Steve Turley, Managing Director of Lundbeck, has been re-elected Chair of the European Medicines Group (EMG), the UK voice of pharmaceutical companies based in continental Europe.

Robin Bhattacherjee, General Manager of Actelion, was re-elected vice-Chair of the EMG; and Mike Sumpter, CEO of Servier Laboratories, was elected Treasurer.

Issues highlighted at the EMG’s twelfth AGM included the impact of NHS reform on European-based companies and European perceptions of the UK as a pharmaceutical market and research base.

The EMG’s 15 member companies are Actelion, Almirall, Bayer, Boehringer Ingelheim, Ferring, Lundbeck, Menarini, Merck Serono, Norgine, Novartis, Novo Nordisk, Roche, Sanofi, Servier and UCB.

Steve Turley (pictured) commented: “We have members ranging from the UK’s biggest pharmaceutical companies, through biotechnology specialists to emerging organisations. Yet we all share common challenges and can benefit from being able to view these through a European-focused lens.”

“How the implementation of the NHS reforms affects European-based companies is a key issue this year,” noted Robin Bhattacherjee.

“Upwards of 60% of the medicines our members have introduced in the last decade have not been subject to a NICE health technology appraisal, so... local decision making in the CCGs about the use of these remains a major focus for EMG.”

Mike Sumpter noted: “Globally the UK is viewed as a tough market where innovative new medicines aren’t adopted as readily as similar economies.

“We want to work closely with our NHS stakeholder partners to demonstrate that the UK and the NHS is worth investing in.”

Lundbeck is based in Denmark, Actelion in Switzerland and Servier in France; all three companies have major UK operations.

A pilot physiotherapy scheme by NHS Newcastle West CCG has helped saved thousands of pounds and reduced unnecessary hospital visits.

Commissioners introduced private appointments in GP surgeries for basic cases and established a call referral management centre to decide how patients are treated before being referred.

The two-year project allowed more serious cases to be transferred to secondary care physiotherapy services at Newcastle Hospitals NHS Foundation Trust whilst reducing demand.

The CCG established a partnership in 2010 with private therapy company Connect Physical Health to bring services closer to patients’ homes.

Patients who had minor requirements saw a physio or specialist at a primary care setting and were also given access to a one-to-one advice line to receive guidance at home.

Patient feedback from the pilot scheme revealed that 96% of patients said the standard of care they received was “excellent or very good” and 97% of doctors agreed the service was better than when it was first introduced in 2010.

Commissioners have estimated that if the scheme was introduced across CCGs in England it could make savings for each group of around £220,000.

This month Brigadier Pinching shares a surprisingly palatable civil service coffee with the Department of Health’s NHS/big pharma relationship expert, Naima Khondkar.

I love Elephant and Castle. If you are in any doubt about where you are, just outside the station, there is large sculpture of... an elephant and a castle. Oxford Circus, King’s Cross and Cockfosters have clearly missed out on a neat trick. Anyway, I digress, for I was in central London on important business – to chat with Naima about how the private and public sector could make their marriage work. Having spent six years in curious governmental buildings, this was my territory. Bring on the future!

Hi Naima, what’s your story?

At the Department of Health I work in the Medicines, Pharmacy and Industry Group. The head is Giles Denham and he has a number of teams which sit under him. One looks after the pricing environment – which is very topical right now because of the negotiations – while the pharmacy team takes care of community and pharmacy issues. Another concentrates on prescription policy, and I’m in the industry sponsorship team.

How do you guys roll?

We’re almost account managers for the pharmaceutical industry, within government, and also the first port of call on health policy issues concerning research-based pharma companies, including global outfits that have locations in the UK. There’s a very high-level of strategic engagement, driven by the Ministerial Industry Strategy Group, which combines global heads of pharma, from as far afield as Japan and America, and ministers from health, business, the treasury and UKTI (UK Trade and Investment). The discussions are a great way to highlight how government policy can help partnerships. Our minister, Earl Howe, is a particularly engaging contributor, while ‘No 10’ frequently sends along a representative, indicating how serious the Government is about forming cohesive inter-sector partnerships.

How has the concept of joint working progressed?

