How practising privileges will be regulated

Dataset to be considered in an annual or biennial review of practising privileges includes: 

Agreed scope of practice review and compliance, including discussion about required volumes for surgical activity and/or ensure practice is sufficient to maintain competency; 

Clinical audit review, clinical metrics or clinical outcomes data derived from the organisation’s clinical governance systems; 

Relevant registry data where appropriate; for example, National Joint Registry data for orthopaedics; 

Adverse events and outcomes review; 

Investigated complaints and outcomes; 

Concerns, investigations or changes to:
    i) practice in other hospitals where the doctor works;
   ii) recognition from an insurer/commissioner;

Concerns relating to a doctor’s work, such as situational awareness and coping with stress; 

Consideration of professional behaviour, including patient as first concern, commitment to quality/safety, collaborative team-working, openness/transparency, fairness, honesty, integrity, insight into strengths/weaknesses, commitment to reflection and learning in line with GMC guidance.


Dataset to be considered on application for practising privileges includes: 

Standard dataset and ID check: proof of identity including recent photograph, basic demographic/identity information, work permit if necessary, Disclosure and Barring Service and Information Commissioner’s Office registration, evidence of compliance with relevant mandatory training and Hep B/Hep C/HIV status, CV and references, designated body and RO; 

Satisfactory evidence of conduct in previous employment; 

Current registration with the GMC, entry on the specialist register and other appropriate professional registrations;

Valid certificate of adequate defence cover to an appropriate level; 

All locations where a doctor holds practising privileges or works;  

Evidence of participation in annual whole practice appraisal, including sharing of appraisal summaries and personal development plans as a minimum and relevant information from whole practice appraisals if insufficient. Providers should consider a mandatory requirement of at least one whole practice appraisal before approving practising privileges applications; 

Description of scope of practice, including surgeon’s procedure codes, procedures done, volume of work in each area of practice and registries where outcome data is shared;

Evidence of participation in quality improvement activities; 

Immediacy of availability of attendance, such as minimum availability/travel distance requirements and requirement to have back-up for known non-availability appropriate to level of care being delivered.