing care or treatment. Where this is the case, you should avoid conflicts of interest that may arise, or where this is not possible, ensure that such conflicts do not adversely affect your clinical judgment. You may wish to note on the patient's record when an unavoidable conflicts of interest arises.
5. If you have a financial interest in an institution and are working under an NHS or employers' policy, you should satisfy yourself, or seek assurances from your employing or contracting body, that systems are in place to ensure transparency and to avoid, or minimise the effects of, conflicts of interest. You must follow the procedures governing the schemes.
6. If you have a financial or commercial interest in a business case being considered by your Primary Care Trust under Practice Based Commissioning 3 arrangements, you should declare your interest and exclude yourself from related decisions in accordance with the Department of Health and your PCT's guidance
7. If you work outside a formal scheme run by an employing or contracting body you should avoid conflicts of interest, where possible. For example, if you are a general practitioner with financial interests in a residential or nursing home, you should not usually provide primary care services to patients in that home. Exceptions may arise, for example, if a patient asks you to continue acting as their general practitioner, or there is no alternative. If you accept a patient in these circumstances you must be prepared to justify your decision.
8. In all cases you must make sure that your patients and anyone funding their treatment is made aware of your financial interest.
Sharing information with patients' general practitioners
9. It is usually in patients' best interests for their GPs to be informed of investigation results, treatments provided by other doctors and other information necessary for the continuing care of the patient. If a patient has not been referred to you by a GP, you should ask for the patient's consent to inform their GP before starting treatment. You should also tell the patient's GP the results of investigations, the treatment provided and any other information necessary for the continuing care of the patient, unless the patient objects.4 You must not encourage the patient to object to your sharing information with their GP. This will be particularly important if you have a commercial or financial interest in providing care or if you think your patient's GP will discourage them from accepting your advice or treatment.
Target payments for preventative health measures and health monitoring
10. Preventative health measures, such as immunisation of children and screening for cervical cancer, have clear benefits for individuals and society, as do health monitoring schemes, such as those encouraged through the Quality and Outcomes Framework. 'Target payments' are used to encourage general practitioners to increase the number of patients involved.
11. While you may wish to recommend treatments and invite patients to participate in assessments, you must not pressurise patients to participate because of the financial benefits for you. It is not necessary to raise the potential conflicts of interest with patients individually, though you must respond honestly to questions.
Doctors' relationships with the pharmaceutical industry
12. Doctors' relationships with the pharmaceutical industry take many forms, some of which might be perceived to influence the way doctors prescribe medicines. You should follow the guidance in the Medicines and Healthcare products Regulatory Agency's Blue Guide and consider the advice of the Prescription Medicines Code of Practice Authority, which is responsible for administering the Association of the British Pharmaceutical Industry's Code of Practice for the Pharmaceutical Industry, which covers inducements, hospitality and other issues.5
13. If you have a financial or commercial interest in a pharmacy your patients are likely to use, see our guidance on Good Practice in Prescribing Medicines.
Recommending services outside healthcare
14. Accepting or offering fees for referring patients to particular services is likely to undermine patients' trust that the referral has been made solely on the basis of what is best for them. It would be an abuse of that trust to put pressure on patients to use a specific product or service which will be to your financial advantage.
15. The same principles apply if you are offered fees for recommending that your patients access services provided by firms or organisations outside healthcare, including insurance companies, solicitors and others. These schemes often involve making payment according to the number of customers referred.
16. Generally doctors will not have professional expertise in these areas on which to base their recommendation of a particular firm, and their chief interest in such schemes is a financial one. For these reasons you should not accept fees for referring patients to, or recommending patients to use the services of, particular organisations, companies or individuals, whether or not the services are health-related.
Sponsorship of conferences and meetings
17. It is normal practice for medical journals to require authors of papers to declare any competing interests. This practice is often not followed at medical meetings and conferences. Delegates are often unaware of who is paying the speaker and whether their contributions might be influenced by such payments or other sponsorship or benefits.
18. Where a contributor to an educational meeting has been sponsored by a pharmaceutical company, this should be announced at the meeting and disclosed in all the papers relating to the meeting and in the published proceedings.
1. The Blue Guide: Advertising and Promotion of Medicines in the UK, Medicines and Healthcare products Regulatory Agency, 2005
2. See GMC prescribing guidance paragraphs 10 to 12 and 17
3. Practice Based Commissioning is an England only scheme
4. See Good Medical Practice, paragraphs 52 and 53
5. See the ABPI's Code of Practice and the Prescription Medicines Code of Practice Authority's Guidance Notes for Health Professionals.
See also the Association of British Healthcare Industries' Code of Business Practice for its members in the medical technology sector.

Dr Ivan Camphor

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