Practising privileges across a multi-site group: evidencing the same consultant at four hospitals

On Monday a consultant orthopaedic surgeon operates at one hospital. Wednesday is an outpatient clinic at a second site, Thursday a theatre list at a third, Saturday a private list at a fourth. All four sit inside the same group, and each granted that surgeon practising privileges separately, on its own paperwork, at its own date. That is four files on one person, each with its own review date.

Accountability for that activity sits at each hospital. The Medical Practitioners Assurance Framework puts it at paragraph 1.3, with the registered manager alongside the registered provider, for compliance with the Health and Social Care Act 2008 and associated regulations. Each hospital has its own registered manager, registered with the Care Quality Commission for the regulated activity there.

The surgeon holds no contract of employment with any of the four. For the purposes of the regulations CQC enforces in England, all four have employed them.

A grant of practising privileges is employment, in the regulations' own words

Regulation 2(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 defines employment for the whole instrument. Limb (b) covers "the grant of practising privileges by a service provider to a medical practitioner, giving permission to practice as a medical practitioner in a hospital managed by the service provider".

Every duty phrased around persons employed therefore reaches a consultant who never signed a contract. Regulation 19 on fit and proper persons employed applies. So do Schedule 3, regulation 18(2) on support, supervision and appraisal, and regulation 17(2)(d)(i) on records kept for persons employed.

The Independent Healthcare Provider Network reads it the same way. Paragraph 1.6 of its September 2022 refresh says: "Even though medical practitioners are independent contractors with regards to employment law, for the purpose of the regulations, medical practitioners working under practising privileges are defined as employees".

That deeming is also why the consultant does not register with CQC in their own right. The exemption holds only while every aspect of the consultation is carried out under the hospital's management and policies.

CQC decides whether a Schedule 3 file is satisfactory

Regulation 19(3) requires the Schedule 3 information to be available for each person employed. Schedule 3 runs to nine paragraphs. The eight substantive ones are the file a medical staffing team assembles:

1. Proof of identity, including a recent photograph.
2. Where required for an exempted question under section 113A(2)(b) of the Police Act 1997, a criminal record certificate under section 113A, with barring information where applicable.
3. Where required for an exempted question asked for a prescribed purpose under section 113B(2)(b), a separate enhanced certificate under section 113B, with suitability information relating to children or vulnerable adults where applicable.
4. Satisfactory evidence of conduct in previous employment concerned with services relating to health or social care, or to children or vulnerable adults.
5. Where the person previously held a position whose duties involved work with children or vulnerable adults, satisfactory verification, so far as reasonably practicable, of why that employment ended.
6. Satisfactory documentary evidence of any qualification relevant to the duties, so far as it is reasonably practicable to obtain.
7. A full employment history, with a satisfactory written explanation of any gaps.
8. Satisfactory information about any physical or mental health conditions relevant to the person's capability, after reasonable adjustments are made, to properly perform tasks intrinsic to their employment or appointment for the purposes of the regulated activity.

Whether a file is complete is not the group's judgement. Paragraph 9(b) defines "satisfactory" as "satisfactory in the opinion of the Commission", and that word governs five of the eight items above.

Item 5 binds hardest across a group. Where privileges were withdrawn or quietly allowed to lapse at a sister site, that is the fact it reaches for.

The evidence does not have to sit at the location

The operative word in regulation 19(3) is available. It does not say held, or held at the location.

CQC guidance on employment checks in the independent sector speaks to providers granting privileges directly. The wording is: "It is not necessary for an IH provider to undertake these checks themselves or to hold the evidence of such checks having been completed at the location". The provider must still be satisfied the checks were completed, and able to evidence it.

That page dates from the pandemic, published 11 September 2020 and last updated 12 May 2022. CQC has not superseded the sentence.

What follows depends on how the group is registered. This step is an inference from the statutory scheme rather than a published CQC position. Registration is of a person in respect of a regulated activity, with locations in the conditions attached. One registered provider holding four locations carries one regulation 19 duty. Four separately registered entities carry four, and common ownership does not merge them. A medical director who cannot say which applies should establish it before the next review cycle.

