Londonwide LMCs

Updated to reflect the publication and implementation of the Policy on managing the NHS Performers Lists which takes effect in October 2024.

Background

The National Health Service (Performers Lists) (England) Regulations (PLR) came into force on 1 April 2013 and require GPs who provide NHS primary care to be on the Medical Performers List (MPL).

The PLR set out (among other points):

The grounds for inclusion on the MPL.

The application process to join (or re-join) the MPL.

The grounds upon which inclusion on the MPL can be declined or deferred.

The obligations with which GPs on the MPL must comply.

What actions can be taken in circumstances when there are concerns about a GP’s performance (which covers performance and/or conduct and/or health issues).

The process in relation to withdrawing from the MPL.

Scope of this guidance

The scope of this guidance will solely relate to how performance concerns are managed in accordance with the PLR in London.

A key reference document for this is NHS England’s Policy on managing the NHS Performers Lists (England), which was published in July 2024 and superseded the Framework for managing performer concerns in October.

Performance concerns are managed by NHS England (London) performance team and each case will be allocated to a case manager, who does not have a decision-making role but will be the principal point of contact and will be responsible for the collation of information and the administration of the case. If there is to be an investigation, a case investigator will be allocated as well, they do not have a decision-making role and work within the scope of the terms of reference.

How concerns come to the attention of NHS England (London)

Concerns can be brought to the attention of NHS England (London) via a number of sources, which include (but would not be limited to):

Patients.

Colleagues (either clinical or non-clinical).

Other bodies (for example – the GMC, the CQC, the CCG, the police etc).

Miscellaneous others (for example – pharmacists, care homes, anonymous complaints etc).

How NHS England (London) decide which concerns to investigate

NHS England (London) operate a triage process in order to decide whether the concerns meet the threshold for investigation. The initial consideration may ask the following:

Do the concerns suggest that the individual practitioner’s conduct, performance or health:
- presents a risk to patient safety (for example – due to a lack of up-to-date knowledge and/or skills, an inability to communicate effectively or work effectively within a team)?
- undermines the efficiency of primary care services (for example – by failing to comply with the PLR obligations, a refusal to comply with the reasonable requirements of the commissioner or employer, behaviour that may compromise patient care or the effective running of the service etc)?
- undermines patient and public confidence in the NHS (for example – by committing a criminal offence)?
- represent a financial risk to the organisation or services?
- represent a significant departure from accepted guidelines and/or professional standards?
Do the concerns suggest that the individual practitioner poses a risk to patient safety as a consequence of their conduct, performance or health (for example – it would not be appropriate to investigate a patient’s concern that they cannot get an appointment with a specific doctor)?
Can the concerns be investigated (for example – it may not be possible to investigate a vague concern raised by an anonymous person)?
Should the concerns be investigated (at least in the first instance) by another body (for example – the police, the GMC etc)?
Could the matter be referred back to the GP and/or practice in the first instance in order that they can respond (for example – a complaint that has not been seen by the GP and/or the practice)?

NHS England will assess the concerns using a risk matrix tool – if this suggests that there is an immediate patient safety concern, then the case will be escalated for consideration as to whether an immediate suspension is indicated.

Please note – The PLR do have provisions that allow NHS England to suspend a GP from the MPL. This guidance is aimed at describing the process that is followed when a suspension has not been imposed (which applies to the vast majority of cases). If you are suspended from the MPL under the PLR, then you will be given tailored advice as to your options based on the circumstances of your case.

NHS England may need to seek further information in order to reach an informed decision as to whether a formal investigation is indicated – this is termed a preliminary enquiry.

If after the preliminary the preliminary enquiry there is insufficient evidence or conflicting evidence to enable NHS England to properly establish the circumstances and events relating to the concern that have been raised NHS England may consider that a formal investigation is required

How you will know if NHS England (London) are investigating you

If NHS England (London) decide to investigate a concern, then you will be contacted by the case manager that has been allocated to your case.

The case managers are mindful of the fact that it is distressing for a GP to become aware they are the subject of an investigation and try wherever possible to make the initial contact by telephone before following this up in correspondence.

The purpose of the initial contact can be summarised as follows:

To explain that an investigation has been opened.

To explain and share with you the nature of the concerns that have been raised.

To explain the procedure.

To indicate what the next steps will be and the associated timeframe.

To indicate whether any immediate action is required on your behalf.

To explain what support is available to you (for example – Londonwide LMCs, your medical defence organisation, the BMA etc).

To explain what support is available in relation to your health and wellbeing.

In addition to the above, you should be provided with the terms of reference for the investigation within five working days of the decision to commission the investigation – you will be given the opportunity to comment on the terms of reference, but they do not require your approval.

If during the course of the investigation, new information comes to light that is beyond the scope of the terms of reference, they may be amended but the revised terms of reference must be shared with you.

The timescale for the investigation will vary according to a number of factors including (but not limited to) the nature, extent and complexity of the concerns – the case manager is obliged to keep you updated as to the progress of the investigation.

Top tips:

Try not to let any frustrations you may have about the concerns or the process to be reflected in any discussions you have with the case manager and/or case investigator.

