Press release 04th Feb 2021

New research reveals extent of conflicted decision making in NHS

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Declare interests. Manage conflicts. Protect the NHS.


This report looks at how changes to the NHS in England over the past decade have created greater risks of abuses of power, and how reforms to local commissioning are exacerbating them. Since 2012, membership organisations made up of General Practitioners (GPs), called Clinical Commissioning Groups (CCGs), have managed most of the NHS’ budget in England. They are responsible for purchasing £78 billion of healthcare services on behalf of the NHS. At the same time, these same GPs are independent contractors to the NHS and are in receipt of around £8.5 billion of NHS funding each year.

Because CCG governing boards comprise commissioners and contractors of health services, obvious conflicts of interest can arise. If not managed properly, this can result in the misuse of public money for private benefit at the expense of patients and taxpayers. As with any public body, these organisations should have measures in place to protect against the risks of impropriety. Specifically, they should have:

  • transparent and effective management of any potential conflicts of interest held by senior officials
  • clear governance arrangements

These core protective measures aim to prevent abuses of power for private gain and to ensure that decisions about healthcare services are taken in the best interests of patients and taxpayers.

This report looks at the potential scale of conflicts of interest within local NHS commissioning organisations in England, and how these organisations protect against their abuse. It covers CCGs and their emerging successor bodies that are taking over the co-ordination of local NHS services – Sustainability and Transformation Partnerships (STPs) and Integrated Care Systems (ICSs).

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February 4, 2021 - Local NHS Clinical Commissioning Groups (CCGs), the bodies responsible for 60% of the NHS budget in England, are hardwired with conflicts of interest that would not be tolerated in any other part of the public sector, according to new research by Transparency International UK.

Declare interests. Manage conflicts. Protect the NHS finds that some £1.5 billion of public funds was paid to companies in which CCG board members had an interest in 2018/19 alone.

Transparency International UK reviewed the accounts of 185 CCGs and identified 150 (81%) that included transactions between members of the CCG’s governing body and an organisation they also held a financial or personal interest in.  

The report also exposes how new organisations due to take over the co-ordination of local NHS services lack basic governance arrangements, despite plans for them to ultimately take responsibility for millions of patients and billions in public funds every year.

We reviewed publicly available information for 44 Sustainability and Transformation Partnerships (STPs) and Integrated Care Systems (ICSs) – the successors to CCGs – and found 18 (40%) did not publish even basic information about who runs them or where responsibility and accountability lie.

And unlike CCGs, ICSs and STPs are not currently required by law to implement safeguards to reduce and prevent the abuse of conflicts of interest.


Duncan Hames, Director of Policy at Transparency International UK, said:

“This research reveals the extent of the conflicts of interest within Clinical Commissioning Groups and highlights how some GPs have effectively been contracting with themselves. While there are some measures in place to protect against abuse, the hardwired nature of these potential conflicts combined with the sheer number would not be tolerated in any other part of the public sector.

“The current governance of local healthcare provision means a large number of conflicts are inevitable, so it is essential lessons from the creation of CCGs are learned and mistakes not repeated. New bodies are now taking responsibility for the wellbeing of millions of patients and billions in public funds, but there is very little transparency over how many of their decisions are made and how taxpayer money is being spent. If asked to identify where the buck stops with these new bodies, in many cases we simply don’t know. This lack of transparency is asking for trouble and need addressing to ensure public confidence in these changes.”


Scale of potential conflicts of interest in CCGs

We reviewed the accounts of 185 CCGs for the year 2018/19 and identified 150 CCGs whose accounts included ‘related party transactions’ - the transfer of resources, services or obligations between connected individuals or organisations, regardless of whether a price is charged - involving the members of the governing body of the CCGs in question.

Across those 150 CCGs, we found £1.5 billion in related party transactions involving CCG governing body members. The average value of related party transactions for each CCG governing body was £11 million.

Analysis of the conflicts of interest registers from a random sample of 20 CCGs found a total of 819 potential conflicts declared – an average of three per governing body member.

We did not investigate whether any of the £1.5 billion in payments were inappropriate and there is no suggestion that any of the individual CCG members have benefited illegitimately from their involvement in CCGs, but the findings reveal the sheer scale of public money implicated in conflicted decision making.

To mitigate these significant risks, Government should prohibit those commissioning local healthcare services from contracting businesses where their board members have a financial interest.


New models of care bring new risks

Whilst CCGs remain the bodies with powers to commission healthcare services and contract with providers, since 2016 responsibility for arranging healthcare services for local populations has been moving to Sustainability and Transformation Partnerships (STPs) and Integrated Care Systems (ICSs).

Unlike CCGs, these bodies are not legal entities and so are not subject to the same protective and accountability measures.

We reviewed publicly available information to understand more about the governance arrangements for these organisations. Of the 44 STPs/ICSs we assessed:

  • Eighteen (40%) did not publish even basic information about how they are run, such as the names of their senior leadership team, a constitution setting out the terms of references for the partnership/care system, or a diagram outlining where responsibility and accountability lies.
  • Twenty-eight (60%) did not publish any minutes of board meetings over the last year. It is not clear whether this is because there were no board meetings, or that these meetings were taking place in private.
  • Just one made a register of interests held by its senior members readily available online.

At a minimum, STPs/ICSs should provide key governance documents on their websites.

These bodies should also be put on a statutory footing so that the law provides clear and transparent governance arrangements.


Notes to editors:

Transparency International is the UK’s leading independent anti-corruption organisation and a member of the Transparency International global movement.

Between November 2020 and January 2021, NHS England consulted on proposals to further embed Integrated Care Systems into the provision of local healthcare services -



Harvey Gavin

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