The GMC protocol for making revalidation recommendations

Introduction

1.1 Your role in revalidation

1.1.1 Connections

You can only make recommendations for doctors you have a connection to.

For ROs, this means doctors that have a prescribed connection to your designated body. The RO Regulations, published by the Department of Health (England) and the Department of Health (Northern Ireland), clearly determine which designated body a doctor has a prescribed connection to. This means:

  • Doctors cannot choose which RO to connect to
  • ROs cannot choose whether to connect to a doctor.

For more information on prescribed connections, please refer to the RO Regulations and accompanying guidance published by the Department of Health (England) for England, Scotland and Wales, and the Department of Health (Northern Ireland) for Northern Ireland. We also have an online connection tool.

For suitable persons, connected doctor(s) are those you have formally agreed with us. More information on the requirements for becoming a suitable person can be found on our website.

1.1.2 Recommendations

There are three types of revalidation recommendations you can make:

  • Recommendation to revalidate
  • Recommendation to defer
  • Recommendation of non-engagement

1.1.3 Your duties when making recommendations

We make a decision about a doctor’s revalidation, based on your recommendations and any other relevant information we hold.  You are responsible for:

  • maintaining an accurate list of the doctors connected to you 
  • checking that the doctors you’re responsible for are regularly appraised on their whole practice
  • discussing reasons for your recommendation with the doctor before it is submitted, particularly for a recommendation to defer or of non-engagement
  • correctly submitting a recommendation on or before the doctor’s revalidation date 
  • all recommendations made in your name (even if someone else submits them on your behalf) 
  • maintaining records of how you decide which recommendation to make 
  • promptly confirming to the doctor the recommendation you have made about them.

To make recommendations that are fair, consistent and reliable you must:

  • apply the criteria for each type of recommendation and understand the statements you must confirm when making your recommendation. The statements can be found on our website
  • consider information about the doctor’s whole practice, from all settings and roles in which they provide medical services, including:
    • the outcomes of a doctor’s appraisals 
    • the completeness and quality of the doctor’s supporting information and their reflections on it
    • information from clinical and corporate governance systems to seek assurance about their fitness to practise
  • ensure arrangements exist with other relevant organisations or persons, to access the information across whole scope of practice for the doctors you are responsible for 
  • contact your ELA if you:
    • need advice to help you reach a judgement
    • plan to make a recommendation of non-engagement, or a second consecutive recommendation to defer
    • are aware that a doctor has raised a public interest concern and you are considering a recommendation of non-engagement or deferral (see section 2.4).

1.2 Other duties of responsible officers and suitable persons

As well as making recommendations, ROs and suitable persons must carry out additional duties outlined below:

Responsible officers1

  • make sure your designated body checks their doctors are completing annual appraisals
  • have effective systems in place which promptly pick up on any fitness to practise (FtP) concerns about your doctors
  • make sure there are adequate processes to investigate FtP concerns about your doctors
  • refer FtP concerns that meet the threshold to us
  • monitor doctors’ compliance with any undertakings we’ve agreed or conditions we’ve put in place
  • maintain records of FtP evaluations, including processes for responding to concerns and other local investigations
  • carry out wider clinical governance responsibilities set out in regulation 16 of the RO Regulations (this applies in England only)
  • regularly participate in local RO network activities

Suitable persons2

  • have effective systems in place which promptly pick up on any FtP concerns about your doctors
  • refer FtP concerns that meet the threshold to us
  • make sure compliance with any undertakings we’ve agreed or conditions we’ve put in place are monitored, and you are alerted to any issues
  • make sure records of FtP evaluations, including processes for responding to concerns and other local investigations, are being maintained
  • regularly participate in local network activities

1.3 The difference between revalidation and raising fitness to practise concerns

Revalidation does not replace or override existing procedures for dealing with concerns about doctors’ fitness to practise:

  • A recommendation should not be used as a way of raising concerns about a doctor’s fitness to practise
  • You should discuss any fitness to practise concerns with your ELA as soon as they arise, who will advise you on fitness to practise thresholds for referral to us.

1.4 Clinical governance and information sharing

As timely sharing of information is an essential component of robust clinical governance, we developed information sharing principles with the support of partner organisations, which can be found on our website.

These principles are designed to support the development of common practice across the UK healthcare system in which information about doctors is shared consistently to ensure patient safety, to support the doctors involved and to promote public confidence. 

Our handbook on effective clinical governance for medical professionals explains more about the role of information sharing and its importance in clinical governance.

1 Regulation 11 and 13 of the RO Regulations and regulation 11 of the RO Regulations (NI).
2 GMC criteria for suitable persons