http://www.kirklees.nhs.uk/uploads/tx_galileodocuments/Procedure_for_the_managemement_of_Performers_

Procedure for the Management of Performers List

Responsible Directorate:

Patient and Professions

Responsible Director:

Sheila Dilks

Date Approved Committee

8 August 2008 Governance Committee

Version Control.

Document Title Document number Author Contributors Version Date of Production Review date Postholder responsible revision Primary Circulation List Web address Restrictions

Procedure for the management of the Performers list 1 Terry Service Jane Kennedy 1 10 June 2008 August 2011 for Terry Service Performance Advisory Group None

Standard for Better Health Map. Domain Core Standard Reference:

Domain 1 Safety, Domain 3 Governance C1 (a), (b). C7 (a), (b). C10 (a), (b). C11 (a),

Performance Indicators

1. Exception reports 2. Performance Advisory Group Minutes 3. Decision Making Group Minutes (as necessary)

Contents

Section 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Appendices A B

Introduction Information Associated Policies and Procedures Aims and Objectives Scope Accountabilities Performance Advisory Group West Yorkshire Central Services Agency Alerts Inclusion onto the Trust Performers list Refusal to include on the Trust Performers list Suspension from the Trust Performers list Removal from the Trust Performers list Equality Assessment statement Training Needs Analysis Compliance systems References Stakeholders

Page 2 2-3 3 3 3 3-4 4 4 4 4 4 5-8 8-14 14 14 14-15 15 15

Oral Hearing Procedure Equality Impact Assessment Tool

16-19 20

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1.

Introduction.

These procedures are in place to ensure that Kirklees PCT has consistent processes to deal with the powers held by Primary Care Trusts.

The National Health Service reform and Healthcare Professions Act 2002 have been enacted and include guidance regarding the implementation of supplementary lists for primary care contractors including medical practitioners, dentists and optometrists.

The regulatory provisions for each of the four main contractor lists (general practitioners, dentists, opticians and pharmacists) were very similar but with specific legislative processes for each.

Primary Care Trusts are responsible for the management and administration of the main performer’s lists which, prior to 2004 were known as PMS and GMS supplementary lists. In 2004 the Performers Regulations were introduced and all doctors included on the GMS list, the GMS supplementary list and the PMS supplementary list were entitled to be automatically transferred to the Performers List.

The performers list is the responsibility of the Kirklees PCT who has the power to accept, remove or to add restrictions to any contractor registered on the list.

The requirement to be on the GP Register came into force from 1 April 2006 which requires a General Practitioner to have undertaken the relevant training and hold a JCPTGP, CCT or a certificate of acquired rights.

A contractor who is not registered on a performers list (GP, Dentist or Optometrist but not pharmacists) is unable to practice and faces serious charges from professional bodies for practicing outside of the regulations.

2.

Information

As well as mandatory grounds for removal or refusal to admit, Trust’s have discretion to remove a practitioner on grounds of efficiency, fraud or unsuitability. It is essential that, when making these decisions, the PCT takes into account any relevant facts and the relevant criteria as set out in the Regulations. The Trust must also avoid taking into account irrelevant facts. It is important that decisions are properly taken by the relevant responsible officer or committee and properly documented not least because all discretionary decisions by the Trust can be appealed to the Family Health Services Appeals Authority (FHSAA).

The details of the new powers are set out in statute, regulations, and national guidance it is important to note that this document is not a substitute for reading the relevant statutory and regulatory provisions and should not be treated as such.

Where the contents of this procedure is in conflict with regulation, then regulation will always take precedence.

Full national guidance has been issued for General Practitioners and for dentists.

'Delivering Quality in Primary Care. Health Authority (and Primary Care Trust) Management of Primary Care Practitioner Lists: General Practitioners’ and Page 2 of 20

'Delivering Quality in Primary Care: Health Authority (and Primary Care Trust) Management of Primary Care Practitioners' Lists: General Dental Practitioners is available on the DoH website at: http://www.doh.gov.uk/pclists/implementationadvice.pdf The intention of the arrangements and procedures is to allow decisions about the acceptability of primary care contractors to be taken locally by those who have responsibility for the quality of primary care services.

3.

Associated Policies and Procedures.

This document should be read in accordance with the following Trust policies, procedures and guidance.

Contractor Professional Support Policy 4.

5.

Aims and Objectives.

•

To ensure that the Trust has a consistent process for managing applications to the performers list.

•

To ensure that the Trust has a consistent and fair process for removal of a contractor from the performers list.

