Conflict Of Interest Policy

Transcription

1 Conflict Of Interest Policy Author (s) AD Governance & Quality Version 5.0 Approval Date May 2015; Sept 2015 Approving Body NHS GCCG Governing Body (May 2015); GEG (Sept 2015) Governing Body (Sept 2016) Review Date Policy Category Whenever legislation/guidance changes or in any event by May 2018 Corporate Policy Reference Number 011 Public Sector Equality Duty Equality and diversity are at the heart of the NHS Strategy. Throughout the production of this document, due regard has been given to eliminate discrimination, harassment and victimisation, to advance equality of opportunity, and to foster good relations between people who share a relevant protected characteristic (as cited under the Equality Act 2010) and those who do not share it. This document therefore abides by the Equality and Diversity Act COI Policy v5.0 1

2 Version Control Version Author Date Reason for review 1.0 Nicola Moore July 2012 Director of Integrated Governance 2.0 Colin Nash CCG Coordinator May 2013 Inaugural Governing Body Policy Statutory requirement To ensure policy complied with NHS Greenwich CCG Constitution and Managing conflicts of interest: guidance for clinical commissioning groups (NHS England March 2013) 2.1 Angelique Kempton, June 2013 Amendments to Version 2.0 Executive Manager 2.2 Maggie Aiken, June 2013 Amendments to Version 2.1 Associate Director, Governance and Quality 2.3 Colin Nash June 2013 Amendments to Version 2.2 following consultation with Lay Member for Governance and Director of Integrated Governance 3 Colin Nash, Corporate Secretary 4 Audley Charles, Executive Manager (Interim) January 2015 April Maggie Aiken September Maggie Aiken September 2016 Amendment of Version 2.3, in the light of NHSE Managing conflicts of interest: Statutory guidance for CCGs Further amendment to Version 3 to take account of guidance issued by NHS E in December 2014 Further amendment to Version 3 on the basis of improvements agreed by Review Group and Chief Officer to ensure better practical application of the policy document after discussion at Governing Body in May Updated in line with national guidance. COI Policy v5.0 2

3 Contents 1.0 Summary Aims and objectives Legislative Framework and General Principles Definition Roles and Responsibilities The Declaration of Interests Maintaining Registers of Interests and Procurement Decisions Data Protection Standards of Business Conduct and Managing Conflicts of Interest Conflicts Of Interest Declaring & Registering Interests Managing Conflicts Of Interests: General Managing Conflicts Of Interest: CCG Governing Body Managing Conflicts Of Interest: Contractors Transparency in Procuring Services Transparency of GP earnings Breaches Of This Policy Training & Awareness Further advice and guidance Equalities Impact Assessment Review Audit and monitoring effectiveness Specific Guidance to deal with COI arising out of Primary Care Joint Commissioning..23 Appendix 1: Declaration Form Appendix 2: Declaration of Interests Form for Members / Employees Appendix 3: Declaration of Conflict of Interests for Bidders / Contractors Template Appendix 4: Declaration of Interests Form for Bidders and Tenderer: organisation..30 Appendix 5. Declaration of Interests: Bidders and Tenderers: relevant person..32 Appendix 6: NHS Clinical Commissioners, Royal College of General Practitioners and British Medical Association - Shared principles on conflicts of interest when CCGs are commissioning from member practices Appendix 7.:Conflict of Interest Panel Terms of Reference... Error! Bookmark not defined. Appendix 8: Register of Interests Declared by the Governing Body and Committee Members and Executive Group Appendix 9: Procurement Template Appendix 10: Register of Procurement Decisions Appendix 11: Equality & Equity Impact Assessment & EDS2 Checklist COI Policy v5.0 3

4 1.0 Summary 1.1. This Policy sets out how the NHS Greenwich Clinical Commissioning Group (the "CCG") will manage Conflicts of Interest ("CoI") arising from the operation of the CCG. Separate policies cover fraud, anti-bribery and whistleblowing, the Procurement Framework and the Standard of Business Conduct. This policy must be read in conjunction with staff s contract of employment, Gifts and Hospitality Policy and Commercial Sponsorship Policy. Clinicians (especially GPs) must also adhere to the principles set out in the, Policy for Joint Working with the Pharmaceutical Industry and Commercial Sponsorship. In December 2014 NHS England (NHSE) published new guidelines: Managing Conflicts of Interest: Statutory Guidance for CCGs. The latest update to this policy has taken that guidance into account. The policy will be monitored by the Audit, Market Management & Procurement Committee and the Governing Body. 1.2 This Policy complies with the standards of business conduct and managing conflicts of interest as set out in the CCG s Constitution (Section 8). 1.3 All employees and members of the CCG are required to observe the principles of good governance in the way it conducts its business. These include (but are not limited to): The highest standards of propriety involving impartiality, integrity and objectivity in relation to the stewardship of public funds, the management of the organisation and the conduct of business; The Good Governance Standards for Public Services; The standards of behaviour published by the Committee on Standards in public Life (1995) known as the Nolan Principles (listed in 3.3 below); The seven key principles of the NHS Constitution; The Equality Act 2010; The Bribery Act 2010; The code of conduct set out in this policy relating to managing conflicts of interest where GP practices are potential providers of CCG commissioned services. Standards for Members of NHS Boards and Clinical Commissioning Group Governing Bodies in England; May Aims and objectives 2.1 The purpose of the policy is to provide guidance and support to all staff and all members of the Governing Body about their conduct relating to conflicts or potential conflicts of interests and whose work brings them into contact in a business sense, with outside companies and organisations of any sort. Some sections of the policy apply to particular groups (for example GPs, contract and COI Policy v5.0 4

