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Conflicts of interest in divisions of general practice
  1. N Palmer1,
  2. A Braunack-Mayer1,
  3. W Rogers2,
  4. C Provis3,
  5. G Cullity4
  1. 1Discipline of Public Health, University of Adelaide, Adelaide, South Australia
  2. 2Department of Medical Education, Flinders University, Adelaide
  3. 3School of Management, University of South Australia, Adelaide
  4. 4Discipline of Philosophy, University of Adelaide
  1. Correspondence to:
 A Braunack-Mayer
 Discipline of Public Health, University of Adelaide, Level 9, 10 Pulteney Street, Mail Drop 207, South Australia 5005;annette.braunackmayer{at}adelaide.edu.au

Abstract

Community-based healthcare organisations manage competing, and often conflicting, priorities. These conflicts can arise from the multiple roles these organisations take up, and from the diverse range of stakeholders to whom they must be responsive. Often such conflicts may be titled conflicts of interest; however, what precisely constitutes such conflicts and what should be done about them is not always clear. Clarity about the duties owed by organisations and the roles they assume can help identify and manage some of these conflicts. Taking divisions of general practice in Australia as an example, this paper sets out to distinguish two main types of conflicts of interest, so that they may be more clearly identified and more effectively managed.

  • DGPs, Divisions of General Practice

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Divisions of general practice (DGPs) are recent arrivals on the healthcare scene in Australia. They engage in a broad range of activities, including population health programmes, IT and general practice support for general practitioners, continuing medical education, research and evaluation activities, health initiatives targeted at particular groups, and allied health programmes.1 The broad scope of these activities means that DGPs need to manage competing priorities for time and resources in pursuit of their aims.

Generally, the principal stakeholders of community-based healthcare organisations are the communities they are intended to serve. Many organisations (eg, the Cancer Councils of Australia) exist to serve specific groups in the community, and these groups are their stakeholders. In the case of DGPs, they support primary healthcare services by supporting the activities of general practitioners working in the community, giving them both general practitioners and their communities as stakeholders. The Commonwealth government from which the DGPs receive most of their funding (as part of the DGP programme) is also a stakeholder.2 From an organisational perspective, DGPs are membership-based organisations and have duties to act in the interests of their members. As recipients of federal funding, the Commonwealth government expects DGPs to demonstrate achievements in line with their national priorities (box 1), via the National Performance Indicators.2 Although many of the expectations outlined by the federal government may fit well with local, member-focused activities, balancing local priorities and those in line with the national priority areas may not be a straightforward matter for DGPs.

Box 1 National priorities2

  • Supporting general practice in a changing environment

  • Improving access

  • Encouraging integration and multi-disciplinary care

  • Focus on prevention and early intervention

  • Improved chronic disease management

  • Supporting quality and evidence -based care

  • Growing consumer focus

IDENTIFYING CONFLICTS OF INTEREST

Standard-model conflicts of interest

The task of managing competing priorities is one shared by organisations and people alike. But what distinguishes a conflict of interest from mere competing priorities? Conflicts of interest on the standard view are commonly understood to occur when the capacity of people or organisations to fulfil their duties to others seems under threat of interference or compromise because of external interests.3 Importantly, what is at stake in conflicts of interest is not simply the proper exercise of judgement, but the proper exercise of judgement in decisions made on behalf of others. Decisions in line with this kind of obligation are normally held to follow from the role held by the decision maker (be it a person or an organisation). A role such as that of company director or public servant or doctor requires people to make decisions and recommendations that serve others, who trust the role incumbent to make the decision or recommendation only on grounds that make for good decisions, not some other indirectly related set of interests or concerns.4 A conflict of interest risks not simply that judgement may be impaired, but further the possibility of a breach of trust with respect to the proper conduct of that role. It is the fidelity of judgement, and not merely the conflict of interest itself that is of concern in cases of conflicts of interest.

DGPs are at risk of having conflicts of interest on this standard view. One example is where DGPs act as gatekeepers for research by third parties who may wish to do research with local general practitioners, their practices or their patients. A typical example would be that where a DGP is approached to support a research project by facilitating the recruitment of general practitioners or their patients. DGPs have to balance the benefits of supporting research and an ongoing contribution to the evidence base by protecting members, their practices and their patients from potential harms such as breaches of privacy or over-exposure to research. Decision making here may be compromised by a conflict of interest where greater access to funding sources may act as an undue inducement to facilitate further research. Here, the conflict of interest is not simply that DGPs must balance access to participants or data with protecting confidentiality and preventing over-research; this responsibility accompanies the role of being a DGP. The conflict of interest (or potential for such a conflict) lies in this responsibility being compromised by a relationship with a third party. In this example, DGPs have to manage internal competing priorities that arise, legitimately, from the role of DGPs acting in the interests of their members. There is some inherent conflict among these priorities themselves. The conflict of interest, however, occurs because of an interest or relationship with an external party.5 In this case, the interest is the potential financial advantage from the external funding source, which may skew the decision in favour of research, rather than basing it on the needs and interests of potential research participants.

