Professional Registration Policy

GENERAL NOTE

NHS Fife acknowledges and agrees with the importance of regular and timely review of policy statements and aims to review policies within the timescales set out.

New policies will be subject to a review date of no more than 1 year from the date of first issue.

Reviewed policies will have a review date set that is relevant to the content (advised by the author) but will be no longer than 3 years.

If a policy is past its review date then the content will remain extant until either such time as the policy review is complete and the new version published, or there is national policy or legislative changes.

1. FUNCTION

There are a range of professional groups for whom professional registration is a statutory requirement for employment in the National Health Service. These groups include Medical and Dental (General Medical & General Dental Council), Nursing & Midwifery (Nursing & Midwifery Council), Allied Health Professionals and Healthcare Science staff (Health Care Professions Council), and Pharmacy staff (General Pharmaceutical Council). A full list of regulatory bodies and the staff categories covered by each is provided in Appendix A. NHS Fife has a duty to ensure that new and existing employees are registered with the relevant regulatory / licensing body in order to comply with the requirements of their employment contract.

The purpose of this policy is to set out the procedural steps necessary to ensure patient safety and public protection relating to the professional registration status of individuals within NHS Fife at the various stages of employment.

2. SCOPE

This policy applies to all employees of NHS Fife for whom professional registration is a statutory requirement for employment. This policy includes third party contractors engaged on behalf of NHS Fife and Bank staff. Where third party employers give an undertaking to NHS Fife regarding the registration status of supplementary staff, registration still requires to be checked in line with this policy. This policy must be used in conjunction with national and regulatory body guidance, as well as HR policies and procedures in place within NHS Fife.

3. RESPONSIBILITY

The responsibility for the application of this policy rests with Line Managers and HR staff within NHS Fife. Employees have a responsibility to ensure that their professional registration is maintained as required by the relevant regulatory body and their contractual requirements.

4. OPERATIONAL SYSTEM

This policy aims to:

• Ensure that employees who require professional registration for employment are fully aware of their contractual obligation to demonstrate fitness to practice through professional registration with their regulatory body.
• Set out the procedural steps necessary for checking of professional registration status at various stages of employment.
• Set out the implications when an employee allows their professional registration to ‘lapse’.

This policy emphasises that it is each individual employee’s responsibility to ensure his or her registration with a professional / regulatory body remains current at all times.

NHS Fife will confirm proof of registration using the employer confirmation services of the relevant professional body.

Where there are concerns relating to an individual’s suitability to be on the professional register, NHS Fife as the employer, will make a decision with regard to submitting a formal referral / complaint to the professional body. This will be carried out in consultation and with the agreement of the Executive Director of the relevant group of staff, following discussion with and notification to the individual employee.

5. DEFINITIONS

For the purpose of this policy, the following definitions will be used:

Professional Registration

A process, which confirms that individuals meet normal standards of competence, training, education and integrity required for practice and ensures entitlement to engage in such practice. In addition, this registration must be current and relevant to their area of employment.

Lapsed Registration

Where individuals have allowed their registration with the professional body required for them to practice within their role, to expire.

Permanent or Temporary Loss or Suspension of Registration

Where individuals have had their registration removed, either permanently or temporarily, by the relevant professional body, including suspension from the relevant register.

Third Party Contractors

A worker, employed via a third party organisation, with which NHS Fife may engage to supply staff on an ad-hoc basis.

6. ORGANISATIONAL ARRANGEMENTS

6.1 Recruitment & Selection

All recruitment packs for positions within NHS Fife will contain details of the professional registration required for the post. It will be the recruiting manager’s responsibility to ensure that this is in place and clearly specified within the relevant documentation. NHS Fife job descriptions will reflect the professional registration requirements for the post advertised. Person specifications must contain the requirements for registration.

Application forms will request details of membership of Professional Regulatory body i.e. full name of organisation, registration number and renewal date and recruiting managers will ensure that this information is completed before considering for shortlisting.