5 commissioning staff, governing body and committee members) but the principles of the policy apply to all staff and members and should be read, understood and accepted by them. 2.2 If a member of staff has any doubts or concerns when dealing with outside companies, organisations or individuals, they should seek the advice of their manager. The executive business manager or equivalent is always willing to provide advice on any of the issues covered in this policy. If a member of the CCG, a member of the Governing body or a member of any CCG committee has any concerns about an actual or perceived conflict of interest, they should feel free to consult the lay member on the Governing Body with special responsibility for governance and conflicts of interest. 2.3 The CCG s Governing Body has ultimate responsibility for all actions carried out by staff and committees. This responsibility includes the stewardship of significant public resources and the commissioning of healthcare for the community within its boundaries. The CCG Governing Body is therefore determined to ensure the organisation inspires confidence and trust amongst its patients, members, staff, partners, stakeholders, funders and suppliers by demonstrating integrity and avoiding any potential or real situations of undue bias or influence in the decisionmaking process. 2.4 The Governing Body has a legal obligation to act in the best interests of the CCG, and in accordance with the Governing Body s Constitution and Terms of Establishment, created by the NHS Commissioning Board now known as NHS England, to avoid or appropriately manage situations where there may be a potential conflict of interest. It is not possible, or desirable, to define all instances in which an interest may be a real or perceived conflict. In line with the Nolan principles, the CCG promotes transparency in this respect. It is for each individual to exercise their judgment in deciding whether to register any interests that may be construed as a conflict. Individuals can seek guidance from their line manager, the Business Executive Business Manager, the Director of Integrated Governance or the Lay Member for Governance. 2.5 The aim of this policy is to protect both the organisation and the individuals involved, from any appearance of impropriety and demonstrate transparency to the public and other interested parties. 2.6 Scope The scope of this policy includes CCG members, those serving on the Governing Body and CCG Committees and Sub-Committees, and CCG employees and contractors engaged by the CCG COI Policy v5.0 5

6 3.0 Legislative Framework and General Principles 3.1 The key legal requirements on conflicts of interest are set out in Section 14O of the National Health Service Act 2006 (as amended by the Health and Social Care Act 2012). This section includes the following. (1) Each clinical commissioning group must maintain one or more registers of the interests of the members of the group, the members of its governing body, the members of its committees, and it employees. (2) Each clinical commissioning group must publish the registers maintained under subsection (1). (3) Each clinical commissioning group must make arrangements to ensure that a person mentioned in subsection (1) declares any conflict or potential conflict of interest that the person has in relation to a decision to be made in the exercise of the commissioning functions of the group, that any such declaration is made as soon as practicable after the person becomes aware of the conflict or potential conflict and, in any event, within 28 days, and that any such declaration is included in the registers maintained under subsection (1). (4) Each clinical commissioning group must make arrangements for managing conflicts and potential conflicts of interest in such a way as to ensure that they do not, and do not appear to, affect the integrity of the group s decision-making processes. 3.2 The 2013 National Health Service (Procurement, Patient Choice and Competition) (No.2) Regulations, regulation 6, requires: (1) CCGs must not award a contract for the provision of NHS health care services where conflicts, or potential conflicts, between the interests involved in commissioning such services and the interests involved in providing them affect, or appear to affect, the integrity of the award of that contract; and (2) Must keep a record of how it managed any such conflict in relation to NHS commissioning contracts it enters into. (NHS England has required this record to be published) The seven Nolan principles on public life are as follows. Selflessness: Holders of public office should act solely in terms of the public interest. They should not do so in order to gain financial or other benefits for themselves, their family or their friends Integrity: Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties COI Policy v5.0 6

7 Objectivity: In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit Accountability: Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office Openness: Holders of public office should be as open as possible about all their decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands Honesty: Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest. Leadership: Holders of public office should promote and support these principles by leadership and example 3.4 The general principle on which the CCG acts is that all members, members of the Governing Body, members of CCG committees and CCG employees must comply fully with the legislative requirements, standards of conduct as set out in Standards for Members of NHS Boards and Clinical Commissioning Groups and the Nolan principles. 3.5 As NHS England has stated in its guidance on conflicts of interest: a perception of wrongdoing, impaired judgment or undue influence can be as detrimental as any of them actually occurring; if in doubt, it is better to assume the existence of a conflict of interest and manage it appropriately rather than ignore it. At the same time conflicts of interest can be managed by: being balanced and proportionate and not compromising input that would be beneficial to the CCG. 4.0 Definition 4.1 Conflict of Interest A conflict of interest is defined as: A conflict between the private interests and the official responsibilities of an individual 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]. COI Policy v5.0 7

8 The NHS England Guidance on Managing Conflicts of Interest (December 2014) states that: "A conflict of interest occurs where an individual's ability to exercise judgment, or act in a role, is or could be impaired or otherwise influenced by his or her involvement in another role or relationship. The individual does not need to exploit his or her position or obtain an actual benefit, financial or otherwise, for a conflict of interest to occur." Conflicts of Interest can include: Direct pecuniary interests: where an individual may get direct financial benefits from the consequences of a commissioning decision (for example as a provider of services) Indirect pecuniary interests: where, for example, an individual s partner is a member or shareholder in an organisation that will benefit financially from the consequences of a commissioning decision. Non-pecuniary interests: where an individual holds a non-remunerative or not for profit interest in an organisation, that will benefit from the consequences of a commissioning decision (for example where an individual is a trustee of a voluntary provider that is bidding for a contract). Non-pecuniary personal benefits: where an individual may enjoy a qualitative benefit from the consequence of a commissioning decision which cannot be given a monetary value (for example a reconfiguration of hospital services which might result in the closure of a busy clinic next door to an individual s house). 5.0 Roles and Responsibilities 5.1 Managers are responsible for ensuring the Standards of Conduct Guidelines for all staff is brought to the attention of all employees and that systems are in place to ensure that the standards are effectively implemented. Staff should be reminded of the guidelines at least annually at team meetings and via updates on the CCG's Intranet. These reflect the safeguard set out in NHSE statutory guidance on Managing Conflicts of Interest (Dec 2014) and the expectations set out in the Standards for Members of NHS Boards and Clinical Commissioning Groups ( 5.2 It is the responsibility of all staff to ensure that they are not placed in a position which risks, or appears to risk, a CoI. This primary responsibility applies to all CCG members, members of the Governing Body, members of CCG committees and staff including the chair, chief officer, general practitioners, executive directors, senior managers, procurement staff, executive manager (who coordinates activities and monitoring of the policy) and those who deal directly with resources (e.g. the ordering of goods) and those who do so indirectly (e.g. prescribing of medicines). COI Policy v5.0 8

