Application for inclusion in the supplementary list4
1
An application by a doctor for the inclusion of his name on the supplementary list shall be made by sending the Health Authority an application in writing, which shall include the information mentioned in paragraph (2).
2
The doctor shall provide the following information—
a
full name;
b
sex;
c
date of birth;
d
private address and telephone number;
e
medical qualifications and where obtained, a copy of evidence concerning the applicant’s qualifications and experience produced in accordance with the National Health Service (Vocational Training for General Medical Practice) Regulations 199710;
f
declaration that he is a fully registered medical practitioner included in the Medical Register;
g
professional registration number and date of first registration;
h
details of professional experience (including the starting and finishing dates of each appointment together with an explanation of any gaps between appointments) separated into:
i
general practice experience (whether as principal, assistant or deputy),
ii
hospital appointments,
iii
other (including obstetric experience),
iv
any additional supporting particulars, including an explanation of why he was dismissed from any post;
i
names and addresses of two referees who are willing to provide clinical references relating to two recent posts (which may include any current post) as a doctor which lasted at least three months without a significant break, and where this is not possible, a full explanation and alternative referees;
j
details of any Health Authority list or equivalent lists from which he has been removed, conditionally removed, or to which he has been refused admission or conditionally included, or from which he is currently suspended, with an explanation as to why, or particulars of any outstanding application (including deferred applications);
k
if the applicant is the director of any body corporate that is included in any list of any Health Authority, or equivalent lists, or which has an outstanding application (including a deferred application) for inclusion in any list of any Health Authority or equivalent list, the name and registered office of any such body, and details of the Health Authority or equivalent body concerned;
l
where he is, or was in the preceding six months, or was to his knowledge at the time of the originating events a director of a body corporate, details of any Health Authority list or equivalent lists for which that body has been refused admission, conditionally included, removed, contingently removed or from which it is currently suspended, with an explanation as to why;
m
any other information that the Health Authority may reasonably require to determine the doctor’s application.
3
The doctor shall provide the following undertakings and consents—
a
undertaking to provide the declarations required by regulation 9;
b
undertaking not to assist in providing general medical services in the area of another Health Authority from whose supplementary, medical 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), without the consent in writing of that Health Authority;
c
undertake to notify the Health Authority within 7 days of any material changes to the information provided in the application until the application is finally determined;
d
undertake 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;
e
undertake to co-operate with an assessment by the NCAA when requested to do so by the Health Authority;
f
consent to the disclosure of information in accordance with regulation 9.
4
The doctor shall send with the application a declaration as to whether he—
a
has any criminal convictions in the United Kingdom;
b
has been bound over following a criminal conviction in the United Kingdom;
c
has accepted a police caution in the United Kingdom;
d
has been convicted elsewhere of an offence, or what would constitute a criminal offence if committed in England and Wales, or is subject to a penalty which would be the equivalent of being bound over or cautioned;
e
is currently the subject of any proceedings which might lead to such a conviction, which have not yet been notified to the Health Authority;
f
has been subject to any investigation into his professional conduct by any licensing, regulatory or other body anywhere in the world, where the outcome was adverse;
g
is currently subject to any investigation into his professional conduct by any licensing, regulatory or other body anywhere in the world;
h
is to his knowledge, or has been where the outcome was adverse, the subject of any investigation by the National Health Service Counter Fraud Service in relation to a fraud case;
i
is the subject of any investigation by another Health Authority or equivalent body, which might lead to his removal from any of that Health Authority’s lists or equivalent lists;
j
is, or has been where the outcome was adverse, the subject of any investigation into his professional conduct in respect of any current or previous employment;
k
has been removed, contingently removed, refused admission to, or conditionally included in any list or equivalent list kept by another Health Authority or equivalent body, or is currently suspended from such a list,
and if so, give details, including approximate dates, of where any investigation or proceedings were or are to be brought, the nature of that investigation or proceedings, and any outcome.
5
If the doctor is, has in the preceding six months been, or was to his knowledge at the time of the originating events a director of a body corporate, he shall in addition make a declaration to the Health Authority as to whether the body corporate—
a
has any criminal convictions in the United Kingdom;
b
has been convicted elsewhere of an offence, or what would constitute a criminal offence if committed in England and Wales, or is subject to a penalty which would be the equivalent of being bound over or cautioned;
c
is currently the subject of any proceedings which might lead to such a conviction, which have not yet been notified to the Health Authority;
d
has been subject to any investigation into its provision of professional services by any licensing, regulatory or other body anywhere in the world, where the outcome was adverse;
e
is currently subject to any investigation into its provision of professional services by any licensing, regulatory or other body anywhere in the world;
f
is to his knowledge, or has been where the outcome was adverse, the subject of any investigation by the National Health Service Counter Fraud Service in relation to a fraud case;
g
is the subject of any investigation by another Health Authority or equivalent body, which might lead to its removal from any of that Health Authority’s lists or equivalent lists;
h
has been removed, contingently removed, refused admission to, or conditionally included in any list or equivalent list kept by another Health Authority or equivalent body, or is currently suspended from such a list,
and if so, give the name and registered office of the body corporate and details, including approximate dates, of where any investigation or proceedings were or are to be brought, the nature of that investigation or proceedings, and any outcome.
6
The doctor shall 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 doctor or a body corporate referred to in sub-paragraphs (2), (4) and (5).