The NASGP is the only independent lobbying and information service for Sessional GPs - locums, salaried and retainer GPs.

This page contains the historical information about Supplementary Lists

1st August 2002 - see the RCGP's excellent analysis of the NASGP's email survey on Supplementary Lists. Although we say so ourselves, a fantastic example of two medical organisations working together to make a real difference for non-principals:

View these documents:
- RCGP analysis word
- RCGP analysis pdf
A word of thanks from RCGP chairman, Professor David Haslam
- Letter pdf

As from 14 Dec 2001, all Health Authorities in ENGLAND were instructed to start setting up their Supplementary Lists.

We have provided the key points below, a summary and the relevant paragraphs of the Department of Health's own DRAFT guidance (still awaiting negotiation with the GPC) for supplementary lists.

Key Points

These lists must be functioning by the 31st March 2002 (was initially February 2002 but deadline extended).
From the 1 April 2002, subject to transitional rules until 31 May 2002, a doctor cannot be employed or engaged to work in GMS unless he is on a medical list, a supplementary list or is named on an agreement under section 2 of the Primary Care Act as a performer of PMS (this latter criteria is temporary pending the introduction of the services (PMS) list). Future references to the latter criteria will be expressed as "named as a performer of PMS".
All non-principals suspended from their supplementary lists will be entitled to suspension payments.

GP principals already have to apply to join a medical list - supplementary lists are simply an extension of that system for non-principals. The Health and Social Care Act 2001 (H&SC Act) received the Royal Assent on 11 May 2001. In part this provides a legal framework for the necessary statutory changes to deliver the NHS commitments on modernising the management of practitioner lists. This gave powers to Health Authorities to remove, exclude or suspend practitioners from those lists.

The NHS Tribunal will be abolished, and the power to suspend or remove GPs from a health authority's list will be devolved to health authorities, subject to a right of appeal to the Family Health Services Appeal Authority, from 2001."

As soon as the proper legislation is in place, the control of these lists will move from Health Authorities to PCTs.

There will also be provisions that allow a doctor to be entered onto a list but subject to conditions set by the Health Authority (a conditional inclusion) or for the doctor's continued presence on a list to be similarly subject to conditions (a contingent removal).

A Health Authority decision will only be effective in relation to its own list.

The introduction of the GMS supplementary list is directly linked to the expansion of the NHS pension scheme to locum doctors. The Pensions Agency is issuing guidance separately . However, when the new GMS supplementary lists have been established by Health Authorities a basic condition for entry to the NHS Pension Scheme is inclusion on a GMS supplementary list.

It is suggested that LMCs should help co-ordinate communications for non-principals.

Has are aked to meet with local non-principals to discuss the introduction of these procedures.

GP principals on the medical list will be asked to give the similar extra application details to those of non-principals.

Has will have new powers to refuse, remove or suspend GPs on any of these lists.

Summary

(paragraph numbers refer directly to paragraphs in the main document)

2.2.1 This will apply only to doctors working, at least in part, in GMS. It will cover such doctors engaged or employed as a deputy doctor or as an assistant (including associates, assistants, salaried GMS doctors, retainees, locums and GP Registrars). Except where the context refers only to part of this group of doctors future references to this group of doctors will use the term "non-principal".

2.2.2 Separate supplementary list provisions for dentists, pharmacists and opticians will be introduced during the first half of 2002. The intention is that those provisions will be broadly similar to the GMS supplementary list rules, which are described here.

2.2.3 Health Authorities will have the same powers over admission, suspension and removal from the supplementary list as are described above in relation to the medical list.

2.2.4. A non-principal can only be on the GMS supplementary list of one Health Authority in England at any one time. He cannot be on a GMS supplementary list whilst also being on a medical list or a services (PMS) list. In addition when applying to the Health Authority the non-principal must provide reasonable assurances that he will provide GMS services in the area of the Health Authority.

2.2.5. Some doctors, especially locums will work in PMS and GMS. Once the services (PMS) list is introduced there will be no requirement that, for example, a locum should have to be on both a supplementary and a services list. A locum on a GMS list will be able to work in PMS and vice versa. A locum who wishes to work in PMS or GMS will be able to choose which list (supplementary or services) he applies to join. In addition a GP Principal on the medical list will be able to work in either GMS or PMS without having to join the supplementary or services list.

2.2.6 Having joined the Health Authority supplementary list if a non-principal does not work in the authority's area for a period of twelve months he may, not must, be removed from the list.

2.2.7 From the 1 April 2002, subject to transitional rules until 31 May 2002, a doctor cannot be employed or engaged to work in GMS unless he is on a medical list, a supplementary list or is named on an agreement under section 2 of the Primary Care Act as a performer of PMS (this latter criteria is temporary pending the introduction of the services (PMS) list). Future references to the latter criteria will be expressed as "named as a performer of PMS".

2.2.8 From 1 June 2002 a GP Principal using an organisation which provides deputy doctors will need a written undertaking from that organisation that it will provide only a doctor on either the existing medical list, the new Health Authority supplementary list or who is named as a performer of PMS.

2.2.9 Before employing or engaging a deputy doctor there is a requirement on the principal doctor to ask for and take up references from the deputy doctor.

2.2.10 These changes are contained in the National Health Service (General Medical Services Supplementary List) Regulations 2001 - S.I. 3740/2001.

GMS Supplementary Lists

The Introduction of Supplementary Lists

4.1 Introduction

4.1.1 This section is only applicable to General Medical Services (GMS).

4.1.2 Health Authorities can start to build their supplementary lists with effect from the 14 December 2001 and should aim to have it substantially in place by 31st March 2002 (was initially February 2002 but deadline now extended). All non-principals, (which includes locums, deputies, associates, assistants, retainers and GP Registrars) who are engaged in the delivery of GMS and who are not on a Health Authority medical list will need to be on a supplementary list. The exception will be a doctor named as a performer of PMS; these doctors will frequently treat GMS patients, for example out of hours, but there is no need for them to separately register on the supplementary list. In due course they will be included in the PMS services list. No doctor, after 1 June 2002, is able to work in GMS unless he is on an English Health Authority's medical list or supplementary list or is named as a performer of PMS. (But see paragraph 4.1.3 for transitional arrangements between 1 April and 31 May.) There is a legal requirement after that date that prevents one doctor engaging another as a deputy, or employing another as an assistant (this term includes registrars, retainers and salaried doctors) unless he is on a supplementary or medical list or is named as a performer of PMS.