Over the last few years we have carefully considered how to fundamentally improve the relationship between industry and the NHS, and a lot of this consideration has been carried out in conjunction with colleagues at the ABPI. There is still a lot of mistrust on both sides, however, and that is one of the greatest challenges reform needs to overcome. The NHS has the perception of pharma as being a big bad wolf, just above the arms and tobacco industries in terms of popularity! For some reason people have a big problem with the pharmaceutical industry making any kind of money. Sometimes I think the level of suspicion is unjustified, but then again, I don’t think pharma do themselves many favours sometimes. It’s important to be open and honest about these things! Equally, the NHS can sometimes be over-sensitive – they don’t like to be told by other people how to do their job.

What needs to change?

There needs to be a shift in how people on both sides view one another and they must learn to wipe the slate clean. Bad relationships can date back to minor incidents that happened 25 years ago, when a young, naive rep went into a meeting with a box of doughnuts to help flog a new product. Something as trivial as this may have resulted in a door being shut. Whereas now NHS representatives need to re-engage, open doors and think about the broader benefits of working together with the pharmaceutical industry towards joint goals. It’s really important that both sides build allegiances and forget past animosities. Ultimately this will benefit everyone.

Do the ‘different’ motivations of the public and private sector make gelling difficult?

There is an incorrect perception that, because pharma makes money, someone else has lost. We must remember that if people have their lives extended due to better treatment then NHS, industry and wider society has won. Recently Helen Bevan, NHS Director for Transformation, said both industries have been very target driven in the last 15 years and, consequently, the humanity factor has eroded. Healthcare professionals on the frontline have been too busy with waiting lists and reductions, while sales reps have been under enormous pressure to shift products and been too focussed on sales. Patient cases have become about performance measurement rather than health outcome, or quality of experience. Clearly there needs to be a radical change in priorities.

What can big pharma do to engender trust?

Their approach can be ill-informed sometimes. Often they think they know the NHS, but actually they need to fully appreciate the complexities of what is an ever-evolving beast. Companies need to consider who they make responsible to forge vital connections and forming sustainable relationships. They regularly send an under-qualified person, who might have the enthusiasm, but not the authority. With joint working one of the big issues has been compliance and, often, the pharma representative at the table can’t actually make a decision about whether a company can work in a certain way. This is one of the areas we are really trying to help with.

How should they alter their approach?

If pharma goes in simply looking for a market share increase, they’ll get figured out straight away. Representatives of the big companies need to prove that they genuinely want to improve a health economy or health outcome, before profits. These are the aspects that make the whole system better, and ultimately everyone wins. The CCGs want more people appropriately treated and that means less hospital admissions and, in turn, more financial resources will be available for commissioning. In this respect pharma needs to look at the bigger picture. Remember, every service that the NHS uses is a business – from nurses to bed sheets – but because of the fractious history, the NHS is suspicious about pharma making money. When they do engage the NHS needs to feel like pharma is an integrated and credible part of the solution, as opposed to a procured service. It’s a fine balancing act.

What are the priorities when it comes to galvanising joint working?

Since joint working was outlined as part of NHS reform we have been keen to establish how it can be improved. A policy working group in 2007 carried out some market research and they came up with some recommendations. The two major areas of focus, on our side, were the issuing of guidance – clear definitions of how the NHS works - and the language that should be used. This is a refreshingly concise 11 page document. We also addressed the practical side by combining with the ABPI to launch the, ‘Joint Working tool kit’. It’s an interactive quick-start guide, which includes exactly what the NHS’s definition of joint working is, essential templates and a versatile project management tool. Above all, it avoids jargon and allows people to understand what is required straight away. This has been endorsed by NICE, the NHS Alliance and Confederation among others. We will be looking again at how we can update these documents and make them more practical in the ‘new world’ and also partnering with industry [through the ABPI] and the NHS to review and revitalise both these tools.

Are you optimistic about fruitful partnerships?

Joint working will continue to be an important focus and a part of my day job. QiPP came and went, so we had to hold fire for a while, but now Innovation Health and Wealth (IHW) has provided a restructure, we are pretty sure of what is happening; six months ago we sat down and established that the shift of power is moving to CCGs. Now individual CCGs. Director of Partnerships, Ivan Ellul is particularly keen on localised, dynamic relationships and Mike Farrar is also a champion. Ian Carruthers is the NHS England lead for IHW and is also keen to encourage this type of engagement.

Do you feel that the tide is turning already?

