All Wales Approved Clinician Procedural Arrangements

Procedural Arrangements for the Approval and  Reapproval of Approved Clinicians in Wales

Please ensure that you have read in full, the Welsh Government Guidance Document Approval of Approved Clinicians (Wales) 2018.

1. Introduction

1.1 The Mental Health Act 1983 (as amended 2007) introduced the new roles of Approved Clinician and Responsible Clinician that can be filled by a range of mental health professionals.

1.2 An Approved Clinician is a mental health  professional approved by the Welsh Ministers to act as such for the purpose of the Mental Health Act 1983.

Some decisions under the 1983 Act can only be undertaken by people who are Approved Clinicians.

1.3 A Responsible Clinician is the Approved Clinician who has been given overall responsibility for a patient’s case. Approved Clinicians who are allocated as Responsible Clinicians will undertake the majority of the functions previously performed by Responsible Medical Officers.

1.4 On 3rd November 2008, Wrexham Local Health Board (LHB) became the approving Body for Approved Clinicians (ACs) on behalf of the LHBs in Wales. This includes the initial approval, re-approval, suspension and termination of approval. The focus of the LHB’s initial work was to approve registered medical practitioners who had previously acted as a Responsible Medical Officer (RMO) or Community Responsible Medical Officer (CRMO) to become Approved Clinicians under the transitional arrangements.

2. Background

2.1 In 2013, Betsi Cadwaladr University Health Board met with Welsh Government to discuss areas within the approval process and governance arrangements that the Approval Team and Health Board considered could be improved. Differences between the processes in Wales and England were adding to the challenge of maintaining service consistency for mental health practitioners and Health Boards within Wales and on a cross-border basis with England.

2.2 An All Wales Task and Finish Group which  comprised of Mental Health and Social Care professionals, service managers or equivalent status and professional bodies was established to review areas of concern. The Group reported their findings and made recommendations to Welsh Government in 2015.

2.3 The following process has been developed as a result of this review and will come into effect for all applications considered with effect from 12th July 2018.

3. Arrangements for New Applications

In addition to the eligibility requirements set out in the Mental Health Act 1983 (Approved Clinicians)(Wales) Directions 2018, further guidance on indicators of readiness to seek approval can be found in the Welsh Government “Approval of Approved Clinician (Wales) Guidance” July 2018.

All applicants must make available to the Approval Team (BCUHB) the following:

3.1 Applications from doctors who are on the Specialist Register of the GMC

Doctors who are on the General Medical Council (GMC) Specialist register are  considered to possess the competencies required to become an Approved Clinician, providing that this is supported by:-

1. Application Form

The application form must be completed fully and should be error free.

2. Two References

Referee 1

One of the referees must be your current or most recent Medical Director or Clinical Director or equivalent, but where an applicant is on a training programme recognised by the Royal College of Psychiatrists, the referee may be the Training Programme Director or a person the approving body considers equivalent to a Programme Director (ie current or most recent Educational Supervisor).

Referee 1 must have known you or worked with you for a minimum of three months in the preceding twelve months.

Referee 2

One of the referees must be an Approved Clinician, however, where the Clinical/Medical/Training Programme Director or equivalent is an Approved Clinician, Referee 2 may be drawn from one of the categories listed.

Referee 2 must have known you or worked with you for a minimum of three months in England or Wales in the preceding 2 years (in the preceding 12 months if the referee nominated is an AMHP).

Referees must be able to comment on your understanding of and ability to implement the Mental Health Act.

The Approvals Team has pro forma reference forms which should be completed by your referee.

• An Approved Mental Health Professional (AMHP) with whom the applicant has worked within the preceding twelve months.
• A Consultant Psychiatrist who is S12(2) Doctor approved.

One of the two referees must have worked with you for a minimum of three months in the preceding twelve months of the date of application.

3. Curriculum Vitae

The CV should demonstrate evidence of activity and learning relating to the AC competencies of MHA leadership and care management.

• The CV should be validated (signed and dated) by the Medical Director or Clinical Director or Service Manager where applicable.
• Current and previous employment must be included in chronological descending order
• All employment to include FROM and TO dates in the format of dd.mm.yyyy
• CV to include the title/grade of post, full name of employer and address.
• CV must evidence working in a senior grade for a minimum of 4 years.