The responsible officer may not be inside your group at all

An independent hospital operator is a designated body under the Medical Profession (Responsible Officers) Regulations 2010. Practising privileges create a prescribed connection expressly, at regulation 10(1)(f): "the designated body owns or manages a hospital and the medical practitioner has responsibility for treating patients in that hospital in accordance with practising privileges for that hospital". That wording was substituted with effect from 1 April 2013, and legislation.gov.uk still serves the 2010 text.

The connection attaches to the designated body, so four hospitals inside one designated body give the surgeon one responsible officer. Where they also work for an NHS trust or a second operator, regulation 10(2)(g) resolves it by volume of clinical practice. If volumes are level and only one of the bodies is an NHS body, that body takes the connection, and failing that the body nearest the doctor's registered address. It can sit outside the group entirely.

The evidence obligation does not travel with it. Appraisal and revalidation follow the responsible officer, who under regulation 11(3) must ensure the appraisal takes account of the doctor's work for the designated body "and for any other body". Regulation 19 and Schedule 3 stay with whoever granted the privileges.

Where the practitioner is practising in England, regulation 16(4)(c) adds a further duty. An investigation into a practitioner's conduct or performance must take account of any other relevant matters within the designated body. A concern raised at one hospital is investigated against what the other three hold.

Three clocks run on the same consultant and none of them align

Practising privileges are reviewed biennially, in the framework's wording, "and more regularly in circumstances where additional scrutiny is required". Whole practice appraisal is annual, and revalidation runs on a five-year cycle set by the GMC. None of the three has any reason to fall in the same quarter as the others.

Reaching a review date without the evidence has a defined consequence: "Where the independent provider does not have the required information necessary to make a decision about renewal, practising privileges should be suspended until that information is available".

The current framework is the September 2022 refresh, with a further refresh led by Professor Sir Stephen Powis expected in autumn 2026. CQC set out its assessment priorities on 26 May 2026. For hospitals it listed an "increased focus on services in the independent sector, reflecting the level of unknown or emerging risk, and the increasing volume of NHS-commissioned activity they are delivering". Service Condition 3.16 of the 2026/27 NHS Standard Contract requires providers other than NHS trusts and foundation trusts to have regard to the framework.

The same review date, run two ways

A biennial review falls due at hospital two. The application dataset there was completed 24 months earlier and describes the scope of practice agreed then. Three procedures the surgeon has added since are logged in hospital four's governance system. A complaint investigated at hospital one eight months ago was closed and recorded there. Medical staffing raises requests with three registered managers and waits. The review cannot conclude on the information in front of it, privileges are suspended until the missing evidence arrives, and two theatre lists and a clinic come off the diary.

The same review date, run against one record covering all four locations, opens differently. The scope of practice was updated when the third and fourth procedures were added at hospital four. The complaint at hospital one is attached to that record, with the date it was raised and the date it closed. Nothing is requested from another site, because nothing is held only at another site.

What one practising privileges record has to hold

Appendix 1 of the framework is the closest the sector has to a standard privileges dataset. Two of its lines settle the record structure question. On application it requires "All locations where a doctor holds practising privileges or works as a doctor". On review it requires consideration of "Concerns, investigations or changes to practice in other hospitals where the doctor works". A group holding four site files can satisfy the first and cannot reliably satisfy the second.

Spire Healthcare, The London Clinic and Cleveland Clinic London are Credentially customers.

A record structure that answers Appendix 1 holds one consultant once, with locations as attributes of that record rather than four copies of it. GMC registration and entry on the specialist register are verified at source and re-checked daily against the connected register, with alerts on expiry. Indemnity certificates, mandatory training evidence and references sit against the same record, each dated and attributed. A practising privileges workflow built this way records the grant, the biennial review date and the review outcome for each hospital on that one record. Audit reporting with a logged activity trail then produces the evidence for a named individual at a named location, without a separate exercise. Where the group holds NHS-funded contracts, the same discipline is already expected of it.

The point at which the group has to tell the GMC

One duty reaches outside the group altogether. Where a person employed by the registered person no longer meets the criteria in regulation 19(1), regulation 19(5) requires action that is necessary and proportionate. Where that person is registered with a health care regulator, the provider must also "inform the regulator in question". For a consultant, that is the General Medical Council.

