Working with doctors Working for patients

Section 1: Introduction

1.1 The purpose of the protocol

1.1.1 Who is the protocol for?

Regulation 15(b) of the Medical Profession (Responsible Officer) Regulations 2010 (“the RO regulations”) place a duty on ROs to ‘have regard’ for guidance produced by the General Medical Council (GMC). The GMC has produced this guidance specifically for ROs with this in mind. It focuses on your responsibility to make recommendations on the revalidation of your doctors, under Regulation 11(2)(e) of the RO regulations. We expect all ROs and Suitable Persons to read, and be familiar with, the RO regulations.

The GMC (Licence to Practise and Revalidation) Regulations Order of Council 2012 “(the Licence to practise regulations”) also allow doctors with no prescribed connection to a designated body to identify a ‘Suitable Person’ to make recommendations about them subject to our approval. A Suitable Person carries out the same functions as an RO in respect of making revalidation recommendations. If the GMC approves someone as a Suitable Person, all guidance, instructions and statements for ROs related to making revalidation recommendations apply to them. Therefore wherever we refer to an RO in this protocol this also applies to GMC approved Suitable Persons, unless otherwise stated.

While Suitable Persons are not covered by the RO regulations, we will use the principles of these regulations when we decide whether to approve a Suitable Person or to accept a recommendation from a Suitable Person.

Because this guidance explains how we expect you to fulfil your statutory responsibility it may also be a useful resource for:

  • designated bodies, who are required to support you in your role under Regulation 14 of the RO regulations, and
  • licensed doctors, about whom you make recommendations.

GMC revalidation staff will also refer to this protocol when considering revalidation recommendations that we have received from you, using the GMC decision-making guidance for revalidation .

We expect designated bodies and ROs to operate in compliance with the RO Regulations at all times. In order to support the conduct of our regulatory functions, we use our employer liaison advisers and our work with other regulators to obtain intelligence about compliance of the healthcare system with the RO Regulations and the practice of ROs. We may act on this intelligence at any time, if the integrity of, or confidence in, revalidation could be undermined. This may include halting the processing or acceptance of recommendations from an RO. Further information on quality assurance of recommendations will be published separately.

1.1.2 What the protocol includes

This protocol provides guidance on making fair and reliable recommendations by:

  • describing the three categories of recommendations that you can submit (see 1.3.1 Making a recommendation to revalidate)
  • providing detailed criteria so that you can be confident that you are making recommendations that are consistent, fair and robust
  • outlining the steps that you should take when submitting your recommendations to the GMC.

1.1.3 What the protocol does not include

The protocol is not general guidance about revalidation or the RO role. It focuses solely on your statutory responsibility to evaluate the fitness to practise of your doctors and advise the GMC accordingly through revalidation recommendations (regulations 11 and 13 of the RO regulations).

The protocol explains how revalidation fits within the GMC’s regulatory system. While the following issues are referenced in the protocol they are not explained in detail:

  • the RO role outside of making revalidation recommendations, including the person specification and appointment of ROs (this is described in the RO regulations and accompanying guidance)
  • processes and systems that support revalidation locally
  • guidance on revalidation for individual doctors, employers and patients and the public
  • information about the licence to practise, or GMC registration more widely
  • the GMC’s core functions more generally.

1.2 The purpose of revalidation

Revalidation is the process through which the GMC confirms that a doctor’s licence to practise will continue based on a local evaluation that they remain fit to practise.

It is a GMC process based upon licensed doctors working within governed environments that have, at their core, regular appraisals of their doctors’ practice that embed the values and principles of Good medical practice (GMP).

This local evaluation of a doctor’s practice must include annual appraisals that consider the whole of their practice.

The purpose of revalidation is to provide assurance for patients and the public, employers and other healthcare professionals that licensed doctors are up to date and fit to practise.

You can find background information on revalidation and the relevant legislation in Annex A.