4.1.3 Between 1 April 2002 and 31 May 2002 a doctor may assist in the delivery of GMS if he is not on a medical or supplementary list or named as a performer of PMS but only if he has applied to join a Health Authority supplementary list prior to 31st March 2002 (was initially February 2002 but deadline now extended) and that application has not been determined by the Health Authority.

4.1.4 In respect of the GMS supplementary list, being on the list of one Health Authority in England will be sufficient to allow a non-principal to work in any Health Authority in England. It will also allow the non-principal to work in a PMS Pilot - subject to any PMS contractual or legislative requirements. In other words a non-principal on the supplementary list in Leeds would not have to join the list of other Yorkshire Health Authorities to locum throughout the county. Separate provisions will apply in Wales, Scotland and Northern Ireland. This greatly reduces the administrative burden on Health Authorities, and all doctors, but does create an expectation that Health Authorities will share information where necessary. They will also need to consider the potential presentational difficulties where they reach different decisions on broadly similar facts relating to the same doctor.

4.1.5 Getting sufficient non-principals on to the supplementary list to meet the demand for such doctors in GMS is clearly important. Health Authorities are strongly recommended to be proactive in constructing and maintaining the supplementary list and are advised to discuss appropriate measures with their Local Medical Committees (LMCs) who are likely to be in a strong position to assist in the publication of these changes. The supplementary list needs to be in place by 31st March 2002 (was initially February 2002 but deadline now extended) and Health Authorities will need to start to build the list immediately.

4.1.6 However, to allow Health Authorities the opportunity to monitor the impact on the supply of deputy doctors and clear any late surge in applications the absolute prohibition on doctors working in GMS unless they are on a medical or supplementary list or named as a performer of PMS does not start until 1 June 2002, but see 4.1.3 above.

4.1.7 The setting up of the supplementary list is also crucial to the opening up of the NHS Pension scheme to locum doctors. Whilst the operational details of this change are for the Pensions Agency Health Authorities need to be aware that access to the pension scheme will be dependent on being on the Health Authority supplementary or services list. Access to the pension scheme will be backdated to April 2001 and to ease related administrative difficulties these doctors need to be on the supplementary list before the end of the 2001- 02 tax year. Most locum doctors will work in both PMS and GMS and admission to the GMS supplementary list in these circumstances should present no problems. There may be isolated locums who consider that they only work in PMS, although in reality most will treat GMS patients in situations such as out of hours provision. Most would also, in reality, be available to work in a GMS practice if that was the only work available to them at any given point in time. Until such time as the PMS services list is in place Health Authorities need to be as flexible as possible in admitting PMS locums to the GMS supplementary list so as to avoid any potential loss of pension rights.

4.1.8 Being on the supplementary list is a pre-requisite of working in GMS as a non-principal. In admitting a non-principal to the supplementary list the Health Authority will consider clinical suitability; they must be satisfied that the non-principal is suitable and that his inclusion would not prejudice the efficiency of general medical services. However, anyone subsequently employing or engaging a non-principal who is on this list is responsible for satisfying themselves that the non-principal has the necessary clinical skills and experience to undertake the tasks they are recruited to perform. No-one should assume that the fact of being on the supplementary list indicates that a non-principal has the necessary level of experience or clinical skill to undertake the tasks they might be recruited to perform.

4.1.9 The content of the supplementary list is for the Health Authority to decide but as a minimum must include the doctor's full name, Medical Register Registration number, the date the doctor's name was entered onto the list and provided that the doctor consents to its inclusion, his date of birth, or, if he does not so consent, the date of his first full registration as a medical doctor (whether pursuant to the Medical Act 1983 or otherwise). The Health Authority are recommended to publish the list with effect from 1 April 2002.

4.1.10 As part of the supplementary list the non-principal's Medical Register Registration number should be directly associated with the relevant DoH organisational code (HA "Q" Code or PCT organisational code) applying to the NHS organisation legally responsible for the list. The organisational code should be the suffix (xxx-yyy where "x" is the GMC number and "y" is the organisational code).

4.1.11 If the published supplementary list is established showing the current HA "Q" code as the suffix it will be necessary to update the list with PCT references next year. This additional task could be avoided if it is possible to establish before publishing the list, which PCT will, in the future, hold a non-principal's registration. This may involve discussions with individual non-principals or with their representatives. No attempt should be made to coerce a non-principal into aligning himself with a particular PCT whilst lists are legally maintained at Health Authority level.

4.1.12 Health Authorities might wish to include in the list some of the detail that they include in their local directory of family doctors (in relation to the medical list) such as second languages or particular clinical interests. However, other than the mandatory items set out above a Health Authority has no authority to include any personal details relating to a doctor on the supplementary list without the non-principal's consent. The list is to be available for public inspection.

4.1.13 Health Authorities may also wish to consider the potential value of sharing information about who is on their supplementary list with other health service related bodies in their area. For instance the support available to a non-principal might be broadened if information such as name and address was to be available to local bodies such as the LMC, and Dean of Post-Graduate Education. Such information may only be shared with the non-principal's permission. Health Authorities are recommended to agree in advance which organisation they were prepared to share this information with; these should be organisations that could help/support the non-principal if they were aware he was working locally. Application procedures could then make clear to the non-principal that his contact details will be shared with the named organisations unless he specifically withholds his consent.

4.2 Admission

4.2.1 A doctor wishing to work in any capacity in GMS will, if he is not eligible to be on the medical list or named as a performer of PMS, have to apply in writing to the Health Authority for admission to its supplementary list.