4. Evidence of the latest satisfactory appraisal outcome to include the name of the appraiser and the  date of appraisal

Details to be provided in Application Form.

5. Up to date evidence of Continuing Professional Development requirements

Applicants are required to submit either a certificate of good standing for CPD issued by the Royal College of Psychiatrists, or a completed All Wales CPD log or evidence of the most recent satisfactory annual appraisal with reference to CPD being achieved. If submitting the most recent appraisal evidence, it would suffice to provide only those pages which evidences the following information:

Name of appraisee, name of appraiser, date of appraisal, the date the summary appraisal was agreed and discussion and reflections on CPD.

Please check the following link to check CPD guidance issued by the Royal College of Psychiatrists.

Submitting your CPD - Royal College of Psychiatrists

6. Certificate of attendance at a two-day AC Induction Training

Attendance at AC Induction Training in Wales or at one of the AC training events in England that has been approved by Regional Approval Panels in England. The training must be undertaken within the two year period immediately preceding the date of  application. All certificates must be in date when the application has been scrutinised and considered complete and error free by the Approvals Team, in readiness to submit to the Panel. The certificate must also remain valid at the point of the Panel assessing  applications.

Note: If the applicant has undertaken training in England, they should contact the Approvals Team in Wales for a copy of the training presentations on The Welsh Measure and the MHA Code of Practice Wales.

7. Copy of extant Professional Registration Certificate to meet the requirement of Schedule 1 of the Directions 2018

Psychiatrists – GMC Certificate

8. An enhanced Criminal Record Certificate under section 113B of the Police Act 1997

A copy of the most recent Disclosure and Barring Scheme (DBS) certificate is required from Applicants who work through a Locum Employment Agency.

The DBS certificate must include checks against the DBS Children’s Barred List information and the DBS Adults’ Barred List information.

9. Confirmation of whether an application for approval as an Approved Clinician elsewhere has been refused

Details to be provided in Application Form

10. Written confirmation from the applicant’s employer that they will have the opportunity to work as an Approved Clinician in Wales

Confirmation should be provided by the Clinical Director.

3.2 Applications from Doctors who are in their final year of RCPsych recognised supervised psychiatric training.

For those doctors in the final year of higher specialist training towards inclusion on the Specialist Register, conditional approval may be granted for the period of acting in the role of Approved Clinician. Certificate of completion of training would be a condition of ongoing approval.

Applications must include the following:

1. Application Form

The application form must be completed fully and should be error free.

2. Two References

Referee 1

One of the referees must be your current or most recent Medical Director or Clinical Director or equivalent, but where an applicant is on a training programme recognised by the Royal College of Psychiatrists, the referee may be the Training Programme Director or a person the approving body considers equivalent to a Programme Director (ie current or most recent Educational Supervisor).

Referee 1 must have known you or worked with you for a minimum of three months in the preceding twelve months.

Referee 2

One of the referees must be an Approved Clinician. However, where the Clinical/Medical/Training Programme Director or equivalent is an Approved Clinician, Referee 2 may be drawn from one of the categories listed:

• An Approved Mental Health Professional (AMHP) with whom the applicant has worked within the preceding twelve months.
• A Consultant Psychiatrist who is S12(2) Doctor approved.

Referee 2 must have known or worked with you for a minimum of three months in England or Wales in the preceding 2 years (in the preceding 12 months if the referee nominated is an AMHP).

Referees must be able to comment on your understanding of and ability to implement the Mental Health Act (1983). The Approvals Team has pro forma reference forms which should be completed by your referee.

One of the two referees must have worked with you for a minimum of three months in the preceding twelve months of the date of application.

3. Curriculum Vitae

The CV should demonstrate evidence of activity and learning relating to the AC competencies of MHA leadership and care management.

• The CV should be validated (signed and dated) by the Medical Director or Clinical Director or Service Manager where applicable.
• Current and previous employment must be included in chronological descending order
• All employment to include FROM and TO dates in the format of dd.mm.yyyy
• CV to include the title/grade of post, full name of employer and address.
• CV must evidence working in a senior grade for a minimum of 4 years.