Prior to interview, the Recruiting Manager will, via the Recruitment & Selection process, ensure prospective employees are informed in writing of the requirement to produce evidence of current registration at the time of interview. 

At interview, candidates should be asked if their professional registration is up to date and if there are any pending actions by the professional regulatory body. They will be asked to provide evidence of registration and it will be the recruiting manager’s responsibility, to visually inspect this and seek confirmation from the relevant professional body.

Offers of employment will be subject to successful candidates being appropriately registered with the relevant professional body. The Recruiting Manager will be required to check with the relevant professional body that the registration is current at the time of appointment. New employees are not permitted to commence duties without the appropriate verification of their registration.

Any prospective employee who cannot, for whatever reason, supply these details to the Recruiting Manager will not be appointed until the individual has contacted the relevant professional body and produced documentary proof of registration.

When an interviewee is awaiting examination results it should be made clear, usually at interview and confirmed in writing, that any offer of employment is subject to:

1. Satisfactory examination results;
2. Production of evidence of their registration as required above prior to confirming the appointment.

A Professional Registration Flowchart is outlined in Appendix B.

Where levels or sub categories of registration are required i.e. GMC Specialist Registration, then this should be verified as above. 

6.2 Management of On-going Registration

Line Managers of registered professional staff will ensure that local arrangements are in place for systematic, regular reviews to ensure that renewal of registration is carried out and checked for the employees for whom they are responsible.

Line Managers must ensure that:

• They scrutinise registration documentation and confirm registration status with the relevant professional body on commencement and review, prior to the annual (or alternative periods as required), renewal dates.
• Details of the registration number and date of expiry are recorded via local systems, (eESS in longer term). Appropriate and adequate records are kept of this information. These records will be regularly reviewed and such action, as the Line Manager feels appropriate taken to seek / obtain evidence of renewal of registration. These records will be stored securely and be subject to Data Protection Act requirements
• They apply the procedures outlined in this policy fairly and equitably.
• Those individuals within their sphere of management / professional responsibility hold the appropriate current registration during employment.
• As professionals specialise, additional qualifications necessary to undertake specialist / expanded roles are entered in the professional register, which is annotated accordingly, e.g. Non-Medical Prescribing Qualification.
• Line Managers should provide regular assurance to their manager and / or professional lead, that registrations are being checked on a regular basis and highlighting any issues.

6.3 Employee Responsibilities

All employees for whom professional registration is a statutory requirement for employment have a duty to maintain their registration status during the course of their employment within NHS Fife. As a member of a profession, the onus is on the individual to ensure that they:

• Produce suitable evidence of up to date professional registration.
• On request by their Line Manager, provide evidence that their professional registration has been renewed in accordance with relevant regulations, when renewal information is available.
• On request provide evidence of additional qualifications necessary to undertake specialist/expanded roles and provide evidence that the professional register has been annotated accordingly.
• Keep the relevant statutory body informed of changes of address, status, etc., in order that records are accurate and up to date.
• Report any information to their employer which impacts on their continued registration i.e. criminal proceedings, being subject to an investigation by the Police or professional regulatory body.
• Pay the fees associated with new/renewal of registration.
• On receipt of / or renewal of registration, ensure that their line manager and / or professional lead is shown original documentation so that the registration can be verified and copies taken for their employee file / entered on to eESS in future.
• Report any failure to re-register with their professional body to their line manager immediately.

6.4 Midwives

In addition to maintaining their registration, it is a statutory requirement for midwives to give notice of intention to practice to the Local Supervising Authority. This may involve more than one NHS Board area.

6.5 Management of Lapsed or Lost Professional Registration

It is the responsibility of the individual employee to ensure that they maintain such registration as is necessary to enable them to practise their profession within NHS Fife.

In circumstances whereby individual members of these professions allow their registration with their professional body to lapse, or where they have lost their registration permanently or temporarily, it is essential that managers who are required to deal with such situations adopt a consistent approach.