9 5.3 The specific duties and responsibilities of key personnel and forums/bodies are set out in Table 1: OFFICER/FORUM DUTIES/RESPONSIBILITIES MONITORING Chair The Chair has a key role in overseeing governance and particularly ensuring that the CCG s Governing Body and the wider CCG behave with the utmost transparency and responsiveness at all times and in line with national guidance and professional codes of conduct. The Chair is able to give an unbiased view on possible internal conflicts of interest. The Chair takes the lead, particularly at meetings, in ensuring that Governing Body members and staff follow this Policy. The Chair may wish to consult the Lay Member for Governance / Guardian for CoI for advice. All decisions should be recorded in the minutes of the CCG s Governing Body meeting. Chair s view expressed on CoI Panel. Lay Member for Governance/CoI Guardian The Lay Member, with responsibility for audit has responsibility for overseeing the management of conflicts of interest and advising on particular cases when requested to do so.. The Lay Member can act as a conduit for members of the public who have any concerns in regard to CoI The Lay Member is responsible for ensuring that the CCG applies CoI principles and policies rigorously and provides the CCG with independent 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 CCG s Governing Body and the wider CCG behave with the utmost probity at all times and be able to give an independent view on possible internal CoI and in particular, when requested, to advise the Chair. The scope of the Lay Member s work is twofold: a. To judge whether there is a risk of a CoI arising; and b. To advise on how that risk should be minimised. The Lay Member operates in two modes: a. Reactively, when the CCG as a whole or individual GP members seek advice on a specific issue; and Minutes of the CCG s Governing Body meetings, CoI Panel and Audit Committee Annual Effectiveness Report of the CCG Governing Body meetings, Audit Committee and CoI Panel COI Policy v5.0 9

10 OFFICER/FORUM DUTIES/RESPONSIBILITIES MONITORING b. Proactively when a potential CoI risk is identified and acts on it. In either mode the Lay Member discusses the issue with the GPs or staff involved and any other relevant party; and he will then issue written advice or judgment for the CCG s Governing Body. The Lay Member for Governance may ask the Conflict of Interest Panel to give its view on a conflict of interest matter where he/she deems it helpful. Minutes of the CCG s Governing Body meetings and those of its committees Chief Officer Has ultimate executive responsibility for ensuring adherence to this Policy. Governance Reports to Governing Body Director of Integrated Governance The Executive Business Manager Ensuring, via delegated responsibilities from the Chief Officer, that the CCG s Governing Body has appropriate governance policies and procedures in place to ensure that it works to best practice and complies with all relevant legislation. They also have responsibility for ensuring that the CCG s Governing Body applies the principles of this Policy and that there are suitable resources to support its implementation and ensure new members receive guidance on the organisation s approach to the management of CoI. This will include mandatory awareness of the CCG s COI policy at Inductions for members, management and staff. The Director of Integrated Governance should ensure they are informed within 28 days of a member taking office, of any interest(s) requiring registrations, or within 28 days of any changes to a member s interest(s) declared. The Executive Business Manager is responsible for maintaining the Register of Interests declared and the CoI Register and ensuring that a copy is available for Members, CCG s Governing Body, Committee members and the public. The Executive Business Manager will ensure that Conflicts of Interests is a standard agenda item for all Committee and Sub-Committee meetings. In the event of withdrawal of a conflicted member, it is the responsibility of the Executive Business Manager, or person acting as secretary to the meeting, to ensure there is a quorum and advise the Chair accordingly. The Executive Business Manager will compile and maintain details of conflicts, how these have been managed and recorded. The Executive Business Manager will ensure the Register of Interest is available for public scrutiny and is on the public website. The Register of Interest is also published within the CCG s annual report. The Executive Business Internal Audit ("IA") and Audit committee reports and minutes. IA review of Register of Interests, its use and monitoring. Inspection of the Registers COI Policy v5.0 10

11 OFFICER/FORUM DUTIES/RESPONSIBILITIES MONITORING Manager will ensure the corporate office holds detail of each query with regard to CoI that provides an audit trail on each query and action (s) taken. In discharging these duties the Business Executive Business Manager is assisted by the Corporate Secretary. Secondary Care Specialist Doctor The Registered Nurse Should have no CoI, i.e. they should not be employed by any organisation from which the CCG secures any significant volume of provisions of service. Should have no CoI, i.e. they should not be employed by any organisation from which the CCG secures any significant volume of provisions of service Register of Interests Register of Interests CoI Panel Market Management & Procurement Committee An advisory body that can be asked to give its view on whether any actual or perceived CoI has been managed, or is being managed effectively. A referral to the Panel may be made by either the Lay Member for Governance, the CCG Governing Body, or the Market Management and Procurement Committee. The Conflict of Interest Panel will provide a clear, recognised and easily enacted system for dispute resolution when, for example, a member of the Governing Body disagrees with a recommendation of the Lay Member with special responsibility for Conflicts of Interest. The ruling of the COI Panel shall be final. The Committee is to receive reports on the bidding and contracting process and decisions made to manage conflicts of interest. Agenda and minutes of the CoI Panel and any reports or investigations having taken place Reports by the responsible officer and minutes of the Committee COI Policy v5.0 11

