The Medical Profession (Responsible Officers) Regulations 2010

PART 3 Additional Responsibilities of Responsible Officers: England

Additional responsibilities of responsible officers: prescribed connection under regulation 10

16.—(1) Where a responsible officer has responsibilities under regulation 11 in respect of a medical practitioner who has a prescribed connection with a designated body in accordance with regulation 10, the responsible officer has the following additional responsibilities to the extent that the medical practitioner concerned is practising in England.

(2) In relation to the entry by the designated body into contracts of employment or for the provision of services with medical practitioners, the responsible officer must—

(a) ensure that medical practitioners have qualifications and experience appropriate to the work to be performed;

(b) ensure that appropriate references are obtained and checked;

(c) take any steps necessary to verify the identity of medical practitioners;

(d) where the designated body is a Primary Care Trust, manage admission to the performers list in accordance with the National Health Service (Performers Lists) Regulations 2004; and

(e) maintain accurate records of all steps taken in accordance with sub-paragraphs (a) to (d).

(3) In relation to monitoring medical practitioners’ conduct and performance, the responsible officer must—

(a) review regularly the general performance information held by the designated body, including clinical indicators relating to outcomes for patients;

(b) identify any issues arising from that information relating to medical practitioners, such as variations in individual performance; and

(c) ensure that the designated body takes steps to address any such issues.

(4) In relation to ensuring that appropriate action is taken in response to concerns about medical practitioners’ conduct or performance, the responsible officer must—

(a) initiate investigations with appropriately qualified investigators;

(b) ensure that procedures are in place to address concerns raised by patients or staff of the designated body or arising from any other source;

(c) ensure that any investigation into the conduct or performance of a medical practitioner takes into account any other relevant matters within the designated body;

(d) consider the need for further monitoring of the practitioner’s conduct and performance and ensure that this takes place where appropriate;

(e) ensure that a medical practitioner who is subject to procedures under this paragraph is kept informed about the progress of the investigation;

(f) ensure that procedures under this paragraph include provision for the medical practitioner’s comments to be sought and taken into account where appropriate;

(g) where appropriate—

(i) take any steps necessary to protect patients;

(ii) recommend to the medical practitioner’s employer that the practitioner should be suspended or have conditions or restrictions placed on their practice; and

(h) identify concerns and ensure that appropriate measures are taken to address these, including but not limited to—

(i) requiring the medical practitioner to undergo training or retraining;

(ii) offering rehabilitation services;

(iii) providing opportunities to increase the medical practitioner’s work experience;

(iv) addressing any systemic issues within the designated body which may have contributed to the concerns identified;

(i) maintain accurate records of all steps taken in accordance with this paragraph.

Additional responsibilities of responsible officers: prescribed connection under regulation 12

17.—(1) Where a responsible officer has responsibilities under regulation 13 in respect of a medical practitioner who has a prescribed connection with a designated body in accordance with regulation 12, the responsible officer has the following additional responsibilities to the extent that the medical practitioner concerned is practising in England.

(2) The responsible officer must ensure that the medical practitioner has established systems and procedures which will enable them to carry out their responsibilities under regulation 16(2) effectively.

(3) In relation to monitoring medical practitioners’ conduct and performance, the responsible officer must—

(a) review regularly the general performance information held by the designated body, including clinical indicators relating to outcomes for patients;

(b) identify any issues arising from that information relating to medical practitioners, such as variations in individual performance; and

(c) take all reasonably practicable steps to ensure that the designated body addresses any such issues.

(4) In relation to ensuring that appropriate action is taken in response to concerns about medical practitioners’ conduct or performance, the responsible officer must take all reasonably practicable steps to—

(a) ensure that the body for whom the medical practitioner is the responsible officer initiates investigations with appropriately qualified investigators;

(b) ensure that procedures are in place to address concerns raised about the medical practitioner by patients or staff of that body or arising from any other source;

(c) ensure that any investigation into the conduct or performance of a medical practitioner takes into account any other relevant matters within that body;

(d) consider the need for further monitoring of the practitioner’s conduct and performance and take steps to ensure that this takes place where appropriate;

(e) ensure that a medical practitioner who is subject to procedures under this paragraph is kept informed about the progress of the investigation;

(f) ensure that procedures under this paragraph include provision for the medical practitioner’s comments to be sought and taken into account where appropriate;

(g) where appropriate—

(i) take any steps necessary to protect patients;

(ii) recommend to the medical practitioner’s employer that the practitioner should be suspended or have conditions or restrictions placed on their practice; and

(h) identify concerns and ensure that appropriate measures are taken to address these, including but not limited to—

(i) requiring the medical practitioner to undergo training or retraining;

(ii) offering rehabilitation services;

(iii) providing opportunities to increase the medical practitioner’s work experience;

(i) maintain accurate records of all steps taken in accordance with this paragraph.

Duty to have regard to guidance

18.  In discharging their responsibilities under regulations 16 and 17, responsible officers must have regard to the following—

(a) guidance given by the Secretary of State in accordance with section 120(6) of the Health and Social Care Act 2008; and

(b) guidance given by the National Clinical Assessment Service division of the National Patient Safety Agency(1), to the extent that it relates to the nomination or appointment of responsible officers or their prescribed responsibilities.

Provision of resources to responsible officers

19.—(1) Each designated body must provide its responsible officer with sufficient funds and other resources necessary to enable the officer to discharge their responsibilities for that body under regulations 16 and 17.

(2) Where the designated body does not employ its responsible officer, the body must provide the resources referred to in paragraph (1) to—

(a) where the responsible officer is employed, the employer of the officer; and

(b) in any other case, the responsible officer.

(3) Where a medical practitioner has a prescribed connection with a designated body by virtue of sub-paragraph (d), (e), (f), (g) or (h) of regulation 10(1), the medical practitioner must provide the designated body with sufficient funds necessary to enable the responsible officer nominated or appointed for that body to discharge their responsibilities under regulation 16 relating to that medical practitioner.

(4) The designated body must determine the amount of the sufficient funds referred to in paragraph (3) and provide to the medical practitioner a written demand for the sum required to be paid.

(1)

The National Patient Safety Agency is a Special Health Authority established by S.I. 2001/1743.