West Midlands performers lists

review framework

May 2010

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West Midlands performers lists review framework

Context

The National Health Service (Performers Lists) Directions 2010 came into effect from
1 April 2010. These directions have been issued to PCTs to review procedures for
managing performers lists (medical, dental and ophthalmic) within three months and
to implement any changes by the end of the financial year 2010-11.

The issuing of the directions follows:

• the national review of the performers list system

• the House of Commons Health Committee report into the use of overseas
doctors in providing out of hours services
• the inquest and death of a patient
• guidance from the Department of Health (DH) on language knowledge for
those performing primary medical services

A list of relevant reference documents is appended at annex A.

Background

The West Midlands NHS Primary Care Commissioning (NHS PCC) steering group
identified training and development in the management of performers lists
management a priority for the West Midlands regional work programme for 2010/11,
at the focus group meeting on March 2010.

As a consequence of this, NHS PCC prepared a planned programme of actions and

events for 2010/11 which included the need to develop a greater understanding
within PCTs relating to:

• the management of primary care performers and contractors lists

• the management of performance concerns involving primary care
practitioners and contractors

Framework document to support the performers lists review process

NHS PCC agreed to develop a framework document to support PCTs with their
review of their procedures for managing performers lists, as set out in the National
Health Service (Performers Lists) Directions 2010, at the management of primary
medical dental, pharmaceutical and ophthalmic practitioners and contractors event
on 12 May 2010.

This framework is a guidance document and should be read in conjunction with the
National Health Service (Performers Lists) Regulations 2004 as amended, and the
National Health Service (Performers Lists) Directions 2010; it is not a substitute for
the regulations. Its aim is to stimulate PCTs’ thinking as part of the review process
and to provide ‘hints in tips’ to ensure that performers lists reviews are sufficiently
robust to meet the requirements of the directions and to meet the requirements as
set out by NHS West Midlands.

NHS PCC commissioned Mike Hillman, Consultancy Services, as the lead author for
the framework. Mike has been supported in the production of the framework by
Marion Todd, PCCM, NHS PCC and Patricia Barnett, Programme Consultant

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Primary Care and PBC, NHS West Midlands. The framework reflects the
contributions from colleagues from West Midlands PCTs and West Midlands shared
services who attended the performers lists event on 12 May 2010.

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 West Midlands performers lists review framework
1. Setting up and managing the review
Action Requirement
Making appropriate The National Health Service (Performers
arrangements for the Lists) Directions 2010 came into effect from
review process 1st April 2010 and directed each PCT to
review its procedures for managing
Performers Lists within what is a fairly tight
timescale [by 1 July 2010] and to implement
any changes by the end of the financial year
2010/11.
PCTs will be performance monitored in
relation to this exercise by the Strategic
Health Authority and it is expected that the
timescales set by the Directions will be met.
Therefore each PCT must meet its
obligations under the Directions and to
ensure this it will be necessary for a
structured approach to be taken and for
robust arrangements to be put in place.
The performance monitoring arrangements
for the West Midlands SHA are set out in a
letter to PCTs dated 23 April 2010 from
Eamonn Kelly and Peter Blythin. If you have
any queries in relation to the contents of this
letter you should contact Patricia Barrett,
Programme Consultant – Primary Care and
PBC on 07875 392965.
Hints and Tips

Set the review up as a specific project and clearly identify who
has overall lead.

Consider whether a project group will be established and if so
what will be its make-up

Set clear terms of reference for the project lead or group

Develop an action plan which clearly identifies who will do what,
by when.

Ensure that the review process covers all current procedures
(written or otherwise) and cross-checks them against the
requirements of the relevant regulations.

Clearly identify any deficiencies within your current
arrangements and any areas of risk for the PCT.

Conclude your review with recommendations for amending the
procedures in order to minimise any identified risks.

Set out a timetable for implementation of the recommendations
and details of how you will review procedures in the future

Once you have completed the exercise you will need to assess
the overall level of risk posed to your PCT by any deficiencies in
your procedures and make a determination as to whether it
warrants being included on your corporate risk register.
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Ensuring the right In order to be effective, the review of
people are involved procedures as required by the 2010
Directions needs to be comprehensive and
should include a full critical analysis of all
component parts.
To achieve this effectiveness the right people
from within the PCT will need to be involved.
Arranging for an As part of the performance management and
external review assurance arrangements for this exercise the
West Midlands Strategic Heath Authority has
asked that, in order to give greater
independence, each PCT should involve an
external body in the review process.
However in its letter dated 21May the SHA

