Performers List Reference Form in Respect of (Name of Applicant )

Performers List Reference Form in respect of (Name of Applicant )

NHS CONFIDENTIAL

standardised CLINICAL reference form to support application for inclusion oN THE

DENTAL / MEDICAL/OPHTHALMIC

performers list

FEBRUARY 2011

NHS CONFIDENTIAL

Standard for references

a)References serve two main purposes in the recruitment process:

they allow organisations to check the accuracy of a prospective employee’s previous employment and training history; and
they provide assurance of an individual’s qualifications, integrity and track record.

Within the context of application to join the PCT’s performers lists they are one of the tools that we use to assess the clinical competence of an applicant who wishes to be included on our performers list.

b)In accordance with Regulation 4 (2)(f) of the NHS (Performers Lists) Regulations 2004, clinical references are required from two recent posts (which may include any current post) where the applicant was a performer and which lasted at least three months without a significant break. Where this is not possible, a full explanation and the names and addresses of alternative referees should be provided. Only one reference will be accepted from the practice or practice group employing the applicant. Where an applicant cannot provide references relating to post lasting at least 3 months (for example, where his/her preferred working pattern is a series of short term locum positions), the PCT may consider separate periods of work within one general practice over a 12 month period that average out at least 13 weeks.

c)If initial references are not satisfactory, the PCT will determine whether further references should be sought. However, in an individual case, the PCT will not pursue references indefinitely on the off chance that one will eventually be satisfactory, as this would not be considered good practice.

d)If the PCT is satisfied that an applicant cannot meet the normal conditions it may accept references from any other practice or practice group who it believes can comment objectively on the applicant’s clinical abilities. When requesting references the PCT will make it clear that it needs clinical (not general) references.

e)A proforma form will be used to elicit the required information on:

the nature of the relationship between the applicant and the referee and the length of time they have known each other;
dates of employment and post held;
clinical skills including duties, responsibilities and organisational abilities;
personal qualities and conduct including attendance, reliability and relationship with colleagues and patients; and
communication skills.

f)The assessment of the satisfactory nature of the references should be performed by the PCT’s Professional Advisor (Medical, Dental or Optometric), whichever is appropriate.

g)Where there are inconsistencies the PCT will proceed in a sensitive manner and will attempt should be made to address concerns directly with the applicant.

h)In exceptional circumstances, where there is substantial misdirection, it may be appropriate to report concerns to the local police or the PCT Local Counter Fraud Specialist or the NHS Counter Fraud and Security Management Service. The making of false representation and the failure to disclose information when legally required are deemed as fraudulent acts by the Fraud Act 2006 c.35.

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Performers List Reference Form in respect of (Name of Applicant )

NHS CONFIDENTIAL

This reference is to support the application of the applicant named below for inclusion in the Medical/Dental/Ophthalmic performers lists of the PCT. Inclusion in the list will allow the applicant to perform primary dental /medical/ophthalmic services under the NHS anywhere in England.

Applicant’s full name:
Professional Registration Number:
List applied for DENTAL /MEDICAL/OPHTHALMIC
nature of relationship

In what capacity did you know the applicant?

If you are personally related to the individual, or have a business relationship, please state the nature of that relationship.

Over what period have you personally known the applicant?

From: To:
Employment dates, post and skills

How long did this applicant work alongside you and in what capacity?

From: To:

What was their position?

What did their duties involve?

What was their reason for leaving, if known?

Please describe your professional relationship with the applicant, for example whether you were a colleague, in a senior position or a junior position to the applicant.
Please describe whether you were responsible for supervising the applicant and whether you saw examples of the treatment they performed.

NHS CONFIDENTIAL

Based on your knowledge of the applicant, please comment, with evidence for your reasons, on their suitability for inclusion in the PCT’s Performers List. Single word responses will not assist the Clinical Adviser in reaching a judgement on the applicant’s suitability and may result in a delay in approval. As well as written comments, please tick the relevant box that, in your view, applies.

Diagnostic skills (history, examination & treatment planning):