4.2.2 Just as if he were applying to the existing medical list to be eligible for entry to the supplementary medical list, a non-principal must be suitably qualified, experienced (but see paragraph 4.2.42 in respect of GP Registrars) and free from national suspensions or disqualifications etc. The seventy age limit which applies to the medical list does not apply to the supplementary list.

4.2.3 The application for admission to the supplementary list has to include the matters listed in Annex G. This is largely self-explanatory. However, Health Authorities are asked to be aware that it could be seen as unreasonable to ask a locum doctor to list every appointment (job) he has undertaken when detailing his career history. An entry such as "locum doctor in general practice from April 1998 to date" would usually be perfectly acceptable. Where the period of locum work was interrupted by a permanent, or semi-permanent post, say six months in a hospital A&E Unit, then the entry could reflect this accordingly (locum - A&E - locum). In addition a doctor who had been in a permanent position would not have to show breaks caused by leave of absence for matters such as maternity or study leave. The entry should simply be, for example, "General Practitioner at [location] from April 1980 to March 1997".

4.2.4 Health Authorities are required to check details provided in applications as far as is practical. In examining the details provided by the non-principal about his professional career it will not normally be practical (or expected) that all the details be checked. However, Health Authorities are asked to consider any significant breaks in the career history. Further enquiries need to be made of the doctor where the Health Authority has concerns.

4.2.5 The non-principal must also supply with the application a declaration as detailed in Annex H concerning such matters as criminal convictions, GMC investigations and NHS Counter Fraud investigations.

4.2.6 A non-principal applying to the supplementary list must also provide a number of undertakings. These are:-

i. not to assist in the provision of GMS in the area of another Health Authority from whose medical, supplementary or services list he has been removed, except where that removal was at the request of the practitioner or in accordance with regulation 10(7) of the NHS (GMS Supplementary List Regulations 2001(see paragraph 4.3.3(vi) below) without the written consent of that Health Authority;
ii. to co-operate with an assessment by the NCAA when requested to do so by the Health Authority;
iii. to notify the Health Authority within 7 days of any material changes to the information provided in the application until the application has been finally determined;
iv. to notify the Health Authority if he is included, or applies to be included, in any other list held by a Health Authority or equivalent body (in Scotland, Northern Ireland or Wales);
v. to provide declarations required by regulation 9 of the NHS (GMS Supplementary List) Regulations 2001(concerning such matters as new criminal convictions, new professional investigations by licensing, regulatory or other bodies and new NHS Counter Fraud investigations.);
vi. consent to a request being made by the Health Authority to any employer or former employer, licensing, regulatory or other body in the United Kingdom or elsewhere, for information relating to a current investigation, or an investigation where the outcome was adverse, by them into the non-principal or a body corporate referred to in regulation 9(1) or 9(2) NHS (GMS Supplementary List) Regulations 2001.

4.2.7 The undertaking in paragraph 4.2.6(i) is not intended to prevent the non-principal treating any patient in an emergency. A non-principal may provide services for an out-of-hours organisation which as part of its' responsibilities routinely covers more than one Health Authority area, including the area of a Health Authority referred to in 4.2.6(i). If so, the non-principal is asked to notify the Health Authority who have previously removed him from their list that he might be called upon to treat patients in their area. It is suggested that in these circumstances only the assumption be that, notwithstanding his undertaking, the non-principal is able to treat any patient covered by the out-of-hours organisation unless the Health Authority notifies the non-principal and the out-of-hours organisation accordingly.

4.2.8 A Health Authority must refuse to include a non-principal on the supplementary list if:-
i. he has not for three out of the last six months, provided General Medical Services in its area, or provided satisfactory evidence that he intends to provide services in its area (but see further advice at 4.2.11 & 4.2.12);
ii. he is on the supplementary or medical list of any other Health Authority in England unless he has given notice in writing that he wishes to withdraw from that list ;
iii. he is on the services list of any other Health Authority in England unless he has given notice in writing that he wishes to withdraw from that list;
iv. unless he is suitably experienced within the meaning of section 31 of the NHS Act 1977 (but for GP Registrars see the advice at 4.2 42);
v. if it is not satisfied that he has the knowledge of English which, in his own interest and those of his patients, is necessary for the provision of General Medical Services in its area (but see further advice at 4.2.9);
vi. where he has been convicted in the United Kingdom of murder;
vii. where, on or after the 14 December 2001, he has been convicted in the United Kingdom of a criminal offence and sentenced to a term of imprisonment of over six months;
viii. where he has been nationally disqualified (as defined in regulation 2 of the NHS (GMS Supplementary List) Regulations 2001 which includes a disqualification - the terms of which include the supplementary list - by the FHSAA in England, a national disqualification by the NHS Tribunal in Scotland and Northern Ireland and similar decisions by the NHS Tribunal under section 46(2) of the NHS Act in Wales) ;
ix. where he has not updated his application in accordance with regulation 7(4) of the NHS (GMS Supplementary List) Regulations 2001 (following a deferment of his application and has not done so with the agreed time);
x. where he does not notify the Health Authority under regulation 15(5) of the NHS (GMS Supplementary List ) Regulations 2001 that wishes to be included in the list subject to specified conditions (set by the FHSAA).

The Health Authority must always be able to demonstrate the factual basis of its decision. In particular in refusing to admit a non-principal under (vi)-(viii) above there is a clear expectation that the Health Authority will have tangible evidence of the conviction/disqualification from an appropriate body or via a confirmatory declaration from the non-principal. There may be no right of appeal against mandatory refusal to admit but the decision can be challenged through the courts.

4.2.9 The English test at 4.2.8(v) mirrors the requirement for acceptance or nomination to the existing Health Authority medical list. Health Authorities are advised to administer it in the same way. It would be very exceptional for a non-principal who had passed the Professional and Linguistic Assessment Board (PLAB) test to be refused under this provision.