4. Evidence of when appraisal was conducted and by whom in order to demonstrate satisfactory appraisal

Copy of satisfactory ARCP outcome should be submitted by email to the Approval Team.

5. Certificate of attendance at a two-day AC Induction Training

Attendance at AC Induction Training in Wales or at one of the AC training events in England that has been approved by Regional Approval Panels in England. The training must be undertaken within the two year period immediately preceding the date of application. All certificates must be in date when the application has been scrutinised and considered complete and error free by the Approvals Team, in readiness to submit to the Panel. The certificate must also remain valid at the point of the Panel assessing applications.

6. Copy of extant Professional Registration Certificate to meet the requirement of Schedule 1 of the Directions 2018

Psychiatrists – GMC Certificate

7. An enhanced Criminal Record Certificate under section 113B of the Police Act 1997

A copy of the most recent Disclosure and Barring Scheme (DBS) certificate is required from Applicants who work through a Locum Employment Agency.

The DBS certificate must include checks against the DBS Children’s Barred List information and the DBS Adults’ Barred List  information.

8. Confirmation of whether an application for approval as an Approved Clinician elsewhere has been refused

Details to be provided in Application Form.

9. Written confirmation from the applicant’s employer that they are in an acting up post and that they will have the opportunity to work as an Approved Clinician in Wales

Confirmation should be provided by the Clinical Director.

10. Certificate of Completion of Training

It is essential that the certificate is submitted to ensure ongoing AC approval.

3.3 Applications from doctors not on the GMC specialist register and from non-medical professionals

Applications must include the following:

1. Application Form

The application form must be completed fully and should be error free.

2. Two References

Referee 1

One of the referees must be your current or most recent Medical Director or Clinical Director or equivalent, but where an applicant is on a training programme recognised by the Royal College of Psychiatrists, the referee may be the Training Programme Director or a person the approving body considers equivalent to a Programme Director (ie current or most recent Educational Supervisor).

Referee 1 must have known you or worked with you for a minimum of three months in the preceding twelve months.

Referee 2

One of the referees must be an Approved Clinician, however, where the Clinical/Medical/Training Programme Director or equivalent is an Approved Clinician, referee 2 may be drawn from one of the categories listed:-

• An Approved Mental Health Professional (AMHP) with whom you have worked within the preceding twelve months
• A Consultant Psychiatrist who is S12(2) Doctor approved.

Referee 2 must have known you or worked with you for a minimum of three months in England or Wales in the preceding 2 years (in the preceding 12 months if the referee nominated is an AMHP). Referees must be able to comment on your understanding of and ability to implement the Mental Health Act (1983). The Approvals Team has pro forma reference forms which should be completed by your referee.

At least one of the two referees must have worked with you for a minimum of 3 months in the preceding 12 months of the date of application

3. Curriculum Vitae

The CV should demonstrate evidence of activity and learning relating to the AC competencies of MHA leadership and care management.

• The CV should be validated (signed and dated) by the Medical Director or Clinical Director or Service Manager where applicable.
• Current and previous employment must be included in chronological descending order
• All employment to include FROM and TO dates in the format of dd.mm.yyyy
• CV to include the title/grade of post, full name of employer and address.
• The CV must evidence a minimum of 7 years WTE in Psychiatry of which 4 years WTE must be at a senior level. Posts of less than 3 months’ duration cannot be included.
• For medical applicants only – should have at least 12 months’ experience actively working as a Section 12(2) Doctor.

4. Up to date evidence of Continuing Professional Development requirements

Psychiatrist applicants are required to submit either a certificate of good standing for CPD issued by the Royal College of  Psychiatrists, or a completed All Wales CPD log or evidence of the most recent satisfactory annual appraisal with reference to CPD being achieved. If submitting the most recent appraisal evidence, it would suffice to provide only those pages which evidences the following information: Name of appraisee, name of appraiser, date of appraisal, the date the summary appraisal was agreed and discussion and reflections on CPD.

Please check the link below to check CPD guidance issued by the Royal College of Psychiatrists.

Submitting your CPD - Royal College of Psychiatrists

Nurses require 35 hours CPD relevant to your scope of practice over the three years prior to your revalidation date.