•

To ensure that the Trust has a consistent and fair process for the any restrictions to be applied to a contractor.

•

To provide all contractors with a written process for appealing any decisions made by the Trust in the application of the regulations.

Scope of the Policy / Procedure

This procedure must be followed by Trust managers and Directors who have the specific responsibility to manage the performers lists in conjunction with agreed policies and procedures.

6.

Accountabilities & Responsibilities

a)

Board Accountability

The Chief Executive has the overall accountability for the management of the performers list but delegates the responsibility to the Director of Patient and Professions (classed as the ‘responsible officer’ within the performers regulations).

The Director of Commissioning and the commissioning team are responsible for providing specialist advice on contracts and related contractual actions. b)

Senior Management

The Assistant Director of Corporate Services and Risk Management is classed as the ‘nominated officer’ (within the performers’ regulations) and is the senior manager for the organisation with delegated responsibility for making decisions on acceptance to the performers list. All exceptional cases will be referred to the contracts team and the Performance Advisory Group. The Investigation and Litigation Manager for the Trust will deputise for this task as necessary.

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7.

Performance Advisory Group (PAG)

The PAG have delegated responsibility for decisions related to exceptional case admissions to the performers list. Further powers are available including suspensions, restriction and removals from the performers list subject to written authority from the Decision Making Group (formerly known as the ‘Reference Committee).

The Assistant Director of Corporate Services and Risk Management is classed as the ‘nominated officer’ with the responsibility for ensuring that the Trust holds a database of all contractor alerts and that any requests to join Kirklees PCT Performers list are checked against this list. The Assistant Director of Corporate Services and Risk Management has delegated authority to authorise the inclusion onto Kirklees PCT Performers list for requests that meet the minimum criterion laid out in regulations. All exceptional cases will be referred to the PAG for decision.

8.

West Yorkshire Central Services Agency (WYCSA)

WYCSA are contracted to the Trust to manage the details of the performers list and to ensure that any applications are managed within relevant regulations and guidance. WYCSA are responsible for ensuring that all applicants are subject to CRB checks and have the necessary qualifications and references. WYCSA will communicate with the contracting team and the Assistant Director of Corporate Services and Risk Management for all applications to the list.

9.

Alerts

The Assistant Director of Corporate Services and Risk Management is responsible for maintaining the list of alerts and alert cancellations issued by NHS Yorkshire and Humber. All alerts will be issued directly to the office of the Chief Executive who will then send them via confidential mail systems to the Assistant Director of Corporate Services and Risk Management for action or inclusion on the database. Access to the data base is restricted to key staff with the relevant authority and requirement to review the content.

10.

Inclusion onto the performers list.

Contractors who wish to join Kirklees Primary Care Trust performers list must apply to WYCSA for inclusion. They must complete a number of standard documents and be appropriately qualified. Two acceptable references must be provided and they must agree to be subject to a check by the Criminal Records Bureau with any concerns noted being reported to the Trust and used within the decision making process.

Once all checks have been completed and accepted, WYCSA will write to the nominated leads within the Trust to seek the authority to be placed upon the list.

General Practitioners are also required to complete an annual appraisal and should work within the boundaries of the Trust.

11.

Refusal of entry onto the performers list.

The Trust has the statutory power to refuse admission where this appears justified on efficiency, fraud or unsuitability grounds. Consideration can be given to any available information but must consider certain specified issues. The Trust defer consideration

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of applications in certain circumstances or make admission to the list conditional on adherence to specific conditions set by the Trust.

Most decisions will be discretionary, amongst other things, upon a practitioner’s declaration of previous criminal convictions, "findings against" by regulatory, licensing or other bodies, content of references, fraud investigations etc.

In some cases the Trust will have no choice but to refuse a request for admission to a list. Examples include any practitioner with a murder conviction in the UK, or a criminal conviction in the UK on or after 14 December 2001 that leads to a sentence of imprisonment of more than six months or where the practitioner is nationally disqualified from the relevant list by the FHSAA. The full list of the reasons why a practitioner must be refused is contained in national guidance. There is no appeal against such a refusal.

12.

Suspension from the Performers list.

The Trust has discretionary powers to suspend a practitioner when it is considered necessary to protect members of the public or it is otherwise in the public interest.

Suspension can be invoked pending a third party investigation (e.g. a practitioner is under investigation by the police, professional body, NHS Counter Fraud or pending the Crown Prosecution Service decision and any resultant court case) or whilst the Trust investigates serious concerns about the practitioner.