Do not be tempted to provide any response to the allegations in the context of the initial call – you will have a chance to provide a considered response in the context of the investigation.

What you should do upon learning being informed that NHS England (London) are investigating you

It is not pleasant to become the subject of an investigation and you may have feelings of anxiety, self-doubt, reduced confidence, distress, frustration or even anger. It is therefore important that you seek professional advice at the earliest possible opportunity – the Londonwide LMCs GP Support Team has a vast range of experience in assisting GPs and can support and guide you through the process.

Your case will be allocated to a member of the team that is best-placed to assist you. One of the first considerations will be whether you need to enlist the support of any organisations at the outset (for example, your medical defence organisation) and if so, who would be best-placed to take the lead. If another organisation does become involved, then (with your permission), your Londonwide LMCs case manager will liaise with them as appropriate.

The investigation meeting (preparation)

You may be invited to provide some clarification in writing, which may suffice, however in most cases you will be invited to an investigation meeting with the case manager and case investigator (which place virtually in the vast majority of cases).

On the assumption that Londonwide LMCs are taking the lead, your case manager will open correspondence with the case manager in order to ensure that…

…they are aware that Londonwide LMCs are representing you.

…you are provided with all the relevant documentation and an agenda in advance of the meeting.

…the meeting is arranged at a mutually convenient time (allowing time for preparation).

Please note that in certain circumstances (including, but not limited to when a meeting is requested at short notice), it is a legitimate strategy not to seek any pre-meeting disclosure – your Londonwide LMCs case manager will provide you with bespoke advice if this is the case.

In advance of the meeting, your case manager will liaise with you to make sure that you are adequately prepared, which may include:

Explaining the procedure.
Going through the agenda and all the relevant documents.
Anticipating what questions may be asked, allowing you to carefully consider in advance your responses and advising you how to approach answering questions (please note your case manager cannot answer the questions on your behalf, or suggest what your answer may be, but can give advice on how you might structure your answers).
Sometimes it may be helpful to prepare a reflective statement in advance of the meeting and whilst the reflective statement would not (usually) be submitted in advance of or at the meeting, it can be a useful exercise for the following reasons:
- It can act as a useful aide memoire during the meeting.
- You will usually be invited to submit a reflective statement after the meeting.
- Londonwide LMCs have produced some guidance in relation to the preparation of reflective statements. If you have been asked to prepare a reflective statement please contact the GP Support Team who will be able to provide you with bespoke advice.

The investigation meeting

The meeting usually follows the following format:

The meeting will open with a round of introductions.

The case manager will then explain the procedure (including what will happen after the meeting with reference to approximate timeframes).

Important note – The case manager and case investigator are not decision makers in your case – their role is to undertake the investigation and present their findings to either the Performance Standards Group (PSG) (Appendix 1) or the Performers Lists Decision Panel (PLDP) (Appendix 2) who will make a decision as to what action (if any) is to be taken).

You will be invited to provide an overview as to your career, your experience and your current role, which will set the concerns in context.
The case manager and/or case investigator will then invite you to provide an explanation of the concerns from your perspective and/or take you through a series of questions that they will have pre-prepared.
Top tips
- Be honest.
- Be insightful.
- Be empathic.
- Be conciliatory.
- Be measured and reasonable.
- Demonstrate any remediation that you have undertaken (or intend to undertake).
- Avoid letting any frustrations you may have be reflected in your answers.
The the case manager and/or case investigator will advise you what other sources of support are available to you.
There will be an opportunity for any further questions or comments.
The case manager and/or case investigator will then explain the next steps, which are likely to include:
- Providing you with a copy of the draft meeting notes in order that we can comment on their factual accuracy before they are finalised.
- Indicating what actions you and/or they will need to take and within what timeframe.
- Indicating whether the PSG or PLDP will consider your case together with a timescale.

At the conclusion of the investigation, the case manager must share a draft report with you in order that you can comment on its factual accuracy before it is finalised and consider by the PSG or the PLDP (see below).

Appendix 1: the Professional Standards Group (PSG) formerly the Performance Advisory Group (PAG)

The London PSG meets routinely every 6 weeks and on an ad hoc basis if the need arises.

Information to be considered by PSG

The submission to the PSG must include:

Key contextual background information.
An assessment as to whether the presenting issues relate to conduct capability or health, including whether there are issues that relate to more than one category.
A summary of information available from the preliminary enquiry and/or external information gathering and/or the investigation report.
A summary of findings from the preliminary enquiry and/or external information gathering and/or the investigation report.
The most recent risk assessment including the rationale for the risk score.
A clear outline of the issues to be considered by the PSG or PLDP.
A summary of case management options for the PSG or PLDP to consider.