Revalidation requirements - Royal College of Nursing

Psychologists please follow the guidance on the Health and Care Professions Council website

Social Workers require 90 hours Post Registration Training and Learning (PRTL) over a 3-year period

Social Care Wales - Continuing Professional Development     

Occupational Therapists – please follow the guidance on the Health and Care Professions Council website

5. Evidence of when appraisal was conducted and  by whom in order to demonstrate satisfactory appraisal

Details to be provided in application form.

6. Certificate of attendance at a two-day AC Induction Training

Attendance at AC Induction Training in Wales or at one of the AC training events in England that has been approved by Regional Approval Panels in England. The training must be undertaken within the two year period immediately preceding the date of application. All certificates must be in date when the application has been scrutinised and considered complete and error free by the Approvals Team, in readiness to submit to the Panel. The certificate must also remain valid at the point of the Panel assessing applications.

7. Copy of extant Professional Registration Certificate to meet the requirement of Schedule 1 of the Directions 2018

Psychiatrists – GMC Certificate
Nurses – NMC Certificate
Social Workers –Social Care Wales Certificate
Occupational Therapists – HCPC Certificate
Psychologists – HCPC Certificate

8. An enhanced Criminal Record Certificate under section 113B of the Police Act 1997

A copy of the most recent Disclosure and Barring Scheme (DBS) certificate is required from Applicants who work through a Locum Employment Agency.

The DBS certificate must include checks against the DBS Children’s Barred List information and the DBS Adults’ Barred List  information.

9. Confirmation of whether an application for approval as an Approved Clinician elsewhere has been refused

Details to be provided in Application Form.

10. Written confirmation from the applicant’s Clinical Director that they will have the opportunity to work as an Approved Clinician in Wales

If the applicant is a non-medical professional, confirmation should also be provided by their Head of Service.

11. A portfolio to provide evidence of possessing the relevant competencies as outlined in Schedule 2 of the Directions

Evidence must be no more than two years old when submitted.

Please refer to and use the Portfolio Guidance document and Portfolio Contents List in the Application Pack.

Note: It is important that the Portfolio Contents list is followed to set out the Portfolio in the correct order. This will also act as a guide to ensure you have submitted all of the documents required for the Panel to complete their assessment.

The applicant must prepare three copies of their portfolio in lever arch files with file dividers, for submission. Initially, submission of one portfolio for scrutiny by the Approval Team is required. When agreed that the portfolio is complete, the applicant will be invited to submit the two remaining copies.

4. Approval Panel for applications from doctors on the Specialist Register of the GMC and doctors who are in their final year of RCPsych recognised supervised psychiatric training:

4.1 An Approval Panel comprising of two Members will review the evidence provided independently of each other.

4.2 In all cases, there will be at least one Panel Member from the same profession or service area as the applicant.

4.3 If all Panel Members are satisfied with the evidence received, approval will ordinarily be provided within a 4 week period from submission of the evidence to the Panel. If there is likely to be a delay beyond the 4 week period, the applicant will be informed accordingly.

If the decision of the Members is not unanimous:-

• the Panel Members will discuss the evidence and reach a decision
• and/or discuss with the AC and Section 12(2) Panel Chair or the Approval Team.

4.4 On completion of the assessment, the Panel will recommend approval if all criteria have been met. The recommendation will subsequently be submitted to the Executive Board of Betsi Cadwaladr University Health Board for ratification. A formal letter confirming the approval will be sent to the applicant.

5. Approval Panel for applications submitted by doctors not on the GMC Specialist Register and from non-medical professionals

5.1 An Approval Panel comprising of three members will meet to review the evidence provided in the portfolio.

5.2 In all cases, there will be at least one Panel member from the same profession or service area as the applicant.

5.3 On receipt of the portfolio application, the All Wales Approval Team will check the portfolio to ensure that all of the documentary evidence has been received (please refer to the Portfolio Guidance document and Portfolio Contents List for further details). It is required that one copy of the portfolio is submitted for initial scrutiny.