12 6.0 The Declaration of Interests 6.1 Employees, members, committee and sub-committee members of the CCG and members of the CCG Governing Body are required to declare any relevant and material interests. 6.2 Interests that must be declared (whether such interests are those of the individual themselves or of a family member, close friend or other acquaintance of the individual) include: roles and responsibilities held within member practices; directorships, including non-executive directorships, held in private companies or PLCs; ownership or part-ownership of private companies, businesses or consultancies likely or possibly seeking to do business with the CCG and /or with NHS England shareholdings (more than 5%) of companies in the field of health and social care; a position of authority in an organisation (e.g. charity or voluntary organisation) in the field of health and social care; any connection with a voluntary or other organisation (public or private) contracting for NHS services; research funding/grants that may be received by the individual or any organisation in which they have an interest or role; any other role or relationship which the public could perceive would impair or otherwise influence the individual s judgment or actions in their role within the CCG. If there is any doubt as to whether or not an interest is relevant, a declaration of the interest must be made. 6.3 A Declaration of Interests Form (see Appendix 1) is provided for this purpose, listing the types of interest that should be declared. 6.4 To be effective, the Declaration of Interests Form must be completed prior to becoming an employee, member, committee or sub-committee member or member of the CCG s Governing Body (and its committees), as part of the appointments process and annually thereafter and when any changes occur. 6.5 All Declaration of Interest Forms and notifications of subsequent changes must be made to the Corporate Secretary, NHS Greenwich CCG. This is presently the CCG Corporate Secretary: colin.nash@nhs.net. 6.6 The CCG s Governing Body will determine whether any applicant has an interest which would be so significantly in conflict that that individual should be precluded from membership of the Governing Body. 6.7 CCG Governing Body members are reminded that there is a distinction between the related party transactions they are required to declare in the CCG s Annual Report and other interests to be declared in the Register of Interests. 7. Maintaining Registers of Interests and Procurement Decisions COI Policy v5.0 12

13 7.1 Chairs of the CCG s Governing Body and its committees are responsible for ensuring a suitable Register of Interests (see Appendix 8) is maintained and updated. The Register of Procurement Decisions (see Appendix 10) will also record how any CoI with the business transacted was managed. Chairs will be assisted in this task by those providing administrative support to the CCG Governing Body or relevant committee. 7.2 The Registers will be published on the CCG s website and the public notified to this effect, giving details of how queries about the Registers should be addressed. Each request for information about the contents of a Register will be dealt with in accordance with the provisions of the Freedom of Information Act Data Protection 8.1 The information provided will be processed in accordance with data protection principles as set out in the Data Protection Act Data will be processed only for the reason(s) for which they are sought. The information provided will not be used for any other purpose. 8.2 Signing the Declaration of Interest Form will mean de facto that you consent to your data being processed for the purposes set out in this policy. 9.0 Standards of Business Conduct and Managing Conflicts of Interest 9.1. Employees, members, committee and sub-committee members of the CCG and members of the CCG Governing Body (and its committees) will, at all time comply with this Policy and be aware of their responsibilities as outlined in it. They should act in good faith and in the interests of the CCG and should follow the Seven Principles of Public Life, set out by the Committee on Standards in Public Life (the Nolan Principles). The Nolan Principles are set out in this Policy at clause 3.3. and compliant with Standards for members of NHS boards and Clinical Commissioning Group Governing Bodies Individuals contracted to work on behalf of the CCG or otherwise providing services or facilities to the CCG will be made aware of their obligation with regard to declaring conflicts or potential conflicts of interest. This requirement will be written into their contract for services. 10. Conflict of Interest Where an individual, i.e. an employee, CCG member, member of the CCG Governing Body, or a member of a committee or a sub-committee of the CCG or the CCG Governing Body has an interest, or becomes aware of an interest which could lead to a conflict of interest in the event of the CCG considering an action or decision in relation to that interest, that must be considered as a potential conflict, and is subject to the provisions set out in the CCG's Constitution and this Policy If in doubt, the individual concerned should assume that a potential CoI exists. COI Policy v5.0 13

14 10.3 Where a CoI would preclude a CCG Governing Body member, or members, with essential skills or knowledge, from contributing to CCG business, provision is made for the CCG Governing Body to appoint special advisors, with similar skills or knowledge, to assist them. These advisors shall not be members of the CCG Governing Body and should have no voting rights. 11. Declaring and Registering Interests 11.1 The CCG will maintain one or more registers detailing with the interests of: the members of the CCG; the members of the CCG Governing Body; the members of the CCG committees or sub-committees and the committees or sub-committees of the CCG Governing Body; and the CCG's employees (together, the "Registers") 11.2 The Registers will be published on the CCG's website to allow the public to access these Registers Individuals will declare any interest that they have, in relation to a decision to be made in the exercise of the commissioning functions of the CCG, in writing to the CCG Governing Body, as soon as they are aware of them and in any event no later than 28 days after becoming aware Where an individual's role or responsibility within the CCG or the CCG's Governing Body changes, any change to that individual's interests must be declared no later than 28 days after that change Where an individual's circumstances change in a way that reflects the individual's interests (e.g. taking on a new role external to the CCG or setting up a new business), then a further declaration should be made to reflect that individual's change of circumstances no later than 28 days after that change Where an individual is unable to provide a declaration in writing, for example, if a conflict becomes apparent in the course of a meeting, they will make an oral declaration before witnesses, and provide a written declaration as soon as possible thereafter to the CCG Governing Body The CCG Governing Body will ensure that the register(s) of interest is reviewed regularly (and at the very least every year), and updated as necessary. COI Policy v5.0 14