The Contractor Professional Support Policy provides details on how an investigation is undertaken and the responsibilities of different officers within the investigation.

The NHS (Performers Lists) Regulations 2004 (Statutory Instrument 2004 no. 585) is explicit on the requirements, actions and right of appeal for a contractor; If the Trust is satisfied that it is necessary to suspend a contractor (performer) from the list for the protection of members of the public or is otherwise in the public interest, it may suspend a performer from its performers list, in accordance with the provisions of regulations (a) while it decides whether or not to exercise its powers to remove them under regulation 10 or contingently remove him under regulation 12; (b) while the Trust waits for a decision affecting him of a court anywhere in the world or of a licensing or regulatory body; (c) where it has decided to remove him, but before that decision takes effect; or (d) pending appeal under these Regulations.

(2) Subject to paragraph (8), in a case falling within paragraph (1)(a), the Primary Care Trust must specify a period, not exceeding six months, as the period of suspension.

(3) Subject to paragraph (8), in a case falling within paragraph (1)(b), the Primary Care Trust may specify that the performer remains suspended after the decision referred to in that paragraph has been made for an additional period, not exceeding six months.

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(4) The period of suspension under paragraph (1)(a) or (b) may extend beyond six months if – (a) on the application of the Primary Care Trust, the FHSAA so orders; or (b) the Primary Care Trust applied under sub-paragraph (a) before the expiry of the period of suspension, but the FHSAA has not made an order by the time it expires, in which case it continues until the FHSAA makes an order.

(5) If the FHSAA does so order, it shall specify (a) the date on which the period of suspension is to end; (b) an event beyond which it is not to continue; or (c) both a date on which it is to end and an event beyond which it is not to continue, in which case it shall end on the earlier of that date or that event, as the case may be.

(6) The FHSAA may, on the application of the Primary Care Trust, make a further order (complying with paragraph (5)) at any time while the period of suspension pursuant to the earlier order is still continuing.

(7) If the Primary Care Trust suspends a performer in a case falling within paragraph (1)(c) or (d), the suspension has effect from the date the Primary Care Trust informed him of the suspension until (a) the expiry of any appeal period; or (b) if he appeals under regulation 15, the FHSAA has disposed of the appeal.

(8) The Primary Care Trust may extend the period of suspension under paragraph (2) or impose a further period of suspension under paragraph (3), so long as the aggregate does not exceed six months.

(9) The effect of a suspension is that, while a performer is suspended under these Regulations, he is to be treated as not being included in the Primary Care Trust's performers list, even though his name appears in it.

(10) The Primary Care Trust may at any time revoke the suspension and notify the performer of its decision.

(11) Where a Primary Care Trust is considering suspending a performer or varying the period of suspension under this regulation, it shall give him (a) notice of any allegation against him; (b) notice of what action it is considering and on what grounds; and (c) the opportunity to put his case at an oral hearing before it, on a specified day, provided that at least 24 hours notice of the hearing is given.

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(12) If the performer does not wish to have an oral hearing or does not attend the oral hearing, the Primary Care Trust may suspend the performer with immediate effect.

(13) If an oral hearing does take place, the Primary Care Trust shall take into account any representations made before it reaches its decision.

(14) The Primary Care Trust may suspend the performer with immediate effect following the hearing.

(15) The Primary Care Trust shall notify the performer of its decision and the reasons for it (including any facts relied upon) within 7 days of making that decision.

(16) The Primary Care Trust shall notify the performer of any right of review under regulation 14.

(17) During a period of suspension payments may be made to or in respect of the performer in accordance with a determination by the Secretary of State.

(18) If a payment is made pursuant to a determination under paragraph (17), but the payee was not entitled to receive all or any part thereof, if the amount to which he was not entitled has not been recovered by other means, it may be recovered as a civil debt.

(19) If a performer is dissatisfied with a decision of a Primary Care Trust ("the original decision") (a) to refuse to make a payment to or in respect of him pursuant to a determination under paragraph (17); (b) to make a payment to or in respect of him pursuant to a determination under paragraph (17), but at a lower level than the level to which he considers to be correct; or (c) in respect of recovery of what the Primary Care Trust considers to be an overpayment, he may ask the Primary Care Trust to review the original decision and, if he does so, it shall reconsider that decision, and once it has done so, it must notify the performer in writing of the decision that is the outcome of its reconsideration of its original decision ("the reconsidered decision") and give him notice of the reasons for its reconsidered decision.

