Verification of employees’ professional registration

Contents

1 Introduction

It is mandatory that certain healthcare professionals, including temporary staff and agency workers, are appropriately registered with a regulatory body to practice. The purpose of undertaking registration checks is to ensure that, where appropriate, any prospective and or current employee within the trust are registered by the appropriate regulatory body and has the right qualification to do the job for which they have been employed. Such professional regulation is intended to protect the public, by assuring that anyone who is practicing as a healthcare professional is doing so safely (NHS Employers, Professional Registration and Qualification Checks 2021).

Whilst it is the responsibility of individual employees to ensure that their professional registration remains current at all times, the trust is required to be able to verify such registrations for all its staff (permanent, temporary or bank) as well as being able to demonstrate that it has systems in place to monitor the registrations of staff on an ongoing basis. If an employee’s registration lapses, they will not contractually, and in many cases legally, be able to continue to carry out the duties of the post, if the post requires them to be registered.

In addition, the trust is required to have systems in place to ensure that any employment agency supplying workers to the trust (for example, NHS professionals, recruitment agencies etc) carries out professional registration checks on workers they supply to the trust as appropriate, and the trust should verify as soon as possible.

2 Purpose

The purpose of this policy is to ensure that the trust has adequate procedures to verify the professional registration status of clinical staff employed by the organisation who are required to hold a professional qualification and maintain registration with a professional regulatory body in accordance with their recommendations. Section 5.5 details the staff which are covered by the policy.

3 Scope

This policy applies to those staff for whom professional registration is a pre-requisite of employment and should be read in conjunction with the trust’s appointment of staff policy.

4 Responsibilities, accountabilities and duties

4.1 Director of people and organisational development

It is the responsibility of the director of people and organisational development to:

• ensure that a professional registration policy and procedure is in place which sets out the verification procedure to be followed for clinical staff
• ensure that external agencies used by the organisation provide assurance that they have undertaken the pre-employment checks, including professional registration specified by NHS Employers for all temporary clinical staff supplied.
• ensure that a central record of professional registration is maintained on ESR (electronic staff record) and that processes are in place to monitor professional registration prior to commencement and during employment
• ensure that a process is in place to monitor the compliance with and the effectiveness of this policy and procedure

4.2 Individual staff

• It is the responsibility of each individual employee to ensure they maintain their professional registration during their employment, even if they are absent from work, and fulfil their obligations set out in the “procedure” section below.
• It is each individual employee’s responsibility to pay their own professional registration fees; ensure that they meet the ongoing registration requirements of the relevant professional body (for example, maintaining an adequate continuous professional development (CPD) portfolio and, where appropriate, to notify the relevant professional body of any further qualifications undertaken.
• It is the duty of the individual employee to inform the trust if, at any point during their employment, they are subject to any form of proceedings initiated by their professional body. This duty applies irrespective of whether the matter is related to their employment with the trust.

4.3 Human resources department

The Medical Workforce team will ensure Section 4.4 is enacted for all medical employees within the trust and the Workforce Systems HR team are responsible for all other professionally registered employees.

It is the responsibility of the trust’s Workforce Systems team to:

• maintain and update a central system of the relevant staff professional registration details through the electronic staff record system (ESR)
• utilise the system to monitor renewal dates and to send an appropriate reminder to staff, advising the relevant staff that they are due for re-registration
• to generate a report from ESR and correct any missing information on a monthly basis to identify any professional body registration numbers and expiry dates which have not been inputted for employees appointed to a clinical role which requires a professional registration
• the Medical Workforce team will check the ESR and GMC systems to confirm that registration has been renewed for all doctors

4.4 HR Recruitment team

The Recruitment team provide training for line managers in the implementation of this policy through recruitment and selection training, as well as raising awareness relating to any updates.