5.4 Once the portfolio application is complete, the Approval Team will make arrangements for the Panel to meet.

5.5 If all Panel Members are satisfied with the evidence received, the Approval Team will contact the applicant to advise accordingly. A formal letter confirming the approval will be sent to the applicant. If the Panel agree approval, the recommendation will subsequently be submitted to the Executive Board of Betsi Cadwaladr University Health Board for ratification.
If the decision of the Panel Members is not unanimous:-

• the Panel Members will discuss the evidence and either agree approval or request further evidence from the applicant.
• If further evidence is required, applicants will be provided with three months for resubmission to demonstrate competency and a suggestion will be sent in writing to the applicant to consider contacting their Clinical Director if assistance is required.
• the Panel Members will meet to assess the newly submitted evidence. If the resubmitted evidence is deemed acceptable by the Panel Members, the applicant will be informed. If the Panel agree that that the resubmitted evidence does not demonstrate competency, the applicant will be provided with a final three months to resubmit evidence. The Clinical Director will be informed that a final three months for resubmission has been granted.
• The Panel Members will meet to assess the final resubmitted evidence. If the evidence is deemed acceptable by the Panel Members, the applicant will be informed. If the Panel assess that the final resubmissions do not demonstrate competency, the applicant and the Clinical Director will be informed. Further new applications for AC approval via the portfolio route may not be submitted within one year from the date of the Panel’s decision.

Note: The assessment process can take a minimum of 6 months to complete from the date the portfolio is originally submitted to the Approval Team.

6. Approved Clinicians already approved in England, seeking approval in Wales, including registered medical practitioners employed on a locum basis.

The Approval Team will require the following information from applicants from England prior to approval being granted to practice as an Approved Clinician in Wales:

1. AC3 Declaration Form

A declaration by the applicant and signed by the new employer in Wales (Clinical Director or an equivalent clinician who has knowledge of the competencies as set out in Schedule 2 of the Mental Health Act 1983 (Approved Clinicians) (Wales) Directions 2018), confirming that the applicant meets the professional requirements and possesses the relevant competencies to carry out the functions as an Approved Clinician in Wales, as set out in Schedule 2 of the Mental Health Act 1983 (Approved Clinicians) (Wales) Directions 2018. It is expected that during recruitment, usually at interview, the employer will ensure the candidate can demonstrate they have knowledge of and can fulfil the additional competencies that apply to Wales.

The signed declaration will detail the additional competencies for Wales (this declaration must be on headed paper using the AC3 template provided by BCUHB Approvals Team).

2. Two References

Referee 1

One of the referees must be your current or most recent Medical Director or Clinical Director or equivalent from England but where an applicant is on a training programme recognised by the Royal College of Psychiatrists, the referee may be the Training Programme Director or a person the approving body considers equivalent to a Programme Director (ie current or most recent Educational Supervisor). Referee 1 must have known you or worked with you for a minimum of three months in the preceding twelve months.

Referee 2

One of the referees must be an Approved Clinician from England, however, where the Clinical/Medical/Training Programme Director or equivalent is an Approved Clinician, Referee 2 may be drawn from one of the categories listed:-

• An Approved Mental Health Professional (AMHP) with whom the applicant has worked within the preceding twelve months.
• A Consultant Psychiatrist who is S12(2) Doctor approved.

Referee 2 must have worked with you or known you for a minimum of three months in England or Wales in the preceding 2 years (in the preceding 12 months if the referee nominated is an AMHP). Referees must be able to comment on your understanding of and ability to implement the Mental Health Act (1983). The Approvals Team has pro forma reference forms which should be completed by your referee.

One of the two referees must have worked with you for a minimum of 3 months in the preceding 12 months.

3. Agreement from their employing organisation that they will have the opportunity to work as an AC

This is usually provided by the Clinical Director.

4. Evidence from the Approving Body in England that the applicant has AC status, and the timeframe for renewal.

A copy of the AC approval letter from England.

5. Curriculum Vitae

The CV should demonstrate evidence of activity and learning relating to the AC competencies of MHA leadership and care management.

• The CV should be validated (signed and dated) by the Medical Director or Clinical Director or Service Manager where applicable.
• Current and previous employment must be included in chronological descending order
• All employment to include FROM and TO dates in the format of dd.mm.yyyy
• CV to include the title/grade of post, full name of employer and address.
• CV must evidence working in a senior grade for a minimum of 4 years.