Consider who needs to be involved to ensure that objectivity
within the critical analysis is achieved? Possible people to
involve to achieve this include representatives from:
 Clinical Governance
 Corporate Governance
 Local Representative Committees
 External body (see below)

Consider who needs to be involved to ensure that knowledge
and understanding of all aspects of the current process are
covered? Possible people to involve to achieve this include:
 Those who are involved in the day-to-day management
(including Shared Service staff where this is applicable)
 Professional Advisers
 Responsible Director or Senior Manager
 Representative from any decision-making group, panel or
committee

Where the day-to-day operation of processing applications is
delegated to a Shared Services Agency, the responsibility for
ensuring that procedures are robust remains with the PCT. The
Director or Senior Manager who has overall responsibility within
the PCT must therefore have ownership of the review process
and should be involved.

Identify at an early stage who will be involved as the external
assessor in your review process. Possible options are:
 Internal audit
 Representative ‘expert’ from neighbouring PCT
 Other external ‘expert’

If using someone from another PCT, explore the possibilities of
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 has allowed for a two part process involving
an internal self assessment followed by an
independent review with an extended time
scale. Refer to the letter of 21 May 2010 for
details.
‘buddying’ arrangements with one or more PCT(s) where you
can be involved in one another’s review processes in order to
provide the necessary independent objectivity.

Agree from the outset how the external assessor will be
involved in the process. Will this be a direct involvement [ e.g.
as a member of your project group] or an indirect involvement
[e.g. taking a totally independent overview of your procedures].

Alternatively, you may wish to carry out an initial self-

assessment of your procedures and use the external assessor
in a complementary way to review your findings.

Reporting on the Given the recent events that prompted the
review issue of the Directions, all PCTs should be
working to ensure that they fulfil all of their
responsibilities in relation to the management
of performers lists. Each PCT should be able
to assure itself that optimal arrangements are
in place and the focus for this should be at
the highest levels within the organisation.

As part of the action plan for the review, ensure that a report is
prepared for the PCT Board (or delegated committee), which
summarises the outcome of the review, identifies risk areas and
makes recommendations for amendments to procedures.

The SHA has indicated that it will accept a copy of the Board
report as confirmation that the appropriate action on the review
at this stage has been taken.

Therefore as part of the performance

management and assurance arrangements
for this exercise the West Midlands Strategic
Heath Authority has asked that:

 The findings of the review are reported to

the PCT Board (or delegated committee);
and
 That each PCT confirms, by 30 July 2010,
that the review has been completed, its
findings, implementation plan and
ongoing review arrangements.

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2. Reviewing procedures against regulatory requirements
Action Requirement
Arrangements in The National Health Service (Performers
relation to Lists) Directions 2010 require each Primary
applications for Care Trust to review its procedures for
inclusion on a processing applications and as a minimum
performers list the review must cover arrangements for:
 Verifying the identity of applicants;
 Checking that information provided by, or
in relation to, the applicant in relation to
their application is complete, accurate
and authentic;
 Satisfying itself that the applicant intends
to perform services which those included
on a performers list perform in the
Primary Care Trust’s area; and
 Satisfying itself that the applicant has the
knowledge of English necessary to
perform services which those included on
a performers list perform in that area.
The recent House of Commons Health
Committee report ‘The use of overseas
doctors in providing out–of–hours services’
clearly identified that EU legislation prevents
the GMC both from testing the clinical
competence of EEA qualified doctors who
wish to work in the UK and also prevents
them from systematically testing their
language skills. It concluded therefore that,
given the GMC’s lack of powers, it is vital that
PCTs carry out thorough checks on the
Hints and Tips

The National Health Service (Performers Lists) Regulations
2004 as amended set out the legal requirements for PCTs in
relation to inclusion of a practitioner in a performers list. These
must therefore be the source document that informs the review.

Given the fact that the Regulations are at the heart of the review
process, the first stage should ideally be a comprehensive
cross-referencing exercise between what the Regulations
require you to do and what you are doing. This will enable you
to identify potential deficiencies in your system. You will need to
be mindful of both the generic requirements, which apply to all
applicants and those which apply specifically to one
professional group. The most relevant sections of the
Regulations are as follows:
 Requirements for all applications - regulations 4 to 9
 Specific to applications by medical practitioners –
regulations 23 to 24
 Specific to applications by dental practitioners – regulations
30 to 31
 Specific to applications by ophthalmic practitioners –
regulations 36 to 40

When you have checked that your procedures cover all of the
regulatory requirements, you will need to carry out a critical
assessment of their effectiveness in each area and identify any
weaknesses that could pose a risk for the organisation.