4.2.10 Otherwise a Health Authority may refuse to include a non-principal in its supplementary list if:-
i. having considered, and checked where practical, the declaration required by regulation 4(4) and (5) of the NHS (GMS Supplementary List) Regulations 2001 (Annex H of this advice) and any other information in their possession in relation to the application it considers he is unsuitable to be included in the list;
ii. having checked the information provided by the doctor in regulation 4(2)(e) & (f) of the NHS (GMS Supplementary List) Regulations 2001 the Health Authority considers he is unsuitable to be included in the list;
iii. (if they choose to contact referees) having contacted referees, the Health Authority is not satisfied with the references given in accordance with regulation 4 of the NHS (GMS Supplementary List) Regulations 2001;
iv. having checked with the National Health Service Counter Fraud Service for any facts they consider relevant to past or current fraud investigations involving the doctor, and having considered these and any fraud case relating to the doctor (fraud within the meaning of section 49F(3) of the NHS Act 1977, as read with section 49H) the Health Authority considers these justify such refusal;
v. there are any grounds for the Health Authority to consider that admitting the non-principal to the list would be prejudicial to the efficiency of the service that he would undertake;
vi. where the non-principal's registration in the register of medical practitioners is subject to conditions imposed pursuant -
· to a direction of the Professional Conduct Committee under section 36 of the Medical Act 1983,
· to a direction of the Health Committee under section 37 of that Act,
· to an order of either of those committees or the Preliminary Proceedings Committee under section 42 of that Act;
· to a direction of the Committee on Professional Performance under section 36A of that Act( ).

Before reaching a decision on the issues in paragraphs (i)-(v) above the Health Authority must consider those matters outlined at Annex E (1).

4.2.11 It is for the Health Authority to determine what constitutes satisfactory evidence of an intention to provide services in its area. This might be something in writing from a general practice or from organisation providing deputy doctors:-

· offering the non-principal work as a deputy or assistant;
· citing a willingness to offer the non-principal work in the future as a deputy or assistant;
· offering to register the non-principal with, for example, a locum agency providing services in the area;

or, it could be evidence that the non-principal has:-

· joined the Local Medical Committee;
· joined a local non-principal group.

Offers of employment might well be conditional on the non-principal being entered on the Health Authority supplementary list by the Health Authority. Indeed where the non-principal's application was accompanied by an actual offer of work the Health Authority ought to be prepared to treat the application expeditiously so that the offer does not fall.

4.2.12 A non-principal may not be able to provide information in paragraph 4.2.11 but may have a genuine and clear intention to work in the Health Authority area. Non-principals returning from maternity leave, overseas work or long term sick leave might have particular difficulty in this respect. In such cases the Health Authority are recommended to be flexible and pragmatic. They may, for example, consider that satisfactory evidence that the non-principal intends to work in its area can come from a written commitment from him coupled with some other factor which links him to the area such as a home in the Health Authority area or evidence that he has, or is, working locally in a NHS Trust or a PMS pilot. It is envisaged that a refusal to admit a non-principal who wishes to be able to work in the Health Authority's area under these provisions would be very rare.

4.2.13 Before placing someone on the supplementary list Health Authorities must, in particular, make full checks on a non-principal's qualifications. The NHS Act 1977 requires that, in order to work in general practice in any capacity (with the exception of GP Registrars in training) doctors must be fully registered with the GMC and suitably experienced. Suitable experience is defined in the NHS (Vocational Training for General Medical Practice) Regulations 1997. The latter requires a certificate of prescribed experience, a certificate of equivalent experience, a certificate of acquired rights or evidence that the doctor is exempt from the need to have acquired the prescribed experience. It is good practice to see original certificates. However, care will need to be exercised to ensure these are returned undamaged. In checking qualifications the Health Authority will need to be satisfied that a person is who they say they are, if there are any reasons for doubt the Health Authority is advised to seek additional evidence of identity such as a passport.

4.2.14 In future whenever a Health Authority refuses to include, conditionally includes, removes, contingently removes or suspends a doctor from any of its lists it ought to forward basic details about that decision to the FHSAA(SHA). Over time this will provide a useful source of information to Health Authorities wishing to verify a doctor's statement about incidents involving list status in the past. See Section 12 paragraph 12.2.5 for details and contact telephone number.

4.2.15 In addition the Health Authority must check with the NHS Counter Fraud Service (NHS CFS) for any past or ongoing fraud investigations relating to the non-principal or in connection with a corporate body to which he has declared a link. Contact numbers are in Annex F. It should be noted that the statutory power for CFS to disclose information about past or current investigations is permissive not mandatory. In particular, for current investigations, CFS staff are not compelled to disclose even the simple fact that there is an investigation if it would be premature to do so and might risk compromising or jeopardising the success of any potential criminal action by effectively forewarning the individual under suspicion. However, in such cases, the NHS CFS will notify the Health Authority of any adverse outcome of an investigation.

4.2.16 Non-principals from overseas are required to conform with Immigration and Employment rules. Health Authorities are already checking the status of overseas doctors who apply to join the medical list and similar checks will be required before a non-principal can be placed upon the supplementary list. Official guidance (A Guide to Immigration ad Employment of Overseas Medical and Dental Students, Doctors and Dentists in the United Kingdom).

4.2.17 Most non-principals who come within the definition of an overseas doctor in paragraph 3 of the aforementioned guidance and those who do not have settled status will require work permits, although some locums may be covered by the self-employed criteria. Work permit status can often be established from passport stamps but self employed status may require a confirmatory letter from the Home Office (a process Health Authorities will be familiar with in respect of GP Principals as eligibility must be positively established before applicants details are forwarded to the MPC). General advice on GMS appointments is at paragraphs 36-39 and advice on how to check eligibility for employment is in Part IV of the aforementioned guidance.

4.2.18 It is a matter for the Health Authority as to whether or not they wish to take up references before admitting a non-principal to the supplementary list. Where they have doubts about the non-principals past, such as ambiguous statements about previous posts, it would be good practice to take up references. However, it is acknowledged that Health Authorities will need to consider the practicalities of handling large numbers of applications between December 2001 and March 2002. Non-principal's will in any event have to provide clinical references to GP before they can be engaged or employed in general practice after 1 April 2002.