(20) If the performer remains dissatisfied (whether on the same or different grounds), he may appeal to the Secretary of State by giving him a notice of appeal within a period of 28 days beginning on the day that the Primary Care Trust notified him of the reconsidered decision.

(21) A notice of appeal under paragraph (20) shall include (a) the names and addresses of the parties to the disputed decision; (b) a copy of the reconsidered decision; and (c) a brief statement of the grounds for appeal.

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(22) The Secretary of State shall thereafter send a written request to the parties to make, in writing and within a specified period, any representations they may wish to make about the matter (and the request to the Primary Care Trust shall include a copy of the performer's brief statement of the grounds for appeal).

(23) Once the period specified pursuant to paragraph (22) has elapsed, the Secretary of State shall (a) give a copy of any representations received from a party to the other party; and (b) request in writing a party to whom a copy of representations is given to make within a specified period any written observations which he or it wishes to make on those representations.(24) Once the period specified pursuant to paragraph 23(b) has elapsed, the Secretary of State shall, as soon as is reasonably practicable, having taken into account any such representations or observations as referred to in paragraphs (22) and (23) (if submitted within the specified periods) and such other evidence as he sees fit to consider (a) determine the appeal, and shall give notice of the determination (including a record of the reasons for it) to both parties; and (b) give the Primary Care Trust such directions in writing, if any, on the matter as he thinks fit 13.

Removal from the Performers List

The Trust also has the power to remove a practitioner from the list in similar circumstances to those that relate to refusal to admit. This includes making retention on the list subject to conditions (described as a contingent removal). The decision to remove a practitioner from the list can only be taken following a meeting of the Decision Making Group (see Contractor Professional Support Policy).

The only exception to this is the annual review of the performers list which identifies contractors who breach regulations related to working within the PCT for the preceding 12 months or who fail/refuse to attend appraisals (regulation 10 (6)). The right or appeal for contractors in these cases is not affected.

The NHS (Performers Lists) Regulations 2004 (Statutory Instrument 2004 no. 585) is explicit on the requirements, actions and right of appeal for a contractor in the event of a removal; 10. - (1) The Primary Care Trust must remove the performer from its performers list where it becomes aware that he (a) has been convicted in the United Kingdom of murder; (b) has been convicted in the United Kingdom of a criminal offence, committed on or after the day prescribed in the relevant Part, and has been sentenced to a term of imprisonment of over six months; (c) is subject to a national disqualification; (d) has died; or Page 8 of 20

(e) is no longer a member of the relevant health care profession.

(2) Where a Primary Care Trust is notified by the FHSAA that it has considered an appeal by a performer against (a) a contingent removal by the Trust and has decided to remove him instead; or (b) a conditional inclusion, where he has been conditionally included in a performers list until the appeal has been decided, and has decided not to include him, The Trust shall remove him from its performers list and shall notify him immediately that it has done so.

(3) The Primary Care Trust may remove a performer from its performers list where any of the conditions set out in paragraph (4) is satisfied.

(4) The conditions mentioned in paragraph (3) are that (a) his continued inclusion in its performers list would be prejudicial to the efficiency of the services which those included in the relevant performers list perform ("an efficiency case"); (b) he is involved in a fraud case in relation to any health scheme; or (c) he is unsuitable to be included in that performers list ("an unsuitability case").

(5) For the purposes of this regulation, in addition to the services covered by the definition of "health scheme" in section 49F(8), the following shall also be health schemes (a) health services, including medical and surgical treatment, provided by the armed forces; (b) services provided by Port Health Authorities constituted under the Public Health (Control of Disease) Act 1984; (c) medical services provided to a prisoner in the care of the medical officer or other such officer of a prison appointed for the purposes of section 7 of the Prison Act 1952; and (d) publicly-funded health services provided by or on behalf of any organisation anywhere in the world.

(6) Where the performer cannot demonstrate that he has performed the services, which those included in the relevant performers list perform, within the area of the Primary Care Trust during the preceding twelve months, it may remove him from its performers list.

(7) Subject to any provision in the relevant Part, in calculating the period of twelve months referred to in paragraph (6), the Primary Care Trust shall disregard any period during which -

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(a) the performer was suspended under these Regulations; or (b) he was performing whole time service in the armed forces in a national emergency (as a volunteer or otherwise), compulsory whole-time service in the armed forces (including service resulting from reserve liability), or any equivalent service, if liable for compulsory whole-time service in the armed forces.