6. An enhanced Criminal Record Certificate under section 113B of the Police Act 1997.

A copy of the most recent Disclosure and Barring Scheme (DBS) certificate is required from Applicants who work through a Locum Employment Agency.

The DBS certificate must include checks against the DBS Children’s Barred List information and the DBS Adults’ Barred List information.

7. Five Yearly Re-Approval

7.1 It is the responsibility of Approved Clinicians to ensure they maintain their status. Applicants should submit their application for re-approval approximately seven weeks prior to the expiry date. To this end, the Approvals Team will send out one reminder, six months prior to the expiry date. If an application is received more than two months prior to the expiry date, the applicant should provide an explanation as to why they are seeking re-approval earlier than expected. Approved Clinicians should note that attendance at AC refresher training is a mandatory requirement for reapproval. All certificates must be in date when the application has been scrutinised and considered complete and error free by the Approvals Team, in readiness to submit to the Panel. The certificate must also remain valid at the point of the Panel assessing applications.

7.2 The Approval Panel will require the following information from applicants on a five yearly basis for Approved Clinicians to continue to practise in Wales:-

1. Application Form

The application form must be completed fully and should be error free.

2. Two References

Referee 1

One of the referees must be your current or most recent Medical Director or Clinical Director or equivalent, but where an applicant is on a training programme recognised by the Royal College of Psychiatrists, the referee may be the Training Programme Director or a person the approving body considers equivalent to a Programme Director (ie current or most recent Educational Supervisor).

Referee 1 must have known you or worked with you for a minimum of three months in the preceding twelve months.

Referee 2

One of the referees must be an Approved Clinician, however, where the Clinical/Medical/Training Programme Director or equivalent is an Approved Clinician, Referee 2 may be drawn from one of the categories listed:-

• An Approved Mental Health Professional (AMHP) with whom the applicant has worked within the preceding twelve months, or
• A Consultant Psychiatrist who is S12(2) Doctor approved.

Referee 2 must have known you or worked with you for a minimum of three months in England or Wales in the preceding 2 years (in the preceding 12 months if the referee nominated is an AMHP). Referees must be able to comment on your understanding of and ability to implement the Mental Health Act (1983). The Approvals Team has pro forma reference forms which should be completed by your referee.

One of the two referees must have worked with you for at least 3 months in the preceding 12 months of the date of the application.

3. Curriculum Vitae

The CV should demonstrate evidence of activity and learning relating to the AC competencies of MHA leadership and care management.

• The CV should be validated (signed and dated) by the Medical Director or Clinical Director or Service Manager where applicable.
• Current and previous employment must be included in chronological descending order
• The CV should demonstrate evidence of activity and learning relating to the AC competencies of MHA leadership and care management.  
• The CV should be validated (signed and dated) by the Medical Director or Clinical Director or Service Manager where applicable.
• Current and previous employment must be included in chronological descending order covering 5 years’ employment.
• CV to include the title/grade of post, full name of current employer and address.

4. Up to date evidence of Continuing Professional Development requirements

Psychiatrist applicants are required to submit either a certificate of good standing for CPD issued by the Royal College of  Psychiatrists, or a completed All Wales CPD log or evidence of the most recent satisfactory annual appraisal with reference to CPD being achieved. If submitting the most recent appraisal evidence, it would suffice to provide only those pages which evidences the following information: Name of appraisee, name of appraiser, date of appraisal, the date the summary appraisal was agreed and discussion and reflections on CPD.

Please check the link below to check CPD guidance issued by the Royal College of Psychiatrists.

Submitting your CPD - Royal College of Psychiatrists

Nurses require 35 hours CPD relevant to your scope of practice over the three years prior to your revalidation date.

Revalidation requirements - Royal College of Nursing

Psychologists please follow the guidance on the Health and Care Professions Council website

Social Workers require 90 hours Post Registration Training and Learning (PRTL) over a 3-year period

Social Care Wales - Continuing Professional Development     

Occupational Therapists – please follow the guidance on the Health and Care Professions Council website

5. Evidence of when appraisal was conducted and  by whom in order to demonstrate satisfactory appraisal

Details to be provided in application form.