In-role conflicts

Apart from a standard model of conflicts of interest, there are also situations where decision makers find that they have legitimate duties to pursue different priorities on behalf of different parties (eg, the interests of general practitioners and patients) or where they perceive conflicting duties or conflicting roles arising from obligations owed to their principal stakeholders. In these conflicts there is no external interest exerting influence; rather, the conflict arises in the scope of the obligations owed by the organisation and its management to the stakeholders. These in-role conflicts, although awkward to deal with for organisations, may in some senses at least be regarded as just “part of the job”. Such conflicts may therefore be distinguishable from conflicts of interest understood on the standard model,3 as there is no third party relationship or interest that potentially compromises the roles in question; each role is legitimate and creates duties that ought to be fulfilled.

As Kalucy et al1 say in their report on DGPs, the challenge faced by them is to achieve a balance among local and national priorities, among the needs of members and their communities, and those of the federal government and a growing number of other funding bodies.1 With respect to the federal government’s national priorities, managing this balance (for DGPs) entails weighing their original and, some would still say, primary priority of representing and supporting the interests of local member general practitioners against those priorities more broadly reflective of national health strategies, the pursuit of which may work against the interests of local members. For example, pursuing priorities 2, 4 and 5 may increase the workloads of general practitioners, with no matched increase in remuneration. In this example we are able to identify the presence of competing interests. Is it useful, however, to identify them as conflicts of interest? If so, why?

We can make a distinction between conflicts of interest in which decision makers must fulfil several roles in the service of a single principal (many roles, one principal) and those in which the person or organisation assumes a single role in the service of more than one principal (many principals, one role).6 Both are described as “in-role” conflicts of interest, distinguishable from the “out-of-role” conflicts akin to conflicts of interest on the standard view.3 The difficulty in applying this distinction in cases such as that of DGPs is that, although prima facie some organisations seem to be prone to conflicts of the second kind (many principals, one role), it is easy to see how various, possibly competing roles may issue from relationships with and obligations to each principal, creating the possibility of conflicts with multiple principals and multiple roles. Although it is useful to be able to distinguish in-role conflicts of interest from those on the standard view, more work needs to be carried out to bridge theoretical accounts of such conflicts with those encountered in practice, such as occurs in DGPs.

In the case of DGPs, there are increasing accountability requirements for federal funding (via the national priorities), which may lead to more conflicts of this kind. The role of DGPs will increasingly entail reconciling competing priorities in pursuit of the interests of their multiple principals: the federal government, which supports their continued existence and the membership around whose priorities and principles the organisations were originally founded; and multiple roles: membership-based organisations focused on local interests and needs, and a broader role in the pursuit of national public health priorities. The challenge for DGPs is not in disclosing or avoiding such conflicts; it is rather in attempting to manage the competing priorities that inevitably arise.

MANAGING CONFLICTS OF INTEREST

To clearly identify types of conflicts is an important step towards their management, as each type needs to be managed differently. Conflicts of interest on the standard model are amenable to standard sorts of solutions: disclosure, recusal or substitution on the part of the decision maker, or the termination of the offending relationship itself.7–9 Options include eliminating the conflict, accepting either the inevitability or the innocuous nature of the conflict, or taking steps to avert the possibility that judgement may be compromised. The onus here is on showing that external interests—for example, financial gain, prestige or public recognition—will not exert an undue influence on the core duties of the organisation. A key strategy is thus to clarify the organisation’s core aims, roles and associated duties, and to be ruthless in identifying and ruling out external or illegitimate ones. Conflicts of interest of the standard type normally respond well to such remedies.