4.2.19 If references are taken up these should be from referees who are willing to provide clinical references in respect of two recent posts (which may include any current post) as a doctor that lasted at least three months without a significant break. There will be cases where the applicant cannot meet this requirement. For example where the non-principal's preferred working pattern is a series of short-term locum positions. However, locum work might be felt to meet the condition where the locum has done separate periods of work within one general practice over a twelve month period that amount to at least 13 weeks. Where the Health Authority is satisfied that a non-principal cannot meet the normal conditions it may accept references from any other clinicians who can comment objectively on the non-principal's clinical abilities. In requesting references the Health Authority must state that they are asking for clinical not general references. If a Health Authority decides to ask the referee to complete a pro-forma, as opposed to a freestyle reference, it is recommended that they first discuss the content with local clinicians or their representatives to establish that the pro-forma is fit for purpose.

4.2.20 Many Health Authorities will have developed best practice human resource initiatives in connection with the admission of a doctor to its medical list. These might include, for example, occupational health checks, immunisation status checks, child protection checks etc. Nothing in this advice should be seen as preventing a Health Authority implementing similar good practice in relation to the supplementary list. However, Health Authorities need to be able to recognise what is required under the law and what is voluntary. Any results from such checks do not create new grounds for refusing to admit a practitioner. They can only be relevant in this sense if they are within the ambit of the grounds for refusal outlined above.

4.2.21 As an alternative to admitting or refusing to admit a non-principal to its supplementary list the Health Authority can decide to make admission to the list subject to conditions. These conditions must be devised so as to minimise any risks associated with fraud or efficiency matters that the Health Authority has identified. For example where there is a history of fraud or dishonesty the conditions might minimise the non-principal's direct access to public funds. In efficiency cases they might address poor performance or other clinical issues by requiring certain additional training or supervision in a particular area.

4.2.22 The conditions cannot relate to issues of suitability. Therefore conditions such as:-

i. that the non-principal avoids future convictions related to alcohol abuse;
ii. that because of a history of convictions for sexual offences that the non-principal should only see certain patients if accompanied,

are unlikely to be appropriate.

4.2.23 Additionally conditional inclusion is not a substitute for a deficient application process. A condition that a non-principal should be admitted to the list subject to providing evidence in support of his application within 6 months would not be appropriate.

4.2.24 A Health Authority is able to review the conditions it applies to a non-principal when it considers such action appropriate. In addition the Health Authority must review those conditions if the non-principal requests a review in writing subject to:-

i. the request being made no earlier than three months after the non-principal was entered onto the list subject to the conditions;
ii. the request being made no earlier than six months after the decision on any previous review.

4.2.25 On any such review the Health Authority can:-

i. maintain the existing conditions;
ii. remove some or all of the existing conditions;
iii. impose fresh conditions.

4.2.26 A Health Authority may remove a non-principal, subject to the normal criteria/procedures, at any time where there is evidence that he has breached a condition imposed on admission or at any subsequent review.

4.2.27 Before deciding to admit a non-principal to the supplementary list subject to conditions (a conditional inclusion) it would be good practice for the Health Authority to give him notice of its intention and why it proposes a particular condition(s) and afford the non-principal an opportunity to discuss the issues with the Health Authority orally or in writing as he might wish. All attempts need to be made to do this in a way that does not unduly delay the process of handling an application to join the list.

4.2.28 A decision to refuse admission, on discretionary grounds (where the Health Authority may, not must refuse) to the list, to make admission subject to conditions or any decision as to conditions made on review, should only be implemented:-

i. where there is no appeal - after the 28 day period for appealing has ended;
ii. where there is an appeal - where the FHSAA finally disposes of the appeal.

The exception to this rule is if a non-principal who is subject to a conditional inclusion and appeals against that decision but is prepared to accept those conditions in writing pending the outcome of the appeal. In those circumstances the non-principal can be entered onto the list. If, following the appeal the non-principal did not undertake to be bound by any conditions decided upon by the FHSAA on appeal the Health Authority will be able to remove him from the list without any further appeal right.

4.2.29 The Health Authority must notify applicants of the result of their applications in writing and, if this involves a conditional inclusion or a refusal to admit to the list the reasons for the decision, including the facts relied upon, and advise the doctor of any right to a review or any right of appeal.

4.2.30 The right of appeal to FHSAA is against any Health Authority refusal to admit to the supplementary list on discretionary grounds (where the Health Authority may, not must, refuse admission), any conditions applied to the non-principal's entry to the list or to any decision made by the Health Authority about such conditions on review. Appeals must be made in writing to the FHSAA within 28 days of the Health Authority's decision. Appeal processes are covered in detail in Section 7 of this advice.

4.2.31 Whenever they refuse to admit a non-principal to their list on grounds of efficiency, fraud or unsuitability the Health Authority should consider approaching the FHSAA for a national disqualification - see section 8.

4.2.32 The Health Authority may also choose to defer making a decision on a non-principal's application to join the supplementary list. The purpose of this provision is to avoid a Health Authority having to make a decision to admit or to refuse admission where there is an matter outstanding against the non-principal which, if the outcome is adverse, would be likely to lead the Health Authority to remove him from its list if it had admitted him in the first place.

4.2.33 The caveat "likely" is important. Before deferring an application the Health Authority must form the opinion that if matters go badly for the non-principal it is probable that if they had admitted him to their list they would choose to remove him from that list.

4.2.34 Deferment can only be used where an application is received after 31st March 2002 (was initially February 2002 but deadline now extended). This is part of the transitional provisions and is intended to place a working non-principal in the same position as a working principal whilst the supplementary list is initially being constructed. When a working principal makes catch up declarations (section 9) the Health Authority cannot use the deferment procedures whilst, for example it awaited the outcome of a criminal case. It would, therefore, be unfair if, for example, a salaried doctor making a similar declaration as part of the process of joining the new supplementary list could have his application deferred when applying to join the new supplementary list in such circumstances. It would be unfair to make a salaried doctor give up his existing work in circumstances where, if he had been a principal, he would have been allowed to continue. This might in extreme cases lead to a non-principal being admitted to a list and then being suspended.