I’m resolutely positive about changes within the NHS. I’ve had heated discussions with clinicians and pharma about joint working, because a lot of them see it as more rhetoric. Some companies, however, are hugely proactive and want to be pioneers of change. GSK are a good example. They’ve shifted their entire salesforce to encourage new ways of working with NHS counterparts. Their leader, Andrew Witty, is passionate about successfully transforming approaches and he’s someone you can believe in, because GSK have freed up patents, conformed to the ‘alltrials’ ideology and shared data. This has filtered down to the way they engage with the NHS and the company have been very smart, as they realise it’s about increasing the whole market. If a healthcare pathway improves it will produce better diagnosis, and better diagnosis means more appropriate and timely use of medicines.

Well said, thanks Naima!

The new statutory regulations for CCG commissioning will mean that lawyers can overrule clinicians, doctors and legal experts have warned.

While a debate and vote on the new regulations in the House of Lords are scheduled for 24 April, campaigners have warned that they will lead inevitably to a full privatisation of the NHS.

Explicitly intended to ensure that CCGs obey the principles of the Health and Social Care Act, the new regulations make it possible for private providers to challenge commissioning decisions on the basis of business law.

The Department of Health, which revised the regulations following protests from the medical professions, insists that CCGs will have the authority to decide which services are put out to tender.

However, legal experts have stated that the decisions of CCGs will be vulnerable to legal challenges from private providers, since the ‘any qualified provider’ concept places commissioning within a business law framework.

Lord Hunt (pictured), Deputy Leader of the Opposition in the House of Lords, has tabled a ‘fatal motion’ against the new commissioning regulations that could temporarily block its passage into law.

Crossbench peer Lord Owen accused the Government of using “specious grounds of urgency” to drive through legislation that contradicts its own principle of ensuring ‘clinically led commissioning’.

According to Dr Kambiz Boomla, a GP in East London, “These regulations are likely to be the death of clinically led commissioning, and the birth of lawyer led commissioning.”

Clare Gerada, Chair of the Royal College of GPs, similarly warned that the new regulations will “remove the legal framework” for a “universal” and “democratically accountable” NHS.

More than half of GPs see accusations of conflicting interests as the greatest danger of the new CCG system.

A survey of more than 1,000 GPs and practice managers by medical indemnity provider the Medical Protection Society (MPS) revealed that 59% were afraid of losing patient trust through their role in the new NHS.

The survey indicates that the new regulations enforcing competition in CCG commissioning are unpopular with the majority of GPs, who see a threat to the doctor-patient relationship.

MPS warned that without “clear and robust governance structures and processes” within CCGs to deal “openly” with perceived conflicts of interest, public confidence in the new NHS could be eroded.

Dr Richard Stacey, Editor of the new WPS journal Practice Matters, said: “MPS has always had concerns that CCGs could place GPs in a potentially challenging position of being not just the patient advocate but also the budget holder, and we believe this leaves GPs vulnerable to accusations of conflicting interests. This survey not only confirms MPS’s fears but those of GPs and practice managers.”

Responding to the survey findings, Dr Mark Porter, Chair of the BMA Council, commented: “The BMA believes that any GP who has financial interests in a private sector company that might be awarded contracts in their area should consider seriously whether they should be a member of a (CCG) governing body.”

He added that the economic pressures facing the NHS will threaten patient and public confidence in GPs, as they will come to be seen as rationers rather than providers of services: “Ministers must ensure that CCGs have an appropriate level of resources so that they can meet the needs of their patients.”

The new NHS structure came into force on 1 April, with local commissioning now entrusted to clinical commissioning groups (CCGs) that combine business and clinical expertise.

The CCGs are managed by NHS England (formerly the NHS Commissioning Board) and governed by new laws that enforce a ‘level playing field’ for provider competition.

The 152 Primary Care Trusts are now abolished, and all NHS hospital trusts are required to qualify for Foundation Trust status within the next year.

NICE, renamed the National Institute for Health and Care Excellence, will set standards for both health and social care services, promoting integrated care.

The statutory role of CCGs in facilitating competition between providers of NHS services has polarised opinion, with only a third of GPs in a Pulse survey saying they felt empowered by the new system.

According to private health analysts Laing and Buisson, the NHS in England spent 11% more on services from private providers in 2012 than in 2011 – a clear sign that the provider base is already shifting.

Professor David Haslam, the new Chairman of NICE, commented: “It is a time of huge risk. We know in medical care in hospital that the greatest risk is when patients are being handed over from one person to another. It is a risky time for the system, so it is important that the big players work together.”