6. Certificate of attendance - AC Refresher Training

Attendance at AC Refresher Training in Wales or at one of the AC training events in England that has been approved by Regional Approval Panels in England. The training must be undertaken within the two year period immediately preceding the date of application. All certificates must be in date when the application has been scrutinised and considered complete and error free by the Approvals Team, in readiness to submit to the Panel. The certificate must also remain valid at the point of the Panel assessing applications.

7. Copy of extant Professional Registration Certificate to meet the requirement of Schedule 1 of the Directions 2018

Psychiatrists – GMC Certificate
Nurses – NMC Certificate
Social Workers –Social Care Wales Certificate
Occupational Therapists – HCPC Certificate
Psychologists – HCPC Certificate

8. An enhanced Criminal Record Certificate under section 113B of the Police Act 1997

A copy of the most recent Disclosure and Barring Scheme (DBS) certificate is required from Applicants who work through a Locum Employment Agency.

The DBS certificate must include checks against the DBS Children’s Barred List information and the DBS Adults’ Barred List  information.

9. Confirmation of whether an application for approval as an Approved Clinician elsewhere has been refused

Details to be provided in Application Form.

10. Written confirmation from the applicant’s Clinical Director that they will have the opportunity to work as an Approved Clinician in Wales

If the applicant is a non-medical professional, confirmation should also be provided by their Head of Service.

8. Conditions of Approval

8.1 All Approved Clinicians must comply with the conditions of approval. Any approval granted is subject to the following conditions as stated in the Mental Health Act 1983 (Approved Clinicians) (Wales) Directions 2018.

8.2 The employing organisation/Approved Clinician must notify the Approving Body (BCUHB) immediately if they no longer continue to meet any of the requirements set out in Part 2 (3 – Granting Approval) of the Mental Health Act 1983 (Approved Clinicians)  (Wales) Directions 2018) in the case of re-approval or if he or she is suspended from registration or listing under such requirements, or has conditions attached to the same.

8.3 The Approved Clinician must immediately cease to act as such and immediately notify the approving Board if they are suspended from any of the registers or lists referred to in the professional requirements;

8.4 The Approved Clinician must immediately notify the approving Board if:

(i) any conditions are attached, by their professional body, to their Registration or listing;

(ii) they become subject to fitness to practise proceedings by their professional body;

(iii) they no longer meet the requirements set out in direction 4 or 9, as the case may be;

(iv) they are convicted of, or receive a caution for, a criminal offence in the United Kingdom, or convicted of or receive a caution for an offence outside the United Kingdom which, if committed in England and Wales, would constitute a criminal offence.

The Approved Clinician must immediately cease to act as an Approved Clinician if the person’s approval is suspended or, upon the expiry of the period of approval where no application for reapproval has been made.

9. Suspension of AC Approval

9.1 If at any time during the period of approval the approved clinician’s professional body suspends that registration or listing, the approving Board must suspend that clinician’s approval for as long as the registration or listing is suspended.

9.2 If at any time during the period of approval an Approved Clinician has conditions attached to their registration or listing by their professional body, the Approving Board may suspend that person’s approval.

9.3 If at any time during the period of approval an Approved Clinician is convicted of, or receives a caution for, a criminal offence in the United Kingdom or is convicted of or receives a caution for an offence outside the United Kingdom which, if committed in England and Wales, would constitute a criminal offence, the Approving Board may suspend that person’s approval.

9.4 Before the Approving Board suspends an approved clinician’s approval under paragraphs 11.1 and 11.2 it must:-

a. give the Approved Clinician its reasons for considering suspending the approval;

b. give the Approved Clinician a period of time which the Approving Board considers reasonable to make representations in respect of the proposed action; and

c. consider representations submitted by the Approved Clinician to the Approving Board.

9.5 When the Approving Board suspends an Approved Clinician’s approval, the Approving Board will inform the Approved Clinician and the professional body responsible for regulating the Approved Clinician’s professional registration or listing of its reasons for the decision.

9.6 If an Approved Clinician approval is suspended, that person may not act in that capacity unless and until the suspension of approval is ended by the Approving Board.

9.7 Where the suspension of approval has ended, the approval will continue to run for the remainder of the period of approval unless the Approving Board ends it earlier in accordance with Direction 8.