15 11.8 The Lay Member for Governance of the CCG Governing Body, will make themselves available to provide advice to any individual who believes they have, or may have, a CoI The CCG Governing Body will take such steps as it deems appropriate, and will request information it deems appropriate from individuals, to ensure that all CoI and potential CoI are declared. 12. Managing Conflict of Interest: general 12.1 Where an interest has been declared, either in writing or by oral declaration, the declarer will ensure that before participating in any activity connected with the CCG s exercise of its commissioning functions, they have received confirmation of the arrangements to manage the CoI or potential CoI from the CCG Governing Body The CCG Governing Body will ensure that for every interest declared, either in writing or by oral declaration, arrangements are in place to manage the CoI or potential CoI, to ensure the integrity of the CCG's decision making processes. Arrangements for the CCG Governing Body are set out below Arrangements for the management of CoI are to be determined by the CCG Governing Body and include: Ensure risk mitigation plan in place should a potential COI be evident in the preparation of agenda items. Checking at every Committee meeting and sub group if COI status has changed and update the register as required Adoption of a standard approach to agenda setting Notify the relevant individual of the arrangements for managing the COI or potential COI ahead of the meeting 12.4 The arrangements will confirm the following (as a minimum): Consideration of whether the individual/s can participate in discussions or not Consideration of whether the individual/s need to withdraw from the meeting Consideration of whether the individual/s can vote In any meeting where an individual is aware of an interest, previously declared or otherwise, in relation to the scheduled or likely business of the meeting, the individual concerned will bring this to the attention of the Chair, together with details of arrangements which have been confirmed by the CCG Governing Body for the management of the CoI or potential CoI. Where no arrangements have been confirmed, the Chair may either allow the individual to join in the discussion but not participate in the decisionmaking itself (i.e. not have a vote) or require the individual to withdraw from the relevant part of the meeting. For the avoidance of doubt, if a CCG meeting is held in public, and if any person with a conflict or potential COI Policy v5.0 15

16 conflict of interest is requested to leave part of a meeting, they shall not be entitled to attend that part of the meeting as a member of the public Where the Chair of any meeting of the CCG, including committees, subcommittees, or the CCG Governing Body, has a personal interest, previously declared or otherwise, in relation to the scheduled or likely business of the meeting, they must make a declaration and the Deputy Chair will act as the Chair for the relevant part of the meeting. Where arrangements have been confirmed with the CCG Governing Body for the management of the CoI or potential CoI in relation to the Chair, the meeting must ensure these are followed. Where no arrangements have been confirmed, the Deputy Chair may require the Chair to withdraw from the meeting or part of it. Where there is no Deputy Chair, the members of the meeting will select one. For the avoidance of doubt, if a CCG meeting is held in public, and if the Chair is requested to leave that meeting (or any part of it) due to a conflict or potential conflict of interest, the Chair shall not be entitled to attend the remainder of that meeting (or the relevant part of it) as a member of the public Any declarations of interests, and arrangements agreed in any meeting of the CCG, committees, sub-committees, or the CCG Governing Body, will be recorded in the minutes of that meeting In any transaction undertaken in support of the CCG s exercise of its commissioning functions (including conversations between two or more individuals, s, correspondence and other communications), individuals must ensure, where they are aware of an interest, that they conform to the arrangements confirmed for the management of that interest. Where an individual has not had confirmation of arrangements for managing the interest, they must declare their interest at the earliest possible opportunity in the course of that transaction. The individual must also inform either their line manager (in the case of employees), or the CCG Governing Body, of the transaction in which they are conflicted (or are potentially conflicted). 13. Managing Conflicts of Interest: CCG Governing Body 13.1 Individual members of the CCG Governing Body will comply with the arrangements determined by the CCG Governing Body for managing conflicts or potential conflicts of interest Where a CCG Governing Body member is aware of an interest which has not been declared, either in the register or orally to the CCG Governing Body, they will declare this at the start of the meeting. The CCG Governing Body will then determine how this should be managed and inform the member of their decision. The member will then comply with these arrangements, which must be recorded in the minutes of the meeting Where more than 50% of the members of the CCG Governing Body are required to withdraw from a meeting or part of it, owing to the arrangements agreed by the CCG s Governing Body for the management of conflicts of COI Policy v5.0 16

17 interests or potential conflicts of interests, the remaining Chair will determine whether or not the discussion can proceed. (See: Section 8 of the CCG Constitution) 13.4 In making this decision the Chair will consider whether the meeting is quorate, in accordance with the number and balance of membership set out in the CCG's Standing Orders. Where the meeting is not quorate, owing to the absence of certain members, the discussion will be deferred until such time as a quorum can be convened. Where a quorum cannot be convened from the membership of the CCG s Governing Body, owing to the arrangements for managing conflicts of interest or potential conflicts of interests, the Chair may invite, on a temporary basis, one or more of the following to make up the quorum so that the CCG can progress the item of business: a non-voting member of the Governing Body; a member of the CCG who is an individual; an individual appointed by a CCG member to act on its behalf in the dealings between it and the CCG; a member of a relevant Health and Wellbeing Board; or a member of a Governing Body of another clinical commissioning group; provided that following such invitation a majority of those comprising the quorum are affiliated with the CCG The transferring of votes from conflicted members will be at the Chair s discretion When transferring votes in accordance with 13.4 above, where it is not possible, for example because of conflicts of interest, to establish a quorum which includes four GP Members, votes may be transferred to persons, from the classes in 13.4 who are not GPs The arrangements made pursuant to the provisions of Section 13.4 must be recorded in the minutes The degree to which a CoI might fetter the ability of an individual to make a full and proper contribution to the CCG s Governing Body will be taken into account when considering appointments and elections to the CCG s Governing Body. 14. Managing Conflicts of Interest: Contractors 14.1 Anyone seeking information in relation to procurement or participating in procurement or otherwise engaging with the CCG in relation to the potential COI Policy v5.0 17