Where professional registration is a condition of employment, and an employee allows their registration to lapse, through their own actions, they are no longer able to work in the capacity for which they are employed. They will not therefore be permitted to work as a in a role which requires professional registration. The employee will be repositioned to the banding equivalent of a non-registered nurse, midwife or Allied Health Professional until their registration is reinstated. The remuneration will be in line with the roles available within the service. In instances where redeployment is unfeasible, remuneration will be withheld. While this is not a punitive action this is a safeguard to both the employee and employer.

However, in circumstances where there is evidence produced that confirms this is an error wholly on the part of the professional registration body, or other circumstances e.g. a major banking systems failure, then these will be dealt with on an individual basis with the Line Manager and with HR support. There will be no detriment to the employee.

Managers will support individuals whose registration has lapsed, to help them to redress this, whilst at the same time, secure the safety of the service by ensuring staff do not work in a professional capacity without valid registration.

When it comes to the attention of a manager that an individual member of professional staff may not be appropriately registered, this must be investigated immediately, in line with the NHS Scotland Workforce Policies Investigation Process. If it is established that the employee’s registration has lapsed or been lost, it must be explained to the member of staff that until they are restored to the appropriate register they cannot continue in their job and are not permitted to work in a role which requires professional registration. This must be communicated to the employee in writing. Notification will also be made to the Payroll Department to ensure that individual receives appropriate payment during this period.

During the course of investigating the circumstances, the line manager will fully explore the reason for the registration having lapsed, been lost or the circumstances where an employee has knowingly worked without registration. Under the NHS Scotland Conduct Policy this may be progressed through early resolution in the first instance or progress straight to NHS Scotland policies Investigation process. The outcome of a formal investigation could be progression to a conduct hearing in line with the NHS Scotland Conduct Policy. Disciplinary action up to and including dismissal may be appropriate having regard to the employee’s culpability in failing to renew or having lost their registration.

The subsequent return to professional role of the member of staff and/or the resumption of pay will be subject to the individual producing satisfactory evidence of registration. Once they are reinstated on the appropriate register, pay will be reinstated at the appropriate band / grade from the date on which the employee resumes registered duties. It is the manager’s responsibility to ensure that the Payroll Department is advised without delay, to ensure that the individual is paid correctly.

6.6 Loss of Professional Registration through the Employee’s Personal Actions or Misconduct

In circumstances whereby individual members of these professions have lost their registration due to their personal action or misconduct, and early resolution is not considered appropriate then this must be investigated, in line with the NHS Scotland Workforce policies Investigation process. It must be explained to the member of staff that unless they are restored to the appropriate register they cannot continue in their job and are not permitted to work in a registered capacity. This must be communicated to the employee in writing. Notification will also be made to the Payroll Department to ensure that individual receives appropriate payment during this period.

If appropriate and depending on the circumstances, staff may be deployed in a suitable non professional registered role as detailed in 6.5 and will be paid at the relevant band / grade for the period of their lapsed registration. Where redeployment is not possible or appropriate in the circumstances, then the employee will not be paid.

During the course of investigating the circumstances, the line manager will fully explore the reason for the registration having been lost. The outcome to an investigation could be progression to a conduct hearing under the NHS Scotland Conduct Policy. Disciplinary action up to an including dismissal may be appropriate having regard to the employee’s culpability in having lost their registration. Where it is felt that disciplinary action may be appropriate, NHS Scotland Conduct Policy will be followed

6.7 Referrals to Professional Regulatory Bodies

In line with this policy, where a decision is made to refer current or former employee of NHS Fife to the relevant professional Regulatory Body following an employee conduct hearing or related matter, for example a concern being addressed via the Drug & Alcohol Policy, the referral will be made by the relevant professional adviser, in line with the regulatory body process and in consultation, and with the agreement of the relevant Executive Director of NHS Fife, following discussion with and notification to the employee.

PROFESSIONAL REGISTRATION BODIES