Mike Farrar (pictured), Chief Executive of the NHS Confederation and a long-time champion of community-based healthcare, warned that trying to improve patient safety while reducing costs would place great pressure on the new NHS.

“We need to recognise the huge challenges facing the health service,” he said. “New structures alone won’t enable us to tackle these challenges, and we should not see them as a silver bullet.”

With the NHS in flux, there has never been a better time for joint working – but pharma might need some help to negotiate the new relationships. Pf looks at the key role of third parties in bringing industry and the NHS together.

Pharmaceutical companies in the UK might be forgiven for wondering if this is really the right time to engage in joint working (JW) projects with the NHS. There seem to be a few questions in the air. What is the NHS now? Who is making decisions there? What are the real priorities? Going into partnership with the NHS might seem like dating someone with too many unresolved ‘issues’ for it to stand much chance.

However, if you keep your nerve, there has never been a better time for JW. The combination of profound structural change and austerity budgeting means that the NHS badly needs support – and the need for healthcare to shift its focus from acute to chronic illness means that the right ways to transform the care pathway are at a premium. Suddenly that mythical bird of business transactions, the win-win, has to be real.

But the opportunities for partnership are highlighting the culture gap between pharma and the NHS. Meeting on the internet and getting married on the run may be romantic, but it won’t lead to a sustainable relationship. The partners need to learn each other’s language, meet each other’s family. This is where mediators and consultants can really make a difference by providing expertise and experience.

Pf talked to two companies that are actively involved in guiding and building JW relationships – one as a facilitator, the other as an active participant. Three common points emerged from their perspectives:

1. The major changes in healthcare in the UK are creating opportunities for pharmaceutical companies to work in partnership with CCGs, local authorities and providers.

2. The payoff for the pharma company is in terms of better medicines management, leading to the company’s products being used more widely and effectively.

3. Realistic mutual understanding is critical for JW – no amount of rhetoric about values and beliefs will help unless there are shared objectives and ways of working.

Embracing the unknown

Chris Morgan of ZS Associates argues that JW does not come easily to either side: “A true appreciation of the value of partnership is still fairly rare, within both pharma and the NHS.” For years, ZS Associates has emphasised the critical importance of key account management for pharma. The current NHS reforms and the development of the JW agenda have strengthened this argument and underlined the consultancy’s role as a thought leader for pharmaceutical sales and management.

“The established relationship between pharma and the NHS can be pretty toxic,” Morgan says. “ There isn’t a whole lot of trust established there. Before we can partner, we have to earn that trust.” He gives the example of a company ZS worked with that had spent six months piloting a new service idea with a PCT. “The PCT loved it, it worked well for the company, the patients loved it – and then they packaged it up and gave it to all their other account execs to sell, and a year later they had sold none.”

Why was that? “The first time they sold it, they thought they were developing a service – but what they were actually developing over six months was the trust required for the customer to buy that service. Then, when they showed up to every other PCT subsequently, the response was ‘Who the hell are you?’”

Too often in pharma, ‘trust’ is interpreted as meaning ‘goodwill’. That might work when the culture is the same on both sides, but between pharma and the NHS it won’t hold. Morgan explains that without clear mutual understanding “it’s not clear who is living up to their end of the deal, and it’s not even clear to you whether you’re living up to what the other person perceives as being your end of the deal.”

In addition, he argues, “those circumstances for partnership where it’s clear that everyone has something to gain end up being easier to defend, and more ethical, than those JW situations where there’s no apparent gain for the pharma company.” If a company sponsors an initiative in a therapy area where it has no products, two questions arise: does the company have the expertise needed, and what are its motives? JW has to be about “genuine mutual interest”. Quid pro quo agreements are not only non-compliant, but make no business sense: “I can sell you £10 notes for a fiver all day. There is no rational economic reason why you should reciprocate to a value greater than what I’ve just given you.” JW has to generate value, to the objective benefit of both sides.

Another key issue is defining who the customer is, and here Morgan illustrates the value of the KAM approach. “Too often we try and define the customer as being the doctor, the patient or the payer – but the only time you find genuine mutual value is when you think about all three stakeholders together.” Pharma companies need to involve providers as well as commissioners in JW projects, since the most successful providers “are actively going out and engaging with commissioners” to redesign care pathways – and thus are already on the JW road.