The recent workshop held by PCC in the West Midlands
involved the sharing of ideas of good practice within PCTs. As a
consequence a number of features were identified which you
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clinical and language skills of EEA doctors.
This must be done because it cannot be
assumed that these skills are always what
they should be where a doctor has an
overseas qualification.
In addition to the arrangements set out in the
Directions, there are other requirements
placed on a PCT when it is assessing
applications for inclusion on a performers list.
Whilst it is not a requirement in the 2010
Directions that these arrangements are
reviewed at this stage, good practice would
indicate that they should be incorporated into
the review. This will include procedures for
 Carrying out mandatory fitness-to-practise
checks
 Ensuring that applicants are suitably
qualified and experienced and free from
regulatory sanctions etc.
 Making decisions about whether to
include, conditionally include or refuse
admission to a list
 Deferring decisions
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may wish to consider including in your procedures and which
may be of help to you when assessing risks in your current
arrangements. These are as follows:
 Remember, no practitioner should be admitted to a
performers list unless the PCT is satisfied that he/she has
sufficient knowledge of English to perform the appropriate
primary care services (see regulation 6(2)(b) of the
Performers List Regulations).
 The PCT is also responsible for ensuring that any
practitioner it admits to a performers list has the necessary
clinical skills and experience to perform the appropriate
primary care services.
 The PCT must therefore ensure their assessment of
applications is robust and comprehensive.
 Consider making arrangements for face to face meetings
with applicants. This could be useful in assessing English
language skills and knowledge of the NHS of overseas
practitioners and of the intension of applicants in relation to
providing services in the area. This could be a staged
process, with the first meeting being informal and requiring
the applicant to bring in all documentation personally. If
there are concerns at this stage the applicant could be
invited for a second more formal meeting. Consideration
needs to be given to the seniority of staff involved in such
meetings and to when it would be appropriate to involve
professional advisers
 Before deciding to include an EEA national in the performers
list, consider the sufficiency of the evidence provided with
the application in relation to language competency. If this is
unsatisfactory, ask the applicant to provide further evidence.
 In addition to a UK language test result, you might consider
evidence that a practitioner may have:
o Pursued part of their education in the UK
o Been taught in English in a recognised institution
abroad
o Recently passed language tests or gained

Arrangements in The National Health Service (Performers
relation to Lists) Directions 2010 require each Primary
notifications and Care Trust to review its procedures for
disclosure of notifications and disclosure of information and
information the review must cover:
 Notifying persons and bodies about
applicants and performers in accordance
with regulation 16 of the regulations; and
 Disclosing information about applicants
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certificates from recognised institutions outside the
UK
o Worked in an English speaking country
 Ensure that all references are critically assessed by the
appropriate professional adviser before they are accepted.
 Clinical references will inform the assessment of clinical
competence as will the details of qualifications and career
history provided by the applicant. This should be a critical
assessment as the PCT is required to assure itself that the
applicant is sufficiently qualified and experienced to perform
the appropriate services. An appropriate clinical advisor
should sign-off this part of the process.
 Clearly identify what the escalation arrangements are for all
stages of the assessment process so that everyone dealing
applications understands when and how to raise an alert if
they have any concerns about an application. The
arrangements may vary from PCT to PCT dependent upon
the seniority and experience of staff and each PCT will need
to assess the level of risk within its own organisation.
 Use a process action sheet, which requires completion
when each stage of the assessment has been satisfactorily
concluded. This should include confirmation that all
information provided by the applicant has been verified and
that all mandatory fitness-to-practice checks have been
made.

Regulation 16 sets out quite specifically the persons or bodies
the PCT must notify when it makes a decision in certain
circumstances to refuse to admit a performer, impose conditions
on his inclusion, or remove or suspend him from a list. This is a
statutory requirement and you should therefore ensure that your
procedures are such that they automatically trigger notifications
to all appropriate persons or bodies. You should ensure your
procedures reflect the appropriate regulations and any periodic
amendments in this respect.
 and performers in accordance with
regulation 20 of the Regulations.
Arrangements for The National Health Service (Performers
keeping lists up to Lists) Directions 2010 require each Primary
date Care Trust to review its procedures for
keeping its performers lists up to date.
The review must, in particular, cover
procedures relating to the removal from a
performers list of performers who cannot
demonstrate that they have performed
appropriate services in the PCTs area during
the preceding 12 months.

When seeking to identify practitioners who may not have
performed appropriate services in the PCTs area during the
preceding 12 months it is important to be proactive.