10 Removal of Approval

10.1 Revocation/suspension of AC Approval will be considered if:

• Evidence of risks to patient safety is received.
• Where there is evidence that a clinician has not demonstrated sound judgement in relation to application and practice of mental health legislation.

10.2 Procedure

In the situations described below concerns will be examined by the Approval Team and recommendations will be made:

a) An individual raises concern about a clinician’s AC status:-

The Approval Team will not investigate individual concerns but will refer the matter back to the employing organisation and/or the regulatory body for further investigation. In the interim, unless the accusation is grave, AC status will be retained.

In the event of the practitioner working on a freelance basis, the Approval Team will review the concerns and decide on the appropriate course of action. If necessary, the Approval Team will refer the clinician to, or advise the complaintant to refer the clinician to, the relevant regulatory body.

b) An employing organisation dismisses, suspends a clinician or places restrictions on practice:-

In this circumstance the Panel will ask the employing organisation for relevant information about the reasons behind the suspension/restriction on practice. The Approval Team will review the available information and recommend a course of action. All organisations have a duty to disclose information pertinent to a reactionary’s AC status as they may work elsewhere and employers have no power to alter AC status.

The outcomes available to the Approval Team are as follows:

1. Remove AC Status
2. Suspend AC Status pending investigations
3. Recommend a reassessment of competence in AC roles by the Panel
4. Leave AC status unaltered.

c) Professional Registration Bodies:-

Please refer to Professional Registration Bodies (General Medical Council, Royal College of Nursing, Health and Care Professions Council) for information regarding their process for dealing with fitness to practise concerns.

Whilst the Approved Clinician is under investigation, the Approving Body will need to take a view about whether or not the individual should continue to be AC approved. If the issues are serious and potentially pose a risk to patients, AC status may have to be suspended; in other circumstances AC status may be unaffected.

11. End of approval

11.1 The approval of an Approved Clinician ends upon the expiry of the period of approval.

11.2 The approving Board must end the approval of an Approved Clinician before the expiry of the period of approval in the following circumstances:

a) if, in the opinion of the approving Board, the Approved Clinician does not comply with any of the conditions listed in direction 6.(1),

b) if, in the opinion of the approving Board, the Approved Clinician no longer possesses the relevant competencies,

c) if the Approved Clinician no longer meets the professional requirements, or,

d) if the Approved Clinician makes a request, in writing, to end their approval.

e) If the Approved Clinician’s licence to practise is removed by their professional regulatory body eg: GMC/HCPC/NMC/SCCW, the approval must end. If the licence is later restored, and the professional requests that their approval status be restored, the Approving Body will require the following information which will be coordinated by the Approvals Team.

1. A confirmation letter from Clinical Director or Medical Director that the professional will have the continued opportunity to work as an Approved Clinician in Wales.
2. The Approving Board will also make relevant enquiries to the professional’s Medical Director or equivalent, for assurances relating to the supervision and management of the professional, or any other relevant enquiry, as deemed reasonable, by the Approving Board.
3. The Approval Team will check that the professional’s licence to practise has been restored.

f) If all of the information is deemed to meet the above requirements by the Approving Board, the Board will consider ratifying the restoration of the approval for the remainder of the five year approval period.

11.3 Before the Approving Board ends an Approved Clinician’s approval under paragraphs (2)(a)-(c), the approving Board will:

1. Give the Approved Clinician its reasons for considering ending the approval;
2. give the Approved Clinician a period of time which the approving Board considers reasonable to make representations in respect of the proposed action; and
3. Consider representations submitted by the person to the Approving Board.

Where the Approving Board ends the approval of an Approved Clinician under paragraph (2), that Board will immediately notify that clinician in writing of the date of the ending of approval and the reason for the ending of approval.

12. Governance Arrangements

12.1 Clinical Directors and service manager or equivalent status are accountable for ensuring that the approved clinicians within their services are qualified to undertake the functions and are supported and supervised in doing so.

They are responsible for ensuring that:-

• Only those eligible to become approved clinicians are allowed to apply for approval
• Only those professionals that are competent to act as a responsible clinician undertake those functions; and
• An effective regimen of clinical supervision, professional development management and performance appraisal is in place for all approved clinicians (and those preparing for or seeking approval).