(8) Where a Primary Care Trust is considering removing a performer from its performers list under paragraphs (3) to (6) or regulations 8(2), 12(3)(c) or 15(6)(b) or contingently removing a performer under regulation 12(1), it shall give him a) notice of any allegation against him; (b) notice of what action it is considering and on what grounds; (c) the opportunity to make written representations to it within 28 days of the date of the notification under sub-paragraph (b); and (d) the opportunity to put his case at an oral hearing before it, if he so requests, within the 28 day period mentioned in sub-paragraph (c).

(9) If there are no representations within the period specified in paragraph (8)(c), the Primary Care Trust shall decide whether or not to remove the performer and then, within 7 days of making that decision, notify him of (a) that decision and the reasons for it (including any facts relied upon); and (b) any right of appeal under regulation 15.

(10) If there are representations, the Primary Care Trust must take them into account before reaching its decision, and shall then, within 7 days of making that decision, notify him of (a) that decision and the reasons for it (including any facts relied upon); and (b) any right of appeal under regulation 15.

(11) If the performer requests an oral hearing, this must take place before the Primary Care Trust reaches its decision, and it shall then, within 7 days of making that decision, notify him of (a) that decision and the reasons for it (including any facts relied upon); and (b) any right of appeal under regulation 15.

(12) When the Primary Care Trust notifies the performer of any decision, it shall inform him that, if he wishes to exercise a right of appeal, he must do so within the period of 28 days beginning with the date on which it informed him of its decision and it shall tell him how to exercise any such right.

(13) The Primary Care Trust shall also notify the performer of his right to have the decision reviewed in accordance with regulation 14.

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(14) Where the Primary Care Trust decides to remove a performer under paragraph (6), he shall not be removed from its performers list, until (a) a period of 28 days starting with the day on which it reaches its decision; or (b) any appeal is disposed of by the FHSAA, whichever is the later.

Criteria for a decision on removal 11. - (1) Where a Primary Care Trust is considering whether to remove a performer from its performers list under regulation 10(3) and (4)(c) ("an unsuitability case"), it shall (a) consider any information relating to him which it has received in accordance with any provision of regulation 9; (b) consider any information held by the Secretary of State as to any record about past or current investigations or proceedings involving or related to that performer, which information he shall supply if the Trust so requests; and (c) in reaching its decision, take into consideration the matters set out in paragraph (2).

(2) The matters referred to in paragraph (1) are (a) the nature of any offence, investigation or incident; (b) the length of time since any such offence, incident, conviction or investigation; (c) whether there are other offences, incidents or investigations to be considered; (d) any action taken or penalty imposed by any licensing or regulatory body, the police or the courts as a result of any such offence, incident or investigation; (e) the relevance of any offence, incident or investigation to his performing relevant primary services and any likely risk to any patients or to public finances; (f) whether any offence was a sexual offence to which Part I of the Sexual Offences Act 1997 applies, or if it had been committed in England and Wales, would have applied; (g) whether the performer has been refused admittance to, conditionally included in, removed, contingently removed or is currently suspended from any list or equivalent list, and if so, the facts relating to the matter which led to such action and the reasons given by the Primary Care Trust or equivalent body for such action; and (h) whether he was at the time, has in the preceding six months been, or was at the time of the originating events a director of a body corporate, which was refused admission to, conditionally included in, removed or contingently removed from any list or equivalent list or is currently suspended from any such list, and if so, what the facts were in each such case and the reasons given by the Primary Care Trust or equivalent body in each case for such action.

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(3) Where a Primary Care Trust is considering removal of a performer from its performers list under regulation 10(3) and (4)(b) it shall consider (a) any information relating to him which it has received in accordance with any provision of regulation 9; (b) any information held by the Secretary of State as to any record about past or current investigations or proceedings involving or related to that performer, which information he shall supply, if the Trust so requests; and (c) the matters set out in paragraph (4).

(4) The matters referred to in paragraph (3)(c) are (a) the nature of any incidents of fraud; (b) the length of time since the last incident of fraud occurred, and since any investigation into it was concluded; (c) whether there are any other incidents of fraud, or other criminal offences to be considered; (d) any action taken by any licensing, regulatory or other body, the police or the courts as a result of any such offence, investigation or incident; (e) the relevance of any investigation into an incident of fraud to his performing relevant primary services and the likely risk to patients or to public finances; (f) whether the performer has been refused admittance to, conditionally included in, removed, or contingently removed or is currently suspended from, any list or equivalent list, and, if so, the facts relating to the matter which led to such action and the reasons given by the Primary Care Trust or equivalent body for such action; and (g) whether he was at the time, has in the preceding six months been, or was at the time of the originating events a director of a body corporate, which was refused admission to, conditionally included in, or removed or contingently removed from, any list or equivalent list, or is currently suspended from any such list, and if so, what the facts were in each such case and the reasons given by the Primary Care Trust or equivalent body in each case.