18 provision of services or facilities to the CCG, will be required to make a declaration of interest. (See Appendix 3) 14.2 Anyone contracted to provide services or facilities directly to the CCG will be subject to the same provisions of this policy and the CCG's Constitution in relation to managing CoI. This requirement will be set out in their contract for services. 15. Transparency in Procuring Services 15.1 The CCG is aware of the importance of making decisions about the services it procures in a way that does not call into question the motives behind the procurement decision that has been made. The CCG will procure services in a manner that is open, transparent, non-discriminatory and fair to all potential providers. This will be monitored by the Market Management & Procurement Committee 15.2 The CCG will publish a Procurement Template (see Appendix 9) approved by the CCG Governing Body which will ensure that: all relevant clinicians (not just members of the CCG) and potential providers, together with local members of the public, are engaged in the decision-making processes used to procure services; service redesign and procurement processes are conducted in an open, transparent, non-discriminatory and fair way. 16. Transparency of GP earnings NHS England s Managing of Conflicts of Interest (Para 83) has stated that there will be a contractual requirement for GP practices to publish on their practice website by 31 March 2016, the mean net earnings of GPs in their practice. 17. Breaches of this policy Breaches of this Policy may result in steps being taken in accordance with the CCG s Constitution and/or the individual being subject to disciplinary procedures of the CCG. Any breaches should be reported to either Richard Rice, Lay Member COI or Colin Nash Corporate Secretary. Breaches will be investigated, led by COI Guardian with help from the COI panel. Meetings will be recorded with meeting notes. Breaches will be notified immediately to NHS England england.londonsubmissions@nhs.net All breaches will be recorded on the Declarations Register which is published on the CCGs website. 18. Training and awareness COI Policy v5.0 18

19 18.1 The following key principles apply: The CCG s Governing Body is committed to ensure that appropriate training takes place on this subject for members of the Governing Body, CCG staff and member practices and that COI will be a mandatory part of the CCG s training programme and as part of the Induction Programme for new members of the Governing Body and new staff. The content of such training includes helping to develop a clear, corporate view about the CCG's appetite for risk in this area. The content of such training will adopt best practice from national guidance and learning from other CCGs/public bodies. CoI training will be provided annually for the CCG Governing Body as part of its development, ensuring that all clinical commissioners are trained in good governance. Dissemination of learning from these events will be shared with all staff of the CCG Awareness of this policy will be raised through the following: The CCG Intranet and internet sites incorporating the policy into training programmes for the CCG Governing Body and members of key Committees of the CCG Governing Body; by sharing with potential members as part of the appointment process; being part of the local induction process; being referred to as part of any procurement process. at any Committee, subcommittee and other relevant meetings of the CCG. 19. Further advice and guidance The following guidance documents give further information relevant to this Policy: Managing Conflicts of Interest: Statutory Guidance for CCGs, NHS England, December 2014 Standards for Members of NHS Boards and Clinical Commissioning Groups, Nov 2012 NHS Clinical Commissioners, Royal College of General Practitioners and British Medical Association Shared principles on conflicts of interest when CCGs are commissioning from member practices, December Section 7, Substantive guidance on the Procurement, Patient Choice and Competition Regulations, Monitor (December 2013) NHS National Leadership Council (2010) COI Policy v5.0 19

20 In the event that further clarification or advice is required in respect of this Policy, please refer to the Executive Business Manager or the Director of Integrated Governance. 20. Equality Impact Assessment 20.1 The CoI Policy supports the three main principles of procurement law, namely equal treatment, non-discrimination and transparency. The CCG is committed to equality of opportunity for its employees and does not unlawfully discriminate on the basis of their protected characteristics as defined in the Equality Act 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 carried out on this Policy. The results indicated that the policy was not likely to impact on the CCG Governing Body s duties under its equalities schemes If you have any concerns or issues with the contents of this Policy or have difficulty understanding how this Policy relates to you or your role, please contact the Corporate Secretary: colin.nash@nhs.net. 21. Review This Policy will be reviewed in 3 years time unless an earlier review is indicated. COI Policy v5.0 20

21 22. Audit and Monitoring Effectiveness The processes for monitoring compliance with this procedure and its effectiveness are outlined in Table 2 below: Measurable Policy/Objective Monitoring/Audit Frequency of monitoring Responsibility for performing the monitoring Monitoring reported to which groups/committees, including responsibility for reviewing action plans Lead Interests will be declared and Register kept and published on CCG s website Audit of Register of Interests Yearly Internal Audit The CCG Governing Body Director of Integrated Governance [Executive Business Manager/Corporate Secretary] Declared conflicts of interests are recorded in the minutes of every meeting of the CCG Governing Body and committees. Audit of minutes of CCG Governing Body and committees Yearly Internal Audit The CCG Governing Body Director of Integrated Governance] Executive Business Manager/Corporate Secretary] Register of bidders and tenders are accurate and up- to-date Record of bidding and tendering process and decisions Quarterly Finance, Performance & QIPP committee Internal Audit Conflict of Interest Panel Market Management & Procurement Committee Audit Committee CCG Governing Body Chief Finance Officer [Executive Business Manager/Corporate Secretary] Procurement decisions Completion of declaration of interest forms for bidders and tenderers by GPs and other conflicted or potentially conflicted persons. Quarterly Audit Committee CCG Governing Body Market Management & Procurement Committee Chief Finance Officer [Executive Business Manager/Corporate Secretary] COI Policy v5.0 21

