Corruption is “the abuse of power or position to acquire a personal benefit.” For individual doctors corrupt behaviour would include ordering unnecessary tests, prescribing irrelevant medication, or performing unwarranted operations in order to make money. Such corruption may be commonplace in many countries where doctors charge patients real money for their services. Surely such things would never happen here in our dear old NHS—would they?

But perhaps the NHS is prone to another sort of corruption that operates not at the level of the individual professional but at the level of the organisation? Corruption then becomes “the abuse of power or position to acquire an organisational benefit.” Suddenly Mid Staffs and Morecambe Bay come sharply into focus. Clearly there are teams, departments and institutions within our beloved NHS that do abuse their bestowed power in order to further their own ends over and above those of patients.

The problem is that the roots of this organisational corruption lie in legitimate behaviors that are required for the system to operate: Trusts need to manage their finances which can mean reducing levels of care, CCGs need to manage resources across their whole population which can legitimate favoring some patients over others. All healthcare organisations and economies broker compromise solutions to satisfy these pressures and most of the time do this with honor and integrity. But not always. Sometimes the system settles at a point where the patient’s interests are systematically and knowingly under-valued in order to meet corporate pressures. It is at this point that it becomes meaningful to talk about institutionalised corruption.

All corruption in healthcare arises in the gap between what the patient needs and what the clinician, team, or organisation wants. This gap is an example of a “principal-agent” problem. These occur whenever “one person or entity (the ‘agent’) is able to make decisions that impact, or on behalf of, another person or entity: the ‘principal’. The dilemma exists because sometimes the agent is motivated to act in his own best interests rather than those of the principal.” So GPs who decide to spend time gathering data to meet smoking, alcohol, or other payment-linked targets rather than listening to the patient have a potential principle-agent problem. And patients held in ambulances to help the hospital manage its four hour A&E target experience the helplessness that lack of agency brings.

Principal-agent problems are inherent in all health settings because the system (the agent) almost always has more information, power, and resources than the patient (the principal) and is often trying to balance requirements that may be peripheral to the patient’s immediate interests. Managing the resulting dilemmas is arguably part of what mature professional behaviour is about.

But decades of well-meaning rhetoric about “putting the patient at the centre of care” show that when managerial push comes to financial shove, corporate and professional agendas often win the day.

If patients are going to be powerful enough as principals to be able to stop their healthcare providers settling on systematically corrupt practices then three conditions have to be met. First patients must have some real power. This means they have to be able influence how significant amounts of real money is being spent. Second that power has to be exercised away from the sick bed—expecting patients to speak truth to power whilst in their pyjamas is foolish. Finally any agency exercised by patients’ needs to operate within the context of limited resources. Not all care will be possible and other patients with other conditions have equally legitimate demands on those resources.

One way to achieve these aims would be to give the power to commission care for a particular disease to the relevant patient organisation. Within the current English NHS for example a group of Clinical Commissioning Groups (CCGs) could ask a patient organisation to work with them to commission care pathways for, say, rheumatoid arthritis. The total cost of the care would be defined at the outset to prevent patient organisations ordering up gold-plated care. Patient organisations would receive a small percentage of a condition-specific tariff as “Visa fee” type payment to cover their costs. And working with the CCGs the patient organisation could contact and consult all patients likely to receive the care they commissioned. Patients could further enhance their agency by using the Friends and Family test or platforms like Patient Opinion to confirm whether or not they had received the levels of care specified by commissioners.

There is a tendency in all healthcare systems for legitimate—and less legitimate—corporate and professional goals to become more important than the patients’ needs. At times these pressures will drive some hospitals, wards, and teams to settle on behaviors that are corrupt—i.e. that consistently abuse patients in order to gain organisational benefits. Increasing patient agency at the collective rather than the individual level is one possible way to exert systematic counter-pressure in favour of patients. Recruiting patient organisations to this role could be a systematic answer to healthcare’s perennial principal-agent problem and help reduce the sporadic occurrence of institutional corruption that afflicts all healthcare systems.

An expanded version of how patient organisations could commission care can be found at www.21stCenturyMedicine.org

Paul Hodgkin worked in general practice until 2011 and in 2005 founded Patient Opinion, a not-for-profit website where patients, service users, carers, and staff can share their stories of care across the UK. In the past he has been a regional lead for Choose and Book, a PCT cancer lead and PEC member, and a member of the Future Forum. Paul has written for The BMJ, British Journal of General Practice, DigitalHealth.net, the Guardian, and the Independent. The Health Service Journal identified him as one of 50 top Innovators in the NHS (2013) and as one of the 50 top clinical leaders in the NHS (2014).

Declaration of competing interests:

• I was CEO and then Chair of Patient Opinion until March 2015.
• I am a trustee of Asthma UK.
• Patient Opinion has been paid a variety of speaker fees for my services over the years. On average this probably amounts to <£3000 per year from > 10 different parties. In my view none constitutes any serious compromise. They don’t include any payments from pharma companies, IT suppliers or medical devices manufacturers.
• I have sat on a wide variety of policy groups at Department of Health and NHS England. None of these were paid.