Working with doctors Working for patients

Information from governance systems, and information transfer

This page is in Section 2: Making a revalidation recommendation- part of the GMC's guide for Responsible Officers and Suitable Persons on making revalidation recommendations.

2.4 Information from clinical and corporate governance

2.4.1 The role of governance information

A doctor’s supporting information and participation in appraisal or assessment are important sources of information for your recommendation. You also need to take account of other relevant information available to you from the clinical and corporate governance systems in which the doctor works. This would be particularly relevant for any information arising from locum practice.

You should have regard for information generated by local processes that provides robust evidence for your recommendation judgement. These processes may include but are not limited to:

  • investigations into serious incidents
  • disciplinary or other human resources processes
  • processes that address a doctor’s non-engagement with revalidation
  • remediation programmes in which a doctor has participated

To make an informed recommendation, you may need to consider the outcome of an ongoing or recently concluded process. In this instance you should consult the GMC’s criteria for recommendations to defer (see Section 4).

In partnership with systems regulators and quality improvement bodies across the UK, we have developed a handbook to help the boards and governing bodies of healthcare providers understand their responsibility to monitor the effectiveness of organisational systems supporting quality care for patients and the revalidation of doctors. The handbook includes a checklist to support sound governance in this area.

Information for the purposes of revalidation

You must base your judgement only on information which is material to your evaluation of the doctor’s fitness to practise, and which gives you evidence on which to recommend whether their licence to practise should be continued.

Revalidation is not a mechanism for resolving local employment or contractual disputes. It does not replace existing mechanisms for dealing with such issues.

2.4.2 Sharing information between organisations

As an RO, you are responsible for ensuring that robust systems of clinical governance exist within your designated body or bodies. You will have access to a range of information from clinical and corporate governance systems including:

  • serious incidents
  • fitness to practise issues
  • time out of practice
  • remediation processes.

You should consider relevant information held by other organisations, or share information with other organisations, about a doctor’s revalidation. You should establish and participate in active and reliable arrangements for timely information-sharing with other organisations, building on RO networking.

The importance of information transfer

As revalidation is based on an evaluation of the whole of a doctor’s practice, designated bodies and ROs may need to obtain governance information from a range of sources. These include but are not limited to:

  • locum work, including where the doctor undertakes this kind of work as one part of their practice
  • voluntary work
  • private practice
  • NHS organisations.

Facilitating the transfer of information from separate systems of clinical and corporate governance will allow doctors to collect and reflect on information drawn from the whole of their practice.

Effective systems of information transfer will enable organisations to:

  • collate information about a doctor’s revalidation
  • transfer information to a doctor’s designated body, and
  • help ROs to ensure that they can consider all available information when making a recommendation.

Designated bodies and ROs will need to ensure that information is exchanged appropriately between organisations. Clearly, consideration should be given to data protection and freedom of information legislation and relevant GMC guidance, including Leadership and management for all doctors and Confidentiality. However the overriding imperative of patient protection should be the key driver in this area.

Under regulation 11(1)(f) of the RO regulations, you are required to maintain records of practitioners’ fitness to practise evaluations, including appraisals and any other investigations or assessments. There is no absolute requirement for information about doctors’ revalidation to be retained or disposed of beyond a particular point, but it should be kept only for as long as it remains relevant. You may wish to consider establishing retention periods in line with the principles of the Data Protection Act (1998).