(5) Where a Primary Care Trust is considering removal of a performer from its performers list under regulation 10(3) and (4)(a) ("an efficiency case"), it shall (a) consider any information relating to him which it has received in accordance with any provision of regulation 9; (b) consider any information held by the Secretary of State as to any record about past or current investigations or proceedings involving or related to that performer, which information he shall supply, if the Trust so requests; and (c) in reaching its decision, take into account the matters referred to in paragraph (6).

(6) The matters referred to in paragraph (5)(c) are -

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(a) the nature of any incident which was prejudicial to the efficiency of the services, which the performer performed; (b) the length of time since the last incident occurred and since any investigation into it was concluded; (c) any action taken by any licensing, regulatory or other body, the police or the courts as a result of any such incident; (d) the nature of the incident and whether there is a likely risk to patients; (e) whether the performer has ever failed to comply with a request to undertake an assessment by the NCAA; (f) whether he has previously failed to supply information, make a declaration or comply with an undertaking required on inclusion in a list; (g) whether he has been refused admittance to, conditionally included in, removed or contingently removed or is currently suspended from any list or equivalent list, and if so, the facts relating to the matter which led to such action and the reasons given by the Primary Care Trust or the equivalent body for such action; and (h) whether he was at the time, has in the preceding six months been, or was at the time of the originating events a director of a body corporate, which was refused admission to, conditionally included in, removed or contingently removed from, any list or equivalent list, or is currently suspended from any such list, and if so, what the facts were in each such case and the reasons given by the Primary Care Trust or equivalent body in each case for such action.

(7) In making any decision under regulation 10, the Primary Care Trust shall take into account the overall effect of any relevant incidents and offences relating to the performer of which it is aware, whichever condition it relies on.

(8) When making a decision on any condition in regulation 10(4), the Primary Care Trust shall state in its decision on which condition it relies.

Contingent removal 12. - (1) In an efficiency case or a fraud case the Primary Care Trust may, instead of deciding to remove a performer from its performers list, decide to remove him contingently.

(2) If it so decides, it must impose such conditions as it may decide on his inclusion in its performers list with a view to – (a) removing any prejudice to the efficiency of the services in question (in an efficiency case); or (b) preventing further acts or omissions (in a fraud case).

(3) If the Primary Care Trust determines that the performer has failed to comply with a condition, it may decide to (a) vary the conditions imposed;

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(b) impose new conditions; or (c) remove him from its performers list.

Removal of a practitioner from the NHS list will be seen as a last resort by the Trust.

Trust policies and systems for clinical governance, continued professional development, appraisal, occupational health services and the support of the National Clinical Assessment Service have been developed to enable practitioners to make use of supportive initiatives to improve the quality of services. These initiatives should play an important part in avoiding the need to use the Trust’s powers of removal.

In the event that a performer wished to exercise their right of appeal or for a full oral hearing they must comply with the 2004 regulations.

In all cases the Trust will make its final determination following the consideration of any written or oral representations. The practitioner will be advised of any rights of appeal in the letter informing him/her of the decision. Where there is a statutory right of appeal, then this would be considered by the FHSAA. Reference should be made to Regulation and the FHSAA's own procedures Appendix A provides a detailed explanation of how an oral hearing is conducted and the rights if individuals herein.

14.

Equality Impact Assessment.

All public bodies have a statutory duty under the Race Relation (Amendment) Act 2000 to “set out arrangements to assess and consult on how their policies and functions impact on race equality.� This obligation has been increased to include equality and human rights with regard to disability age and gender. The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others.

In order to meet these requirements, a single equality impact assessment is used to assess all its policies/guidelines and practices. This document and associated procedures were found to be compliant with this philosophy.

15.

Training Needs Analysis.

Training is only necessary for staff who perform the duties laid out within this document and the Contractor Support Policy and are intrinsic within job descriptions and person specifications. No training is required for any other staff member.

16.

Monitoring of Compliance

Details of all contractors who have current entries to the performers list will be held

by West Yorkshire Central Services Agency. The Trust Contractor lead will review this list in an annual basis and advise the Professional Advisory Committee of any breaches that require action to be taken.