4.2.35 The regulations specify the only circumstances where a deferment can be applied; these are listed at Annex J.

4.2.36 The Health Authority must notify the non-principal that it is deferring the application and once the outstanding matter is resolved they must process the application. However, before processing the application they should ask the non-principal if he wishes to continue with the application and if so to confirm the details in the application remain correct, updating the details as necessary.

4.2.37 The non-principal must be allowed 28 days to respond. Where the Health Authority considers it to be reasonable they can agree a longer period. This provision is included so an application is not left in a state of limbo and Health Authorities should be helpful if asked to allow a longer period. They should consider that, for example, a court case, which cleared an individual of all allegations against him, might leave him unsure about continuing to live or work in the area. It is proper to allow the non-principal time for reflection if asked. If he does not respond within that period the Health Authority can refuse to admit him, as they will not be aware whether or not the application is still current.

4.2.38 Where the application continues it needs to be processed expeditiously given the delay which the deferment will have caused. Delay by the Health Authority at this stage is not acceptable.

4.2.39 There is no right of appeal against a deferment.

4.2.40 However, a non-principal subject to a deferment can at any time withdraw his application without restriction. He can also re-apply at any time. On a re-application the Health Authority must consider the question of deferment afresh.

4.2.41 Section 6 of this advice discusses how Health Authorities shall apply the discretion they are given in relation to these decisions and looks in more depth at the related procedures and information sharing.

GP Registrars

4.2.42 GP Registrars are doctors training in a general practice setting (the equivalent of a Senior House Officer in a hospital). GP Registrars may treat patients as a general practitioner in the context of their training under the supervision of a GP Trainer. Because of the direct patient contact the provisions of the supplementary list have been extended to GP Registrars.

4.2.43 GP Registrar training is sometimes used as a means of refresher/orientation training by doctors who already possess the right to work in general practice. With these exceptions, the majority of GP Registrars are doctors working towards the award of a certificate of prescribed experience or equivalent experience. As such they will not be able to meet the condition of being suitably experienced in accordance with section 31 of the NHS Act 1977. Nevertheless, Health Authorities should admit these doctors to the supplementary list. As a substitute for the check that the doctor has the appropriate vocational training qualification a check can be made with the local Dean that the doctor is a GP Registrar undergoing a period of approved training.

4.2.44 It would be good practice to note the Health Authority records specifically to identify GP Registrars and to record the period of training being undertaken. If the doctor ceases to be a GP Registrar before receiving his certificate he should be removed from the list. Otherwise, when a doctor receives his certificate at the end of a period of training it would be good practice to ask the doctor if he wishes to remain on the supplementary list. It would be perfectly acceptable for a fully trained and certificated GP returning to a hospital post to stay on the list if he wished so that he could undertake occasional locum work in general practice.

4.2.45 Further information on GP Registrars is available in the DoH publication "The GP Registrar Scheme (Vocational Training for General Medical Practice) - The UK Guide".

4.3 Removal

4.3.1 A Health Authority must remove a non-principal from its supplementary list where he:-

i. has been convicted in the United Kingdom of murder;
ii. has been convicted in the United Kingdom on or after 14 December 2001 of a criminal offence and has been sentenced to a term of imprisonment of more than six months;
iii. has been nationally disqualified (as defined in regulation 2 of the NHS (GMS Supplementary List) Regulations 2001 which includes a disqualification - the terms of which include the supplementary list - by the FHSAA in England, a national disqualification by the NHS Tribunal in Scotland and Northern Ireland and similar decisions by the NHS Tribunal under section 46(2) of the NHS Act in Wales) ;
iv. has died;
v. is no longer a doctor (that is no longer a registered medical practitioner);
vi. is the subject of -
· a direction given by the GMC Professional Conduct Committee under section 36 of the Medical Act 1983, or
· an order made by that committee under section 38(1) of that Act;
viii. is included in the medical or services list of any Health Authority , or the supplementary list of another Health Authority;
ix. when notified by the FHSAA that it has,
· considered an appeal by the non-principal against a contingent removal by the Health Authority ad has decided to remove him instead;
· considered an appeal by a non-principal against a conditional inclusion, where the non-principal has been conditionally included in the list until an appeal has been decided, and has decided not to include him.

In removing a non-principal under these provisions there is a clear expectation that the Health Authority will have tangible evidence of the conviction/disqualification/FHSAA decision etc. from an appropriate body or via a confirmatory declaration from the non-principal as appropriate. There may be no right of appeal against mandatory removals but the decision can be challenged through the courts.

4.3.2 The removal is effective from the date of the Health Authority's determination or, where paragraph 4.3.1 (iii), (vi) & (ix) applies, the date on which the decision, direction or order takes effect, if that date is later than the date of the Health Authority's decision.

4.3.3 A Health Authority may remove a non-principal from its supplementary list in the following circumstances:-

i. the non-principal's continued presence on the list would be prejudicial to the efficiency of the services which those included in the list assist in providing; (an efficiency case as per NHS Act 1977 section 49F(2));
ii. the non-principal concerned (whether on his own or together with another) is involved in a fraud case in relation to a health scheme (NHS Act 1977 sections 49F (3) and 49H);
iii. the non-principal is unsuitable to be included in the list (an unsuitability case as per NHS Act 1977 section 49F(4));
iv. if it decides the non-principal is in breach of a condition imposed on him on inclusion on the list under regulation 8 of the NHS (GMS Supplementary List) Regulations 2001;
v. if it decides the non-principal has failed to comply with a condition imposed on a contingent removal under regulation 12 of the NHS (GMS Supplementary List) Regulations 2001 (see 4.3.5 below);
vi. where the non-principal cannot demonstrate that he has assisted in the provision of General Medical Services within the area of the Health Authority during the preceding twelve months.

In all cases outlined in paragraphs (i)-(iii) the Health Authority must consider the relevant matters outlined in Annex E (2-4).