It is also important to remember that any decision to remove a
practitioner on these grounds must be based on evidence, so
this must be gathered as part of your process.

Consider how your procedures might include an ongoing
process to verify whether all practitioners on your list continue to
work in the area. This might, for example, include:
 Contacting any practitioner who is not a named performer
under one of your contracts or agreements on an annual
basis for confirmation of work they have undertaken over the
past 12 months;
 Ensuring that all associated correspondence is sent
recorded delivery, so that evidence is available that the
practitioner has received the request fir information. Where
correspondence is returned undelivered contact could be
made with the appropriate professional body seeking
confirmation of address.
 Including all locum GPs on your list in appraisal
arrangements. Not only is this good practice in relation to
maintaining high quality services, it also enables you to keep
in contact with this group of doctors;

Whilst not a requirement of the Directions, it would be prudent
for the PCT to identify any other instances that would lead to a
list being out-of-date and consider how these might be
addressed.
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Drawing-up, The National Health Service (Performers
amending and Lists) Directions 2010 require each Primary
further reviewing Care Trust that has no written procedures to
procedures draw up procedures at the earliest
opportunity and in any event, by 31 March
2011.
Where a PCT already has written procedures,
but as a consequence of the review

Establish at the outset of your review what written procedures
exist and bring together all associated documentation.

It is possible you have different procedures for different parts of
the process or for different lists (i.e. medical, dental and
ophthalmic). It would be more appropriate to bring everything
together in one document.

Written procedures should be detailed and should enable
anyone to be able to follow your process from start to finish.

required by the Directions has
identified a need to review those procedures,
it must do so at the earliest opportunity and in
any event by 31 March 2011.
The Directions further require PCTs to review
and amend their procedures at regular
intervals and in particular when there are any
amendments to Regulations or further
directions are given by the Secretary of State.

It is also important to ensure that your procedures are fair and
equitable and that the utmost care is taken to avoid any risk of
imposing preferences or prejudices. Unfair discrimination can
occur as a result of prejudice, misconception and stereotyping
which can hinder the proper consideration of an individual’s
skills and ability. Consequently, always seek to ensure that
there is no opportunity within your procedures for discrimination
on any grounds to occur.

Make sure that it is someone’s responsibility for identifying
amendments to Regulations new Directions being issued and
that this triggers any necessary changes to your procedures.

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3. Structure and organisation
Action Requirement
Ensuring adequacy In order that performers lists are managed
and appropriateness effectively, both in terms of dealing with
of staff applications for admission to the list and its
ongoing maintenance, it is important that
PCTs have adequate
administrative/management staff assigned to
the task. Numbers required will obviously
vary from PCT to PCT and it is for each PCT
to assess its own needs dependent upon the
volume of work generated.
It is also important that staff involved in the
associated processes have the necessary
knowledge and skills.
In addition to the administrative/management
staff involved in the process appropriate
Professional Clinical Advisers need to be
available as they play a crucial role in
assessing applications
Hints and Tips

When carrying out the review of procedures, it would be
appropriate to make an assessment of current workload, staffing
levels and the knowledge and skills of those involved, In
assessing the levels of risk to the organisation some of the
issues to look for include:
 Are applications processed within reasonable timescales?
 Is there specialist induction training available for new
recruits?
 Is ongoing update training available for all staff?
 Are all staff fully conversant with the governing Regulations?
 Are all staff fully conversant with local procedures?

Networking arrangements between staff in different PCTs can
provide an invaluable support mechanism, and, given the
current requirements, would be particularly useful in relation to
those staff working on performers lists. The further enhancing of
existing network could usefully be discussed at a future Primary
Care Leads meeting

The experience of those involved in assessing applications
plays a significant part in the effectiveness of the process. This
can only be developed over time. It is a major risk to the
organisation if all the knowledge and experience is invested in
one person. You should also consider your cover arrangements
when those involved are on annual or sick leave.

Professional Advisers for each of the three clinical areas
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Arrangements for It is important that all decisions made by the
decision-making PCT in relation to applications for admission
to a performers list are made in accordance
with the appropriate Regulations.
Every effort needs to be made to ensure that
any decision taken by the PCT is procedurally
robust and is likely to be held to be lawful if it
Even in the case of routine approval of applications you should
comes under judicial scrutiny.
Decision-making processes must therefore
be clearly defined and understood by all.
Use of standardised In order to ensure a consistency of approach
documentation for each application and the subsequent
assessment process it is advisable to have a
suite of standard forms.
(medical, dental and ophthalmic) should be available to support
the application assessment process? They should be fully
conversant with the requirements of the Regulations in relation
to assessing applications and should be able to allocate
sufficient time to the process so as not to hold it up.