22 Measurable Policy/Objective Monitoring/Audit Frequency of monitoring Responsibility for performing the monitoring Monitoring reported to which groups/committees, including responsibility for reviewing action plans Lead Register of Decisions Registers are accurate and up-todate and how conflicts were managed are recorded and published via the Register of Procurement Decisions Form Quarterly Audit Committee CCG Governing Body Chief Finance Officer [Executive Business Manager/Corporate Secretary] Transparency of GPs net earnings (from March 2016) Evidence proactively produced by GPs Published on CCG website Annually Internal/External Audit Remuneration Committee Lay Member [Chief Finance Officer/Director of Integrated Governance] 23. Specific Guidance to Deal with Conflicts of Interest Arising out of Primary Care Joint Co-commissioning. Table 3 below sets out the key recommendations by NHSE in its guidance document issued in December Some recommendations made are already in place; only new guidance will be listed. The actions set out will have effect as part of this policy and will be monitored as part of its effectiveness SUBJECT ACTION CONSTITUTIONAL AMENDMENTS Legislative framework CCGs will keep a record of how it manages any conflict in relation to NHS commissioning contracts it enters into. Yes Maintaining a register of interests and a register of procurement decisions Maintain separate Registers for Members, CCG Governing Body members, all staff and for members of all committees A register of procurement decisions to be kept and published for access by the public. No Yes COI Policy v5.0 22

23 SUBJECT ACTION CONSTITUTIONAL AMENDMENTS Procurement issues where GPs are providers or potential providers Governance and decision-making processes A Procurement Template to be filled in to give assurance that conflicts of interests have been properly managed (see Appendix 8 ) Internal controls to detect breaches of the CCG s conflicts of interest policy, including appropriate external oversight and adequate provision for whistleblowing. Yes No Appointing governing body or committee members Decision-making when a conflict of interest arises: general approaches Decision-making when a conflict of interest arises: primary medical care CCGs will need to consider whether conflicts of interest should exclude individuals from being appointed to the governing body or to a committee or sub-committee of the CCG or governing body. These will need to be considered on a caseby-case basis but the CCG s constitution should reflect the CCG s general principles. Depending on the nature of the conflict, GPs or other practice representatives could be permitted to join in discussions by the governing body, or such other decision-making body as the CCG has created, about the proposed decision, but should not take part in any vote on the decision The membership of the committee will be constituted so as to ensure that the majority is held by lay and executive members. In addition to existing CCG lay members, members may be drawn from the CCG s executive members, except where these members may themselves have a conflict of interest (e.g. if they are GPs or have other conflicts of interest). Provision could be made for the committee to have the ability to call on additional lay members or CCG members when required, for example where the committee would not be quorate because of conflicts of interest. It could also include GP representatives from other CCG areas and non-gp clinical representatives (such as the CCG s secondary care specialist and/or governing body nurse lead). Yes No Yes COI Policy v5.0 23

24 Appendix 1: Declaration Form NHS Greenwich Clinical Commissioning Group (the "CCG") Member / employee / Governing Body member / committee or sub-committee member (including committees and sub-committees of the Governing Body) declaration form: financial and other interests This form is required to be completed in accordance with the CCG s Constitution (Section 8) and the guidance issued by NHS England to meet the requirements of section 14O of The National Health Service Act Notes: Each CCG must make arrangements to ensure that the persons mentioned above declare any interest which may lead to a conflict with the interests of the CCG and the public for whom they commission services in relation to a decision to be made by the CCG. A declaration must be made of any interest likely to lead to a conflict or potential conflict as soon as the individual becomes aware of it, and within 28 days. If any assistance is required in order to complete this form, then the individual should contact the CCG Executive Business Manager or the Corporate Secretary. They may in turn seek advice from the Lay Member with special responsibility for conflict of interest. She is presently Amana Humayun at amana.humayun@nhs.net The completed form should be sent by both and signed hard copy to the Corporate Secretary at the main Headquarters of the CCG which is: NHS Greenwich Clinical Commissioning Group The Woolwich Centre 35 Wellington Street London SE18 6HQ The Corporate Secretary is presently Colin Nash at colin.nash@nhs.net Any changes to interests declared must also be registered within 28 days by completing and submitting a new declaration form. The register will be published on the CCG's website. Paper copies can be obtained from The Corporate Secretary at the above address. Any individual and in particular members and employees of the CCG must provide sufficient detail of the interest, and the potential for conflict with the interests of the CCG and the public for whom they commission services, to enable a lay person to understand the implications and why the interest needs to be registered. COI Policy v5.0 24

25 If there is any doubt as to whether or not a conflict of interest could arise, a declaration of the interest must be made. Interests that must be declared (whether such interests are those of the individual themselves or of a family member, close friend or other acquaintance of the individual) include (but are not limited to): roles and responsibilities held within member practices; directorships, including non-executive directorships, held in private companies or PLCs; ownership or part-ownership of private companies, businesses or consultancies likely or possibly seeking to do business with the CCG and/or with NHS England; shareholdings (more than 5%) of companies in the field of health and social care; a position of authority in an organisation (e.g. charity or voluntary organisation) in the field of health and social care; any connection with a voluntary or other organisation (public or private) contracting for NHS services; research funding/grants that may be received by the individual or any organisation in which they have an interest or role; and any other role or relationship which the public could perceive would impair or otherwise influence the individual's judgment or actions in their role within the CCG. If there is any doubt as to whether or not an interest is relevant, a declaration of the interest must still be made. COI Policy v5.0 25