The distinction between conflicts of interest (on the standard view) and the other kind of role conflicts identified above is important, as conflicts of the second type respond to different remedies. Role conflicts result from the range of legitimate roles and duties that organisations have. The problem is not the fault of the decision makers concerned; rather, conflicts arise because organisations are committed to duties that become contingently incompatible. Standard approaches, such as disclosure or recusal, are not effective in such cases. Substituting the decision maker does not eliminate the conflict, as the conflict is not associated with private, personal interests. There are some measures that may be used in other conflicts, which resemble this sort of role conflict. For example, it may be possible to deal with a conflict between auditing and provision of financial advice by splitting off potentially conflicting functions into separate organisational units separated by so-called “Chinese walls”.10 However, such measures are also unavailable in cases such as ours, because it is impossible or impracticable to allocate different decisions or functions to different parts of the organisation.

With respect to managing such conflicts, O’Neill11 notes that it can be useful to use a design analogy to describe a commitment to a range of competing and possibly conflicting duties, much like having to balance design constraints on a construction project (quality, the scale of the project, cost, time to completion, safety standards and so on). Hard choices are often required in situations where the roles of decision makers make conflicting demands, and not all priorities may be pursued equally. When faced with competing priorities in this way, judgement is “a matter of finding some act … or policy that meets a plurality of requirements”, and sometimes there will unavoidably be “remainders” that call for regret.11 Skill in managing such conflicts lies in establishing which of these constraints may be traded off against others (eg, time to completion) and which may not (eg, safety standards). Good judgement here is needed to arrive at the best overall outcome without undue compromise; however, any remainders, no matter how good the outcome, still need to be accounted for. Transparency and a clear focus on which duties can be met and which cannot become instrumental to this end.

Transparency and the mere disclosure of potential conflicts and unmet priorities, however, are not enough. There remains the danger of an attitude in management that as such conflicts and remainders seem inevitable, and not all of the organisation’s roles need be fulfilled completely, it may be perfectly acceptable to allow one role (eg, representing the interests of the membership) to be emphasised to the exclusion of others. Staying with the example of DGPs, we propose three further strategies for managing this. The following represent some basic steps towards offering structural incentives to prevent boards of management converging unevenly around the roles they have duties to fulfil. Following from more general accounts of acting in good faith and avoiding conflicts of interest,4 they describe strategies for helping to prevent decision-making processes from focusing on one role or set of obligations at the expense of others.

  1. Identifying aims and duties: each division should formally identify what its aims and duties are and the minimum acceptable standards of performance in regard to those aims and duties. It then needs to assess whether it has the capacity to meet those minimum standards in respect of each of those aims and duties. Where trade-offs occur, adverse effects on competing priorities should be noted, ideally as part of the strategic planning process.

  2. Structural factors—representation: boards of divisions should seek a composition that includes a diverse range of competence and background. This should include people with a stake in the various aims or duties identified by the DGP’s board of management—for example, community representatives and individuals representative of local risk group populations (HIV/AIDS, etc). Such measures can help to avoid “groupthink”.12 Excluding stakeholders from decision-making processes may be more risky in the long run than being more inclusive and running the risk of dissenting views in discussion.

  3. Accountability and dialogue: divisions should ensure that they are accountable to their various stakeholders. As membership-based organisations, they need to be accountable to their members for activities that seek to conform to the requirements of the federal government. As taxpayer-funded organisations, they need to account to the federal government for the extent to which their activities aim to further the interests of their members. This implies a process of open and explicit dialogue that should inform the identification of minimum acceptable standards of performance at (1) above. It should inform thinking within each division about the extent to which its different aims and duties can be simultaneously fulfilled, and should also inform the division’s work on a continuing basis.

CONCLUSION

The challenge of managing competing priorities is common to all public and semipublic organisations. Many difficulties may be attributed to conflicts of interest of one form or another. In the case of DGPs, some instances clearly resemble conflicts of interest. In others, conflicts do not arise through a person or institution having an external relationship that risks compromise to the primary duties of the role; they arise instead because of conflicts within or between the legitimate roles and activities of the organisation. Although these role conflicts do not conform to the standard view of conflicts of interest, they remain nonetheless conflicts between duties owed to a range of stakeholders and the interests that follow from the range of activities they pursue. This distinction is important, as it helps reframe the question of how such conflicts may be best managed when standard measures fail to be effective. The roles of organisations need to be clearly defined and the potential for conflict should be anticipated and managed appropriately. Steps should also be taken to include stakeholders to whom duties are owed in the definition of the role and priorities of organisations to help ensure accountability in the sense that the legitimate expectations are met with regard to the role and duties of organisations and are appropriately defined and acted upon.

Acknowledgments

This project was funded partly by a grant from the University of Adelaide Faculty of Health Sciences Small Research Grants Scheme.

REFERENCES

Footnotes

  • Competing interests: None.

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