4.5 Purchasing department or agency

• It is the responsibility of the purchasing department to ensure that the recruitment agencies used by the trust are registered on the crown commercial services framework and that the associated agreement incorporates the NHS employment checks standards.
• This includes the requirement for the relevant agency to ensure appropriate checks on professional registration are undertaken.
• It is the responsibility of the agency co-ordinator to request evidence of professional registration and qualifications before a candidate starting with the trust. For ad-hoc cover, the reliance is on the framework agencies to have this in place.

4.6 Care group directors

Where the trust is working in partnership with external providers, for example, local authorities, it is the care group directors responsibility to ensure the external provider has provided the trust with reassurance that they undertake appropriate checks on professional registration.

5 Procedure or implementation

The majority of healthcare professionals have to renew their registration regularly (normally annually). The trust is unable to employ someone in a post for which they are not appropriately registered or are unable to provide evidence of registration. Failing to renew registration, or being removed or suspended from a professional register, is a serious matter and has an adverse effect on the trust’s ability to care for patients or clients or service users.

5.1 Appointment of staff

• No person may be employed by the trust in any occupation requiring professional registration unless that person is included in the appropriate professional register and can demonstrate evidence of his or her registration.
• The Recruitment team will ensure that the professional registration number provided by an applicant is valid, in date and appropriate for the role that they are being appointed to.
• The pay services department will ensure that new starters will only be entered onto the appropriate pay band once confirmation has been received of their professional registration number.
• Newly qualified employees may commence their employment prior to receiving formal confirmation of their entry to the professional register but line managers must check the qualifications in accordance with the appointment of staff policy and not delegate any duties which require professional registration until such time as formal confirmation has been received. In this situation, new employees will be paid at the appropriate rate for an unqualified member of staff until formal confirmation of registration is received at which point payment at the qualified rate will be paid on a retrospective basis if applicable. Such confirmation must be in written form and registration checked.
• Ongoing checks are then conducted in accordance with section 5.2.
• In respect of agency workers, the only recruitment agencies which line managers are permitted to use are those which are covered by the crown commercial services framework, which includes the requirement to check professional registration status. However, in all instances where the trust uses an agency worker the line manager must confirm with the agency that the prospective agency worker has the correct and current registration, if it is required for the role, as indicated in section 4.3.ii.

5.2 During employment for existing staff

• Each employee who is professionally registered must renew their registration before it lapses.

It is illegal to work in a role requiring registration in any circumstance whilst an employee is unregistered with their professional body.

In addition to the reminders which are sent directly from the relevant professional bodies, the Recruitment team will notify non-medical registered staff via email or telephone to inform them of their registration renewal date (and revalidation date if appropriate). The Recruitment team will monitor the progress of re-registration via ESR and maintain contact with the employee and employee’s line manager as this deadline date approaches.

In the event that the Recruitment team receive a notification that a registration has lapsed, then this will be communicated to the People Experience team with immediate effect so that it can be investigated and actioned appropriately.

Where an employee is in a situation whereby they believe that their professional registration may lapse for any reason they must immediately notify their line manager.

• In the event that an employee allows their registration or their specialist registration to lapse for any reason they must immediately notify their line manager and will not be permitted to work until their registration has been renewed and verified (see section 5.3 below)
• If an employee is paying their registration via quarterly direct debit and they fail to maintain their payments, the NMC and HCPC will make contact with the employee to pay the outstanding fee. If the NMC or HCPC do not receive payment the employee will be de-registered by the NMC or HCPC. The trust does not receive any notification of non-payment; therefore, it is imperative that employees ensure payments are kept up to date. In these circumstances the provisions of section 5.3 will be applied.
• Medical staff are not de-registered by the GMC for non-payment for approximately 3 months after their annual retention date. The Medical Workforce team will check the information held on ESR immediately after the GMC renewal date and advise those doctors that may be at risk of becoming unregistered. The relevant information is imported into ESR from the GMC system.