26 Appendix 2: Declaration of Interest Form for Members/ Employees Name (Please print): Position within or relationship with, the CCG: INTERESTS Type of Interest Details Personal interest or that of a family member, close friend or other acquaintance? Roles and responsibilities held within member practices Directorships, including nonexecutive directorships, held in private companies or PLCs Ownership or partownership of private companies, businesses or consultancies likely or possibly seeking to do business with the CCG and/or with NHS England Shareholdings (more than 5%) of companies in the field of health and social care Positions of authority in an organisation (e.g. charity or voluntary organisation) in the field of health and social care Any connection with a voluntary or other organization (public or private) contracting for NHS services Research funding/grants that may be received by the individual or any organisation they have an interest or role in Any other role or relationship which the public could perceive would impair or otherwise influence the COI Policy v5.0 26

27 Name (Please print): Position within or relationship with, the CCG: INTERESTS Type of Interest Details Personal interest or that of a family member, close friend or other acquaintance? individual s judgment or actions in their role within the CCG To the best of my knowledge and belief, the above information is complete and correct. I undertake to update as necessary the information provided and to review the accuracy of the information provided regularly and no longer than annually. I undertake to complete a new declaration of interest form within 28 days of any previously declared interests changing. I give my consent for the information to be used for the purposes described in the CCG s Constitution and published accordingly. Signed: Date: The completed form should be sent by both and signed hard copy to NHS Greenwich CCG HQ Colin Nash Corporate Secretary NHS Greenwich Clinical Commissioning Group The Woolwich Centre 35 Wellington Street London SE18 6HQ colin.nash@nhs.net COI Policy v5.0 27

28 Appendix 3: Declaration of Conflict of Interest for Bidders/Contractors Template NHS Greenwich Clinical Commissioning Group s Bidders/potential contractors/ service providers' declaration form: financial and other interests This form is required to be completed in accordance with the CCG s Constitution, and s14o of the NHS Act 2006 (as amended by the Health and Social Care Act 2012) and the NHS (Procurement, Patient Choice and Competition) (No2) Regulations 2013 and related guidance 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, or with NHS England in circumstances where the CCG is jointly commissioning the service with, or acting under a delegation from, NHS England. If any assistance is required in order to complete this form, then the Relevant Organisation should contact the Chief Finance Officer at NHS Greenwich CCG The completed form should be sent to the Chief Finance Officer at NHS Greenwich CCG 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 be notified to the CCG by completing a new declaration form within 28 days of the change occurring and submitting it to [the Chief Finance Officer]. Relevant Organisations completing this declaration form must provide sufficient detail of each interest so that the CCG, NHS England and also 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 or NHS England (including the award of a contract) might arise. If a Relevant Organisation is in doubt as to whether a conflict of interest could arise, a declaration of the interest should be made. A "Relevant Person" means any person employed or engaged by or otherwise connected with a Relevant Organisation. 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: o if a Relevant Person has provided or is providing services or other work for the CCG or NHS England; or COI Policy v5.0 28

29 o o A Relevant Organisation or Relevant Person is providing services or other work for any other potential bidder in respect of a project or procurement process; or A Relevant Organisation or Relevant Person has any other connection with the CCG or NHS England, whether personal or professional, which the public could perceive may impair or otherwise influence the CCG or any of its members or employees judgments, decisions or actions. COI Policy v5.0 29

30 Appendix 4: Declaration of Interest Form for Bidders and Tenderers Relevant Organisation Name of Relevant Organisation: Interests Type of Interest Provision of services or other work for the CCG or NHS England Details 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 or NHS England, 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 COI Policy v5.0 30

31 Appendix 5. Declaration of Interest Form for Bidders and Tenderers-Relevant Person Name of Relevant Person Interests [complete for all Relevant Persons] Type of Interest Details Personal interest or that of a family member, close Provision of services or other work for the CCG or NHS England friend or other 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 or NHS England, 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 undertake to update as necessary the information. Signed:. On behalf of:. Date:. COI Policy May

32 Appendix 6: NHS Clinical Commissioners, Royal College of General Practitioners and British Medical Association - Shared principles on conflicts of interest when CCGs are commissioning from member practices This is available in NHS England s Managing Conflicts of Interest, December COI Policy May

33 Conflict of Interest Panel Terms of Reference 1.0 Introduction 1.1 The Conflict of Interest Panel is an advisory and decision-making body that can be asked to give its view on whether any actual or perceived conflicts of interest to the business of the CCG have been managed, or will be managed in a way that is consistent with the CCG s policy on managing conflicts of interest and current NHS guidelines on these matters. 1.2 A referral to the Panel may be made by any member of staff, or any Governing Body or committee member. This should be in writing, usually to the Lay Member for Governance on the CCG Governing Body, or the Director of Quality and Governance. 2.0 Remit To advise on any conflict of interest matter referred to it. 3.0 Membership Governing Body Lay Member for Governance (Chair when considering matters referred by the Market Management and Procurement Committee and the Governing Body where the Lay Member for Governance has not already been involved in making a recommendation on the referred matter) Governing Body Lay Member for Patient and Public Engagement (Deputy Chair) [If neither the Lay Member for Governance nor the Lay Member for Patient and Public Engagement can serve on the Panel because they themselves are conflicted, the Panel will elect a chair from amongst the non-conflicted members]. The Membership of the Panel shall consist of: Lay Member for Governance and Conflict of Interest Lay Member for Patient and Public Engagement Director of Quality & Governance (can deputise for Chief Officer) Chief Officer (can deputise for Director of Quality & Governance) Two GPs from the Governing Body OR Syndicate Leads (if not conflicted) Governing Body Secondary Care Doctor OR Governing Body Registered Nurse COI Policy May