4.3.4 Where paragraph 4.3.3 (vi) applies the Health Authority ought to take particular care to examine the reasons why the non-principal has not worked in its area of late. If this involves matters such as prolonged sickness or maternity leave then if the authority believe that the non-principal will resume work in its area removal is unlikely to be the right course of action. Prolonged contractual work with a local Trust or PMS pilot that is shortly to end ought to be treated in a similarly understanding manner. Additionally any period specified in regulation 10(8) of the Supplementary List regulations must be ignored. In these cases once the decision has been determined, or an appeal decided, the non-principal's name should not be removed for three months to allow him the opportunity to apply to another Health Authority.

4.3.5 In relation to the requirement to provide GMS locally there is no requirement on a Health Authority to check every non-principal every year or to keep ongoing employment records. However, it is in no-ones interest to have the list populated with non-principals who no longer have any realistic connection with the delivery of GMS in the area. When looking at tidying up its supplementary list using the criteria in 4.3.3 (vi) the Health Authority will be able to look at local records, such as NHS superannuation records, appraisal record etc. Where doubt still remains they will need to consider approaching the non-principal.

4.3.6 The H&SC Act also provides for contingent removal from the supplementary list as an alternative to removing a non-principal from the Health Authority list. The primary power is in sections 43D(6) & 49G of the H&SC Act. The simple concept is that conditions are placed on the non-principal's retention on the supplementary list. If these conditions are subsequently breached the non-principal can be removed from the list. They represent a way of improving patient protection without taking the ultimate step of removing the non-principal. The conditions put in place must be designed to minimise any risks associated with any fraud or efficiency matters that the Health Authority has already identified in connection with the individual doctor. For example where there is a history of fraud or dishonesty the conditions might minimise the non-principal's direct access to public funds or seek additional checks on any direct or indirect claims. In efficiency cases they might address poor performance and other clinical issues by requiring certain additional training or supervision in a particular area.

4.3.7 The conditions cannot relate to issues of suitability. Therefore conditions such as:-

are unlikely to be appropriate.

4.3.8 The Health Authority is able to review the conditions it applies to a non-principal when it considers such action appropriate. In addition the Health Authority must review those conditions if the non-principal requests a review in writing subject to:-

i. the request being made no earlier than three months after the decision of the Health Authority to impose conditions;
ii. the request being made no earlier than six months after the decision on any previous review.

4.3.9 On any such review the Health Authority can:-h

i. maintain the existing conditions;
ii. remove some or all of the existing conditions;
iii. impose fresh conditions.

4.3.10 A Health Authority may remove a non-principal, subject to the normal procedures, at any time where there is evidence that there has been a breach of a condition imposed as part of a contingent removal or as a result of a subsequent review.

4.3.11 A Health Authority cannot, however, review conditions applying to a contingent removal decided upon by the FHSAA at an appeal. These must be reviewed by the FHSAA although the Health Authority may seek such a review in the same way as the doctor. The time limits appropriate to reviews requested by the Health Authority or the doctor to conditions imposed by the FHSAA are:-

i. the request being no earlier than three months after the decision of the FHSAA to impose conditions;
ii. the request been no earlier than six months after the decision on any previous review;
iii. where the non-principal and the Health Authority jointly apply for the conditions to be changed, varied or revoked no earlier than one month after the previous FHSAA decision.

4.3.12 Before making a contingent removal or a discretionary decision under paragraph 4.3.3 or 4.3.10 to remove the non-principal from its supplementary list, the Health Authority must give the doctor 28 days notice of its intention and why it proposes a particular course of action. It must afford the non-principal an opportunity of making representations to the Health Authority orally or in writing as he might wish.

4.3.13 A decision to remove from the list, on discretionary grounds (where the Health Authority may, not must, remove) to make retention subject to conditions or any decisions about conditions made on review, should only be implemented:-

i. where there is no appeal - after the 28 day period for appealing has ended;
ii. where there is an appeal - where the FHSAA finally disposes of the appeal.

4.3.14 Where the Health Authority determines that it will remove a non-principal's name from its supplementary list, or make retention subject to conditions it must give notice in writing of its determination to the non-principal together with the reasons for it, including any facts it relies on, and inform him of any right of review or any right of appeal.

4.3.15 The right of appeal to FHSAA is against any Health Authority decision to remove from supplementary list on discretionary grounds (where the Health authority may, not must, remove), any conditions applied to the non-principal's retention on the list or to any decision made by the Health Authority about such conditions on review. Appeals must be made in writing to the FHSAA within 28 days of the Health Authority's decision. Appeal processes are covered in detail in Section 7 of this advice.

4.3.16 Whenever they remove a non-principal from their list on grounds of efficiency, fraud or unsuitability the Health Authority is advised to consider approaching the FHSAA for a national disqualification - see section 8.

4.3.17 Section 6 of this advice discusses how Health Authorities shall apply the discretion they are given in relation to these decisions and looks in more depth at the related procedures and information sharing.

4.4 Suspension

4.4.1 Suspensions are intended to be a very rare event. It is imperative that suspensions are not misused as this can result in serious individual injustice damaging an individual's career and personal life as well as being a major waste of public money. It is, therefore, in the interests of all concerned to ensure alternatives to suspensions are carefully considered. In this context it is important in these cases that the Health Authority can substantiate its decision that the suspension was necessary in order to protect patients from the potential actions of the non-principal or that there was a genuine public interest justification. If there is no risk to patients and no public interest justification there can be no suspension.

4.4.2 A Health Authority can suspend a non-principal from the supplementary list when it is necessary to do so for the protection of members of the public or is otherwise in the public interest. All suspensions must meet these criteria.

4.4.3 Additionally, even where the condition in 4.4.2 is met, a suspension is only possible in the following circumstances:-

i. whilst the authority considers whether or not to remove or contingently remove the non-principal;
ii. whilst it awaits the decision of a court or body which regulates the doctors profession anywhere in the world affecting the non-principal;
iii. where it has decided to remove the non-principal but before the decision can take effect;
iv. whilst an appeal against a decision to remove the non-principal is being considered.