The Assistant Director of Corporate Service and Risk Management will report any exceptions to the Professional Advisory Committee at every meeting. Routine admissions to the list will not be reported.

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The minutes of the Professional Advisory Committee will be provided to the Governance Committee (anonomised where necessary) with specific actions reported to the Board (under a closed agenda) or the Decision Making Group who in turn report directly to the Board (under a closed agenda).

The Professional Advisory Committee is responsible for ensuring that the procedures outlined within this document and the Contractor Professional Support Policy are complied with and will report any discrepancies or failures to the Governance Committee.

The Governance Committee have the responsibility for ensuring that any failures of the procedures are managed and action is taken.

17.

18.

References •

Statutory Instrument 2004 no. 585

•

The NHS (Performers Lists) Regulations 2004

•

Matters which deal with (1) the inclusion, and refusal to include GMS, GDS and GOS Principals, and (2) the removal, or contingent removal of the Principal, are covered by amendments to the main GMS, GDS and GOS Regulations through a new Statutory Instrument 2001/ 3742, 2001/ 3741 & 2001/ 3749 respectively Appendices.

•

Delivering Quality in Primary Care. Health Authority (and Primary Care Trust) Management of Primary Care Practitioner Lists: General Practitioners’ 2002.

•

Delivering Quality in Primary Care: Health Authority (and Primary Care Trust) Management of Primary Care Practitioners' Lists: General Dental Practitioners 2002.

Key Stakeholders consulted / involved in the development of the document.

•

Terry Service – Assistant Director of Corporate Services and Risk

•

Jane Kennedy – Investigation and Litigation Manager

•

Mark Jenkins – Contracts Manager

•

Gillian Curry – Audit Manager

•

Policy Development Group

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Appendix A

Oral Hearings procedure Procedure to be followed for an Oral Hearing i.e. where a practitioner requests to make representations to the PCT in accordance with: The National Health Service (Performers Lists) Regulations 2004 • • •

Paragraph 10 Removal from performers list Paragraph 13 Suspension Paragraph 14 Reviews: Procedure to review a decision to conditionally include, contingently remove or suspend a doctor

The National Health Service (GDS) Amendment (No6) Regulations 2001 • • •

Amendment to Regulation 8E: Procedure on Removal Amendment to Regulation 8F Procedure on suspension Amendment to Regulation 8G Procedure to review a decision to conditionally include, contingently remove or suspend a dentist

The NHS (GOS) Amendment (no2) Regs 2001 • • •

Amendment to Regulation 9E Procedure on Removal Amendment to Regulation 9F Procedure on suspension Amendment to Regulation 9G Procedure to review a decision to conditionally include, contingently remove or suspend an Optometrist.

Oral Hearing In the event of a practitioner requesting an oral hearing, the Trust will set up a Panel, which will consist of at least three members to hear the case; one will be a nonexecutive member, one a professional, and one an Executive Director.

The PCT may extend the panel membership depending on the circumstances, but the hearing should not commence with less than three members, but should be able to continue if one member is taken ill or is unavoidably called away.

The Chair of the Panel will be the executive board member who has the authority to exercise the powers provided to the Trust under legislation. For the purpose of the legislation this officer is known as ‘the Responsible Officer’ and would normally be an Executive Director.

The timescales for the operation of the panel are provided within the regulations.

The panel will not sit in public and the minutes and related documents are considered confidential and privileged under English Law. The professional member(s) of the Panel will not include any member who has been directly involved in advising the Investigating Officer.

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Representation at hearing The practitioner is to be afforded the opportunity of making his/her own representations. A friend of his/her choice may accompany and represent the practitioner. This can be a representative of the LMC, LDC, LOC or someone from a defence organisation.

There is nothing to prevent the friend being legally qualified, however, these are internal procedures and there will be no right or need for legal representation for either the Trust or the practitioner in these circumstances. This means no legally qualified person addresses the committee or puts questions directly, or indirectly, to witnesses either on behalf of the PCT or the practitioner.

Notice The practitioner will be sent full details, including any written evidence, of the Trust’s case against him/her. In cases of removal, and contingent removal this will be no less than 14 calendar days prior to the date set for the panel. Any late documents will be sent as soon as possible together with an offer to put back the date of the panel to comply with the 7 calendar day advance notification requirement if the practitioner wishes. In cases of suspension, the period of notice is 24 hours.

Reference will be made to Regulation in respect of any queries about timescales.