Consider carefully who will have authority for making decisions
at each stage of the process.

Many PCTs use a formal sub-committee of the Board to make
all decisions other than those that are routine and this is
something you may wish to consider.
consider the seniority of staff making the decision and
determine levels of risk involved.

Once you have decided who will make what decisions, a formal
scheme of delegation should be drawn up and approved by the
Board or other appropriate committee. The scheme of
delegation should clearly set out the limits of the decision-
making powers of each individual or group.

When setting-up your decision-making arrangements you also
need to be mindful of timescales and ensure that applications
are not unduly delayed.

Where a sub-committee of the Board or other group is being
given decision-making powers you should ensure that they have
appropriate training.

Each PCT should ideally have standard forms which include:
 Covering letter with the application pack explaining the
process etc to a potential applicant
13

It is also important that a documentary trail is
available as evidence to substantiate each
decision a PCT makes in relation to
admittance to a performers list. This is as
equally important in cases where applications
are either refused or approved. The used of
standardised documentation would help
facilitate this requirement.
 The application form
 Proformas for clinical references
 Checklist to facilitate and record the carrying out of
reference and information checks etc

The national review of performers list arrangements
recommends that a national suite of standard forms be
developed and this will probably be developed in time. In the
meantime there appears to be interest within the West Midlands
area for developing something locally. PCC is happy to facilitate
this process and will contact PCTs shortly to make appropriate
arrangements.
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 Annex A

West Midlands performers lists review framework

Reference documents

Consolidated Performers Lists Regulations May 2008

http://www.pcc.nhs.uk/uploads/Optometry/May%2008/consolodated_performers_list_regs_may0
8.pdf

National Health Service (Performers Lists) Directions 2010

http://www.dh.gov.uk/en/Publicationsandstatistics/Legislation/Directionsfromthesecretaryofstate/D
H_114482

Tackling Concerns Locally

http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Managingyourorganisation/Workfo
rce/Professionalstandards/ProfessionalRegulationandPatientSafetyProgramme/TacklingConcern
sLocally/index.htm

Delivering Quality in Primary Care: Performers Lists - Language Knowledge

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/D
H_111901

Primary medical performers lists: delivering quality in primary care - advice for primary care trusts
on list management

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/D
H_4087622

Delivering quality in primary care - Primary care trust management of primary care practitioners'
lists: general dental practitioners

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/D
H_4006595

Guidance for primary care trusts on general ophthalmic services contracts

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/D
H_084741

Care Quality Commission interim statement October 2009

http://www.cqc.org.uk//newsandevents/pressreleases.cfm?cit_id=35381&FAArea1=customWidge
ts.content_view_1&usecache=false

Dr David Colin-Thomé letter of 2 October 2009 regarding the Care Quality Commission interim
report

http://www.npci.org.uk/cd/public/docs/dh.pdf

15
General Practice Out-of-Hours Services: project to consider and assess current arrangements; Dr
David Colin-Thomé and Professor Steve Field, January 2010

http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitala
sset/dh_111893.pdf

Care Quality Commission responds to coroner's inquest and Department of Health's review of
out-of-hours services, 4 February 2010

http://www.cqc.org.uk/newsandevents/newsstories.cfm?FaArea1=customwidgets.content_view_1
&cit_id=35849

NHS Confederation and NHS Alliance statement on out-of-hours care

http://www.nhsconfed.org/PressReleases/2010/Pages/statement-ooh-care.aspx

Transcript of evidence to the Health Select Committee meeting in March 2010 on Out of Hours
Services

http://www.publications.parliament.uk/pa/cm200910/cmselect/cmhealth/uc441/uc44102.htm

House of Commons Health Committee: the use of overseas doctors in providing out–of–hours
services Fifth Report of Session 2009–10

http://www.publications.parliament.uk/pa/cm200910/cmselect/cmhealth/441/441.pdf

Use of overseas doctors in providing out of hours services

http://www.publications.parliament.uk/pa/cm200910/cmselect/cmhealth/441/441.pdf

Royal College of General Practitioners guidance regarding the admission of GPs from outside the
United Kingdom

http://www.rcgp.org.uk/practising_as_a_gp/admitting_gps_from_outside_uk.aspx

Equality Act 2010

http://www.opsi.gov.uk/acts/acts2010/pdf/ukpga_20100015_en.pdf

http://www.equalities.gov.uk/equality_bill.aspx

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