What the PSG can do

The PSG cannot take any action in relation to a GP’s inclusion on the MPL under the provisions of the PLR, however the PAG can:

Conclude that there is no case to answer or that the matters have been resolved and close the case.
Agree on any further interventions or support that would assist in resolving the concerns.
Review progress against any interventions or support that have been put in place.
Request further investigation (for example – a records audit).
Offer agreement terms to mitigate the concerns – agreement terms (which would need to be SMART [specific, measurable, achievable and realistic]) are essentially a consensual way of managing the concerns, which avoids the need for the imposition of conditions and the expectation is they would be reviewed within six months.
Request an occupational health assessment.
Refer to an appropriate external agency (for example – Practitioner Performance Advice [formerly NCAS]), the contracts team, etc.
Refer the matter to the PLDP.

Who sits on the PSG

The PSG consists of the following voting members:

A senior NHS England professional standards manager.
A discipline-specific practitioner (which may not necessarily be a GP).
An NHS employed member of staff whose primary role is patient safety.
A lay member.

A Londonwide LMCs representative sits on PAG (as a non-voting member) to ensure due process – they would need to declare a conflict of interest if they have been assisting you and are not able to notify you of the outcome in advance of the formal notification (see below).

Important note – the PSG considers cases on the papers, which means that you will not be invited or required to attend (either in person or virtually).

What happens at a PSG meeting?

The case manager and/or case investigator that have been dealing with your case will prepare and submit the papers (in anonymised form) in advance of the PSG meeting.

The case manager and/or case investigator will present the case after which there will be a discussion leading to an agreement on the next steps by the voting members.

When will I be notified of the PSG decision?

The PAG decision will usually be relayed to you by the case manager and/or case investigator that is allocated to your case – they are mindful of the importance of the decision to you and endeavour to provide you with the decision as soon as they are able to do so.

Appendix 2 – The Performers List Decision Panel (PLDP)

The London PLDP meets routinely every 6 weeks and on an ad hoc basis if the need arises. The information it considers is the same as the PSG and the submission to it should follow the same form (detailed above in Appendix 1).

What can the PLDP do?

The PLDP can take action in relation to a GP’s inclusion on the MPL under the provisions of the PLR and it is open to them to:

Close the case.
Take any of the actions that are open to the PSG (see above).
Refer the matter to one or more of the following bodies:
- The Primary Care Contracts Team.
- The GMC.
- The police.
- The NHS Counter Fraud Authority (NHSCFA).
Refer the matter to another body for remediation or intervention (for example – Practitioner Performance Advice [formerly NCAS]).
Invite the GP to appear before an oral hearing if one of the following actions under the PLR is being contemplated:
- Suspension – the PLR do allow for a GP to be suspended immediately, but there is an obligation for the PLDP to review any decision to suspend within 2 days and to offer the GP the opportunity to have an oral hearing before the PLDP.
- Conditions – the PLDP can impose conditions on a GP’s inclusion on the MPL. The conditions will be tailored to the concerns and will usually involve educational and/or clinical supervision, together with appropriate support and/or supervision in relation to health matters (if relevant).
- Variation or review of previously imposed conditions or a suspension.
- Removal from the MPL – the PLDP can remove a GP from the MPL on the following grounds:
  - A mandatory basis (for example – if a GP was convicted of murder, there is a mandatory requirement for them to be removed from the MPL) or
  - If a GP’s inclusion on the MPL would prejudice the efficiency of services (this would include GPs with significant performance concerns [or more rarely health concerns] that are beyond remediation) and/or
  - If a GP is deemed to be unsuitable (this would usually relate to a conduct matter) to be included on the MPL.
  - Important note – if the PLDP is contemplating taking action under the PLR, they must put the GP on notice of what action is being contemplated and provide them (the GP) with an opportunity to make representations and/or to put their case before an oral hearing (see below).
Issue a Healthcare Professional Alert Notice.

Who sits on the PLDP
The PLDP consists of the following voting members:

- - 1. An NHS England Chair.
    2. The responsible officer or medical director (system improvement and professional standards) (MD SIPS).
    3. A discipline-specific practitioner (which may not necessarily be a GP).
    4. An NHS employed member of staff whose primary role is patient safety.

The case manager and/or case investigator will present the case after which there will be a discussion leading to an agreement on the next steps by the voting members.

The outcome of the PLDP will be usually relayed to the GP by the case manager.

PLDP oral hearings

If action is being contemplated under the PLR, then your case will be heard at an oral hearing before a specially convened PLDP, in which case:

- - - You will be provided with the allegations and a case pack in advance of the oral hearing.
  - - You will be informed of what action is being considered in advance of the oral hearing.
  - - You will be provided with an opportunity to make written representations in advance of the oral hearing.
  - - You will be provided with an opportunity to attend (with representation) and make oral submissions before the PLDP.

Important note – the GP Support Team do not provide representation at a PLDP oral hearings (it is expected that a medical defence organisation would provide assistance or that the GP would privately instruct their own legal representative in such circumstances) – your case manager will provide you with tailored advice in the event that you case is referred to an oral hearing.

When you will be notified of the PLDP decision

The PLDP decision will be relayed to you in writing (if your case is considered at an oral hearing then the decision will usually be relayed to you in writing within seven days of the hearing)..

Appealing a PLDP decision

A PLDP decision can be appealed to the First Tier Tribunal (Primary Health Lists) – your case manager will provide you with bespoke advice in relation to pursuing an appeal should the need arise.