The best JW projects, Morgan says, often involve “care pathway re-engineering”. An area ripe for partnership is diabetes care, as its problems are well-known: poor service integration, poor medication compliance, high levels of complications. The JW opportunity is for the pharma company to help commissioners and providers improve care by improving diagnosis, monitoring or compliance, thereby reducing complications and hospital admissions. “The pharma company benefits as well because its product is used earlier, more persistently or in a larger or more appropriate group of patients.” The win-win is not only real, it is flying.

A time of change

Karen Bell, Business Manager at Ashfield In2Focus, argues that a window of opportunity exists now for pharma in terms of JW, and that there’s no time to waste. Ashfield In2Focus provides a range of services to pharmaceutical companies to help them develop and implement JW relationships with the NHS. Most importantly, it provides quality healthcare development managers (HDMs) and key account managers (KAMs), many of whom have NHS backgrounds, to mediate between the two sides and facilitate the process.

There are three reasons why this is a crucial time for JW, Bell explains. Firstly, the drive towards more patient-centred care, the QIPP agenda and the increasing role of private provider competition are all making the NHS engage with industry in new ways. Secondly, the Department of Health and ABPI guidance around JW have made the NHS “less nervous about working with industry and more open to win-win types of partnership”. Thirdly, its new emphasis on innovation has made the NHS more aware of its weaknesses in that area, and more ready to involve people with different experience.

The focus of JW projects is closely linked to the NHS’ need for increased patient throughput, especially in primary and community-based healthcare. “Typically the JW projects which we tend to see succeeding are in CHD, diabetes, women’s health, mental health – really any long-term condition, and also where there’s a drive to keep patients out of hospital” – while “for the sponsoring pharma company it means more patients going into the total patient pool for their product”.

However, the current business climate does not reward risks. Aren’t those pharma companies who decide to wait until things settle down being sensible? Bell’s response is emphatic: “They’ll miss the boat. Because we are now in a time of change or flux, with innovation and efficiency high on the agenda, the NHS is very open to hearing about and indeed engaging in new ways of doing things. Those pharmaceutical companies who go out there and talk about these initiatives now, and those NHS organisations who engage with them, will be the ones who will capitalise in the longer term.”

Even so, why is a mediator needed – isn’t that one partner too many? Bell argues that as a service provider already working with the NHS and industry, Ashfield In2Focus is a key link between the two cultures. It provides experience of working on both sides and knowledge of the regulations around the provision of NHS services. Any service it provides is backed up with the necessary documentation to “protect the NHS, the patient and the pharmaceutical company”.

In addition, Bell argues, Ashfield In2Focus is well placed to bridge the culture gap between the NHS and pharma: “When our HDM teams talk to an NHS customer, they can often be having a peer to peer conversation, and that facilitates the whole partnership process, building engagement, mutual understanding and trust from the start. As many of them have come from that background (we employ a number of ex-commissioners or Department of Health personnel), they understand the world of the NHS, and they can more effectively identify and implement a solution.”

JW projects require the right people to engage with “the new NHS stakeholders” and “to develop and carry through these initiatives and make them sustainable”.  They also need to be able to influence local authorities and Health and Wellbeing Boards, and to “talk coherently around the joint strategic needs assessment process”.

In classical mythology, Hermes was the messenger between worlds. Bell uses a similar image: “People sometimes see our staff as being one step removed from pharma – working for us on behalf of a pharmaceutical company, but not directly for them. Our nursing services are a perfect example of this.” In addition, she says, Ashfield In2Focus attracts and recruits quality personnel for these roles, through its vast database and network of contacts, by offering a permanent contract of employment to potential employees in uncertain times – reafirming the value of the third-party role for pharma and the NHS.

A health expert has predicted that the failings of CCGs will see them replaced after only two years by a more effective system of commissioning healthcare services.

Kieran Walshe, Professor of Health Policy Management at Manchester Business School, told the BBC 4’s Today programme that there are no real benefits to GP-led commissioning and accused the Government of being obsessed with this approach.

“This is the most recent version of GP-led commissioning,” he said. “None of them have worked very well. The research suggests there aren’t really great benefits in GP-led commissioning, so why this Government is embarking upon essentially doing the same thing is very hard to follow.”

Professor Walshe said the UK should follow the commissioning models adopted across Europe to get better value for money. He claimed that larger organisations instead of smaller commissioning groups are in a better position to leverage better deals for patients.