5.3 Action to take in the event of a staff members professional registration lapsing

Where clinical staff are not registered, or have failed to maintain their specialist registration, immediate action must be taken to protect the interests of the public and patients. This will involve ensuring that the employee immediately ceases to practise and is suspended on no pay (unless there are extenuating circumstances (see 5.2)) For further information refer to the trust’s disciplinary policy.

• The trust cannot employ an employee in a post for which they do not hold the requisite qualifications and registration. Accordingly continuation in such a post beyond a due re-registration date is not permissible.
• Where, on the day re-registration was due, the employee has not re-registered or maintained their specialist registration or licence to practise, the line manager, will.
• Suspend the employee from duty without payment for a maximum period of six weeks. The suspension, with the exception of pay, will be in accordance with the disciplinary policy or maintaining high professional standards for medical staff. The authority to suspend rests with the appropriate senior member of staff on duty at the time; however, they should attempt to obtain advice from the People Experience team or on-call director before suspending. The deduction from payroll will be actioned the month following the incident, for example, suspension with no pay in July will be deducted from the August salary.
• During the period of suspension, the employee may be permitted by the line manager to resume normal duties and customary pay if they are is restored to the professional register or specialist register. However, in all instances the trust will formally investigate (at the time of the lapse) the lapse of registration in line with the disciplinary policy (or maintaining high professional standards for medical staff), which may result in a disciplinary hearing and ultimately the employee’s dismissal. The line manager must also notify the pay services department of the suspension on no pay.
• It is acknowledged that there may be occasions when for some staff there are reasons, known in advance, why re-registration by the due date will not be possible. In such situations the employee is responsible for advising their line manager before the due re-registration date so that the line manager can consider appropriate action including possible non nursing duties.
• In cases where there are extenuating circumstances which are beyond the employees control, these should be discussed with the line manager who may consider non nursing duties as an alternative to suspension.
• Where an employee fails to re-register by six weeks after the original renewal date, it will be deemed that the employee has invalidated their contract of employment with the trust. No further contract of employment will be offered, which will result in a disciplinary hearing and the employees dismissal from the trust

5.4 Requirements of registration

Each professional registration body has its own requirements in relation to matters such as lapsed registrations; career breaks; continual professional development; etc. Where these factors complicate the basic employment question of whether the employee is registered or not, advice must be sought from a HR Advisor.

5.5 Professionally registered trust staff and the professional bodes with which they must be registered

5.5.1 General medical council (GMC)

Doctors (all grades) to practice medicine all doctors are required by law to be both registered and hold a licence to practise.

For some doctors it is a condition of their employment that they have and maintain appropriate Mental Health Act approval, that is, section 12 and or approved clinician status

5.5.2 Nursing and midwifery council (NMC)

Registered nursing staff (all grades).

5.5.3 Health and care professions council (HCPC)

• Occupational therapists.
• Arts therapists.
• Dieticians.
• Physiotherapists.
• Podiatrists.
• Social workers.
• Speech and language therapists.
• Practitioner psychologists.

5.5.4 General pharmaceutical council

• Pharmacists.
• Pharmacy technicians.

6 Training implications

6.1 Staff

• How often should this be undertaken: On revision of the policy or new appointments or promotions.
• Delivery method: Trust communications.
• Training delivered by whom: Line managers.

6.2 Managers

• How often should this be undertaken: On revision of the policy or new appointments or promotions.
• Delivery method: Trust communications.
• Training delivered by whom: Line managers.

6.3 Recruitment team or pay services

• How often should this be undertaken: On appointment or revision of the policy.
• Delivery method: On the job training mentoring.
• Training delivered by whom: Team leaders or head of people experience.

6.4 Staff side

• How often should this be undertaken: On appointment or revision of the policy.
• Delivery method: On the job training mentoring.
• Training delivered by whom: Head of people experience via policy forum.

Page last reviewed: April 30, 2024
Next review due: April 30, 2025

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