Postponement (this paragraph does not relate to suspensions) If the practitioner requests a postponement for any reason other than on health grounds they will be asked to offer an alternative date, convenient to the Trust, within 7 calendar days of the original hearing. This also applies if the Trust wish in exceptional circumstances, to seek a postponement and any such postponement must not be unreasonable. The Trust Chief Executive should be informed and is responsible for ensuring that extensions are absolutely necessary and kept to a minimum.

If the practitioner’s ill health prevents the hearing taking place the Trust should consider at what point they refer the matter to an occupational health service. After a reasonable period (not normally less than 6 weeks) proceeding with the hearing in the practitioner’s absence ought to be considered unless there are compelling reasons for further delay.

Non attendance at hearing If the Trust representative or the appellant fails to attend the hearing the Panel may consider the appeal in the absence of that party, except where there is an adjournment by consent, or the Panel, at their discretion, decide that in all the circumstances it would be reasonable to adjourn the appeal.

A period of fifteen minutes beyond the notified time of commencement shall elapse before either party is deemed not to have attended.

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Witnesses Witnesses who have made statements that may be used during the hearing may be called to attend the hearing. The decision to call witnesses lies solely with the Chairperson and they ought only to be called where that officer is certain that their attendance will be crucial to the decision making process. There is no requirement for all or any witnesses to attend and in most cases written statements should prove sufficient. Witnesses who are asked to attend a hearing are there to give direct evidence. If in exceptional circumstances they choose to be accompanied by a representative, the representative will not be able to participate in the hearing.

Procedure at hearing At the hearing of an appeal, the following procedure shall be observed: The Trust representative shall state the Trust case in the presence of the appellant and his representative and may call witnesses whose presence has been agreed by the Chair at least 7 days in advance of the hearing.

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The Appellant or their representative shall have the opportunity to ask questions of the Trust representative and witnesses.

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The members of the Panel shall have the opportunity to ask questions of the Trust representative and witnesses.

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The Trust representative shall have the opportunity to re-examine their witnesses on any matter referred to in their examination by members of the Panel, the appellant or their representative.

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The Appellant or their representative shall present their case in the presence of the Trust representative and may call witnesses whose presence has been agreed by the Chair at least 7 days in advance of the hearing.

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The Trust representative shall have the opportunity to ask questions of the appellant, their representative and their witnesses.

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The members of the Panel shall have the opportunity to ask questions of the appellant, their representative and their witnesses.

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The appellant or their representative shall have the opportunity to re-examine their witnesses on any matter referred to in their examination by members of the Panel or the Trust representative.

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The Trust representative and the appellant or their representative shall have the opportunity to sum up their case if they so wish. The appellant or their representative shall have the right to speak last. In their summing up neither party may introduce any new matter.

Nothing in the foregoing procedure shall prevent the members of the Panel from inviting either party to elucidate or amplify any statement they may have made, or from asking such questions as may be necessary.

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The panel is free to consider written and oral submissions from third parties where this appears relevant to them. The chairperson has the absolute right of adjudication where there is a dispute relating to admissibility The Panel may, at their discretion, adjourn the appeal in order that further evidence may be produced by either party or for any other reason.

The Trust representative, the appellant and their representative and witnesses shall withdraw.

The Panel, with the officer appointed as Secretary to the Panel shall deliberate in private only recalling both parties to clear points of uncertainty on evidence already given. If recall is necessary both parties shall return, notwithstanding only one is concerned with the point giving rise to doubt.

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Equality Impact Assessment Tool

Appendix B:

To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval.

Insert Name of Policy / Procedure Yes/No 1.

Does the policy/guidance affect one group less or more favourably than another on the basis of: • Race • Ethnic origins travellers)

2.

3.

4.

5.

6.

7.

(including

gypsies

and

Comments

No No

• Nationality

No

• Gender

No

• Culture

No

• Religion or belief

No

• Sexual orientation including lesbian, gay and bisexual people

No

• Age

No

• Disability - learning disabilities, physical disability, sensory impairment and mental health problems

No

Is there any evidence that some groups are affected differently?

If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

Is the impact of the policy/guidance likely to be negative?

If so can the impact be avoided?

What alternatives are there to achieving the policy/guidance without the impact?

Can we reduce the impact by taking different action?

No No

No NA NA NA

If you have identified a potential discriminatory impact of this procedural document, please refer it to Human Resources Dept together with any suggestions as to the action required to avoid/reduce this impact.

For advice in respect of answering the above questions, please contact Human Resources Department

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