“GP commissioning groups are smaller than the old PCTs and are going to be like ‘corner shop commissioners’ – who gets better value for money? A corner shop or a supermarket?” he said.

“The change in all of this which is really interesting is the creation of the NHS Commissioning Board and its local area teams. That’s commissioning at scale. They’re going to be dealing with around 40% of the budget and they will be the driving force in this. In two years’ time I suspect we’ll be back sitting around a table saying ‘CCGs haven’t worked. What shall we put in their place?’ But the scale of commissioning by the NHS Commissioning Board may have some future.”

Dr Michael Dixon, NHS Alliance Chair and acting president NHS Clinical Commissioners, argued that Professor Walsh’s prediction was inaccurate and GP-led commissioning will see improved standards of care. “The benefits [of CCGs] are that doctors and nurses that actually see patients make the decisions as to what needs to happen,” he said.

“The Nuffield Trust report showed only last week that money continues to go into hospitals and not into primary care services. What we need to do is to turn that around.”

The NHS CB has completed its authorisation process for the 211 CCGs across England after finalising the fourth and final wave of commissioning groups.

The remaining 48 CCGs in wave four have been authorised by the Board’s assessment experts, meaning all commissioning groups are ready to take on their new responsibilities from 1 April 2013.

Dame Barbara Hakin, NHS Commissioning Board National Director: Commissioning Development, called the completion of the assessment process a “tremendous achievement”.

In total, 43 CCGs were fully authorised after they met all of 199 criteria set by the Commissioning Board. A further 168 groups were authorised with conditions, after issues were raised with certain elements of their development. Fifteen CCGs were also issued legal directions after serious concerns were raised. These CCGs will be given additional support by the NHS CB and by neighbouring CCGs to assist their development.

Commissioning groups in the first three waves of the process which were authorised with conditions will be re-assessed by the NHS CB at the end of March to check on their progress since their initial assessment. CCGs in the final wave will be reviewed in June 2013.

“CCGs are a vital foundation of a new, clinically-led NHS that is focused on delivering improved health outcomes, quality, patient safety, innovation and public participation,” said Dame Barbara Hakin.

“CCGs will have wide-ranging responsibilities with regard to patient safety and will manage very large budgets, so it is vital that they are robust and capable of making important decisions. The NHS Commissioning Board has a duty to ensure CCGs have made arrangements to deliver their responsibilities, and we take that duty very seriously.”

The Government has revised its proposed regulations governing competition between NHS providers, following widespread protest from doctors.

The regulations, published a month ago, were criticised as removing the right of clinical commissioners to make decisions based on patient interests rather than the business rights of competing providers.

The amended version broadens the freedom of commissioners, stating that “integration” and “quality” are both valid reasons for not putting a service out to competitive tender.

However, the Royal College of General Practitioners (RCGP) has expressed concern that the new regulations, by virtue of their statutory nature, are imposing too many conditions on commissioners.

The aim of the new regulations was stated by the Government to be a replacement for the Secretary of State control abolished by the NHS reforms. In other words, having emphasised the “autonomy” of the new CCGs, the Government is imposing strict controls to defend the interests of the private sector.

The original secondary legislation, published in February, appeared to create a legal basis for the forced tendering of nearly all NHS services, enforced by Monitor.

A letter to the Daily Telegraph signed by more than 1,000 doctors urged MPs to force a debate on the new regulations, while the Academy of Medical Royal Colleges expressed concern that services would be disrupted by legal disputes.

Health Minister Lord Howe said: “It has never been and is absolutely not the Government’s intention to make all NHS services subject to competitive tendering or to force competition for services.”

New amendments to the regulations include:

• Commissioners are required to record how their decisions support the integration of services.

• Exceptions to competitive tendering include cases where avoiding competition leads to better quality or integration of services.

• Monitor no longer has the power to enforce competitive tendering.

The underlying purpose remains the same: to protect “patient choice” by ensuring that NHS commissioners have to put services out to tender unless they can justify not doing so in terms of better clinical outcomes.

The publication of the new secondary legislation coincides with that of a BMJ study stating that 40% of CCG board members have financial ties to private healthcare providers.

Clare Gerada, Chair of the RCGP, commented: “The revised regulations do not go far enough in ensuring that commissioners are genuinely free to decide whether or not to expose services to competition. Despite the revisions, they will still be required to show that there is only one capable provider in order to avoid having to put a service out to tender.”