4.4.4 A risk to the public might be said to exist if there is evidence of dangerous medical practice or if the non-principal is awaiting trial for serious offences of a sexual or violent nature. A public interest justification might be said to exist if:-
· allowing the non-principal continued access to staff, patients or records might significantly prejudice a major fraud investigation either by the NHS Counter Fraud Services or the police;
· allowing the non-principal to continue to work in that area would seriously compromise/disrupt the efficient delivery of local health care.

4.4.5 The effect of a suspension is that although the non-principal's name remains part of the supplementary list he is treated as though he has been removed. The effect is, therefore, that he cannot provide any aspect of GMS to any patient.

4.4.6 A suspension under 4.4.3 (i) cannot exceed six months. The Health Authority are obliged to tell the non-principal the extent of the suspension and where that is less than six months the Health Authority can extend the period but not in such a way that the overall period exceeds six months.

4.4.7 A suspension under 4.4.3(ii) is not restricted to six months but any period of suspension imposed following the decision of the court or body cannot exceed six months and again the non-principal must be told the length of any additional period of suspension as appropriate.

4.4.8 Suspensions under 4.4.3(iii) last until the removal is effected.

4.4.9 Suspensions under 4.4.3(iv) last until the appeal is disposed of by the FHSAA.

4.4.10 Suspensions under 4.4.3 (i) and (ii) can be extended beyond six months by the FHSAA on application. There will be cases where the original six-month suspension expires after the Health Authority has applied to the FHSAA for an extension but before the FHSAA has reached a decision. In such cases the suspension will continue until the FHSAA has disposed of the application. Applications may also be made to the FHSAA to extend any period of suspension that the FHSAA have already imposed.

4.4.11 A Health Authority can revoke a suspension at any time.

4.4.12 A Health Authority is able to review a suspension under 4.4.3 (i) & (ii) imposed upon a non-principal if it considers such action appropriate and must review the decision to suspend if the non-principal requests a review in writing subject to:-

i. the request being made no earlier than three months after the non-principal was suspended;
ii. the request being made no earlier than six months after the decision on any previous review.

4.4.13 On any such review the Health Authority can:-

i. maintain the suspension;
ii. revise the period of the suspension;
iii. revoke the suspension.

4.4.14 A Health Authority cannot be required to review a suspension under 4.4.3 (iii) & (iv). However, it can of its own volition revoke or extend the period of suspensions at any time. However, where it extends a suspension it must follow the same procedures as apply to a review.

4.4.15 For suspensions under 4.4.3(ii) the Health Authority must lift a suspension when the criminal process or the regulatory, licensing or other body investigation is completed and there is no finding against the non-principal. Where there is a criminal conviction or a "finding against" by the regulatory, licensing or other body the Health Authority shall consider whether or not there are grounds to remove the non-principal from the supplementary list under the normal procedures. This can include a further suspension not exceeding six months subject to the usual conditions being met.

4.4.16 The Health Authority shall give notice to the non-principal of any decision to suspend him from the supplementary list giving reasons for its decision, including any facts it relies upon, and informing him of any right to a review. There is no right of appeal against a suspension. However, there is a very strong expectation that the Health Authority will use all reasonable efforts to resolve the reasons for the suspension and either take substantive action against the non-principal or allow him to resume his duties as quickly as possible.

4.4.17 Section 6 of this advice discusses how Health Authorities shall apply the discretion they are given in relation to these decisions and it is important that Health Authorities acquaint themselves with these details. It also looks in more depth at the related procedures and information sharing.

4.5 Amendment of or Withdrawal from the Supplementary List

4.5.1 A non-principal is not required to withdraw from the supplementary list simply because he changes his address or the focus of his employment switches to another Health Authority. However, there are benefits to registering with the Health Authority where the non-principal does most work. That Health Authority might well be better placed to offer support through CPD, clinical audit, appraisal etc.

4.5.2 If a non-principal chooses to remain on the list of the Health Authority where he works irregularly this is acceptable (but see paragraph 4.3.3(vi) where the non-principal does not work in the Health Authority area for twelve months). In these circumstances it would be good practice to encourage the non-principal to build informal links, if he wishes, with the Health Authority where the he does most of his work for the purposes of accessing support functions such as CPD, clinical audit and appraisal. It would be good practice for the health authority to offer the same support in these circumstances to that afforded to non-principals on the list locally.

4.5.3 Where a non-principal is removed from the supplementary list the Health Authority are advised to retain a record of his identification and contact details for a period of at least 6-12 months. This would help in tracing the non-principal should the Health Authority become aware of any matters that require them to contact him.

4.5.4 A non-principal is required to notify the Health Authority of any changes to the details recorded about him on the supplementary list or any change of the address provided by him when he applied to go on the list. The Health Authority is then required to amend the list and associated records accordingly. It would be sensible to remind non-principals that if their address details are not kept up to date important Health Authority communications might not reach them.

4.5.5 Equally a non-principal can ask to have his name removed from the supplementary list. Having given notice that he wishes to withdraw from the supplementary list a non-principal can rescind that request at any time before the Health Authority remove his name except where the withdrawal is under 4.5.6. The non-principal name should be removed from the list three months after the date of the notification or on any earlier date to which the Health Authority has agreed unless 4.5.3 applies.

4.5.6 A non-principal on a Health Authority supplementary list is required to withdraw from that list when he is admitted to any Health Authority medical list or to any Health Authority services (PMS) list. This is treated as a voluntary removal and the non-principal name should be removed immediately.

4.5.7 Where the Health Authority is considering:-

i. the removal of any non-principal on the grounds of fraud, efficiency or unsuitability;
ii. where the non-principal is suspended;
iii. where a decision has been made to remove or contingently remove the non-principal but that decision has not yet been given effect (pending a potential appeal or pending the outcome of an appeal,

the non-principal shall not, except with the consent of the Secretary of State, be entitled to have his name removed from the supplementary list until the matter has been determined by the Health Authority. This prevents the non-principal evading a determination by the Health Authority (which would then be a matter of record) by voluntarily removing his name from the list.

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