With the privileges record held in Credentially, a change to a consultant's GMC registration surfaces from the daily re-check, before the next biennial review would find it.

The trigger is a state of affairs. It does not wait for a board to conclude anything, and regulation 2(1) puts the duty on the provider that granted the privileges. Whether the group meets it in time depends on whether the information that would reveal the state of affairs, held at four sites by four registered managers, reaches one place before the review date does.

References

1. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, regulation 2, interpretation, including the definition of "employment". https://www.legislation.gov.uk/uksi/2014/2936/regulation/2 (retrieved 23 August 2026)
2. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, regulation 19, fit and proper persons employed. https://www.legislation.gov.uk/uksi/2014/2936/regulation/19 (retrieved 23 August 2026)
3. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Schedule 3, information required in respect of persons employed or appointed. https://www.legislation.gov.uk/uksi/2014/2936/schedule/3 (retrieved 23 August 2026)
4. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, regulation 17, good governance. https://www.legislation.gov.uk/uksi/2014/2936/regulation/17 (retrieved 23 August 2026)
5. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, regulation 18, staffing. https://www.legislation.gov.uk/uksi/2014/2936/regulation/18 (retrieved 23 August 2026)
6. Health and Social Care Act 2008, sections 10 and 12, registration as a service provider and conditions of registration. https://www.legislation.gov.uk/ukpga/2008/14/section/10 (retrieved 23 August 2026)
7. The Medical Profession (Responsible Officers) Regulations 2010, S.I. 2010/2841, regulations 10, 11 and 16 and the Schedule. Served as made and not consolidated. https://www.legislation.gov.uk/uksi/2010/2841/contents (retrieved 23 August 2026)
8. The Medical Profession (Responsible Officers) (Amendment) Regulations 2013, S.I. 2013/391, regulation 3(4)(g), substituting regulation 10(1)(f) with effect from 1 April 2013. https://www.legislation.gov.uk/uksi/2013/391/made (retrieved 23 August 2026)
9. Care Quality Commission, Types of service provider or legal entity, scope of registration, page last updated 29 January 2025. https://www.cqc.org.uk/guidance-regulation/providers/registration/scope-registration/who-has-register/types-service-provider-or-legal-entity (retrieved 23 August 2026)
10. Care Quality Commission, Employment checks and training in the independent sector, published 11 September 2020, page last updated 12 May 2022. https://www.cqc.org.uk/news/providers/employment-checks-training-independent-sector (retrieved 23 August 2026)
11. Care Quality Commission, Regulation 19: Fit and proper persons employed, page last updated 16 May 2025. https://www.cqc.org.uk/guidance-regulation/providers/regulations-service-providers-and-managers/health-social-care-act/regulation-19 (retrieved 23 August 2026)
12. Care Quality Commission, Priorities for delivering more assessments and tackling aged ratings, 26 May 2026. https://www.cqc.org.uk/about-us/improving-how-we-work/0526-update (retrieved 23 August 2026)
13. Independent Healthcare Provider Network, Medical Practitioners Assurance Framework Refresh, September 2022. https://www.ihpn.org.uk/wp-content/uploads/2022/09/IHPN-MPAF-refresh-final.pdf (retrieved 23 August 2026)
14. Independent Healthcare Provider Network, MPAF resources, confirming launch on 23 October 2019 and refresh in September 2022. https://www.ihpn.org.uk/mpaf-resources/ (retrieved 23 August 2026)
15. Independent Healthcare Provider Network, MPAF refresh 2026, refreshed framework expected in autumn 2026. https://www.ihpn.org.uk/medical-practitioners-assurance-framework-mpaf-refresh-2026/ (retrieved 23 August 2026)
16. NHS England, 2026/27 NHS Standard Contract, Service Conditions (Full Length), Service Condition 3.16. https://www.england.nhs.uk/wp-content/uploads/2025/11/03-nhssc-26-27-full-length-service-conditions.pdf (retrieved 23 August 2026)
17. General Medical Council, What is revalidation, on the five-yearly cycle. https://www.gmc-uk.org/registration-and-licensing/managing-your-registration/revalidation/what-is-revalidation (retrieved 23 August 2026)