About this handbook

Signatories to this handbook

We have developed this handbook in partnership with the following organisations:

Who is this handbook for?

This handbook is aimed at organisations which employ, contract or oversee the practice of doctors in the UK. In the majority of cases these organisations will also be designated bodies (DBs). It is also relevant for healthcare providers in the crown dependencies and suitable persons.

In particular, the handbook is designed for those individuals or groups of individuals who play an important leadership role in delivering and assuring the quality of clinical governance processes for doctors. In most cases this will be the board or governing body of an organisation but it may also include owners of private organisations and, in some circumstances, individual doctors. Those involved in managing and delivering clinical governance will also find the handbook a useful resource.  

For ease of reference the handbook will use the terms ‘organisation’ and ‘board’ when referring to individuals or groups of individuals responsible for leading in the delivery and assurance of clinical governance processes in an organisation. In addition when we refer to patients we do so in the broadest sense. This includes, for example, service users, customers and clients.

What is its purpose?

It aims to provide boards with a description of the core principles underpinning effective clinical governance for doctors focussing particularly on responsibilities outlined in the Responsible Officer (RO) regulations. In doing so it acts as a resource to support organisations in evaluating the effectiveness of their local arrangements including:

  • Leadership, delivery and quality of clinical governance for doctors
  • Medical revalidation
  • Identifying and responding to concerns about doctors
  • Pre-employment checks for doctors (The RO Regulations only impose obligations in respect of pre-employment checks on responsible officers in England; Reg. 16(2) Medical Profession (Responsible Officers) Regulations 2010.)

Responsibilities for and delivery of various aspects of clinical governance for doctors are different across the UK, sectors and type of organisation. They are also dependent on whether an organisation acts at a national or local level. For this reason the handbook may require a certain level of interpretation by organisations to ensure they maximise its benefits. It should also be used in conjunction with other relevant clinical governance guidance.

There is no specific requirement to report against the handbook but organisations may find it useful to record, alongside other relevant standards and guidance, how it has been used in practice, when preparing for future inspection and internal audit work. It may also be used as an aid to annual board reporting.