Strategy and Policy Board meeting, 22 March 2016

Agenda item: 3

Report title: GMC regulation in and other overseas territories

Report by: Richard Marchant, Assistant Director, Regulation Policy [email protected], 020 7189 5024

Considered by: Strategy and Policy Board

Action: To consider

Executive summary There is no requirement in UK legislation for doctors who are working outside the UK to be registered or licensed with the GMC. Those doctors outside the UK who choose to be registered or licensed with us are subject to our jurisdiction and we have arrangements in place that make it possible for them to revalidate. However, where we rely on local processes overseas to support this, our regulatory levers are limited and it can be difficult to regulate effectively.

Crown Dependencies such as the Channel and are not part of the UK. We have nevertheless established agreements with those territories to facilitate the revalidation of doctors within their jurisdiction using local system. Similar arrangements are now being put in place for and we have received initial enquiries from the UK Government with regard to GMC regulation in other British Overseas Territories.

We have so far made decisions on a case-by-case basis. We need to establish a framework to help us decide when it is appropriate to extend our regulatory processes overseas.

The Board considered a proposed framework at its meeting on 14 July 2015. This has now been modified following further reflection and to take more fully into account our plans for GMC services.

Recommendation The Strategy and Policy Board is asked to agree the policy framework at Annex A.

Strategy and Policy Board meeting, 22 March 2016 Agenda item 3 - GMC regulation in Crown Dependencies and other

overseas territories

The current situation 1 Our advice to doctors working outside the UK is to relinquish their licence to practise and apply for it to be restored should they return to UK in the future. If they choose to maintain their licence we have provided a route to revalidation. Most licensed doctors working outside the UK would do so through the arrangements for doctors with no prescribed connection to a UK designated body.

Crown Dependencies* 2 Dependencies (the Isle of Man, and ) wish doctors working in their jurisdictions to be GMC licensed. They therefore requested a process for their doctors to revalidate and maintain their licences to practise.

3 As the UK legislation and systems which support revalidation do not apply in the Crown Dependencies, analogous local arrangements (and legislation) were put in place. This involved the creation of ‘suitable persons’ approved by the GMC who would fulfil the role of the UK Responsible Officers (RO) in overseeing local clinical governance arrangements and making revalidation recommendations to the GMC.

4 We agreed to this for a number of reasons. The Isle of Man and Jersey both provide placements for UK doctors in training and we require trainees to be supervised by a doctor with a prescribed connection to an RO or suitable person. There is also a regular flow of doctors between these jurisdictions and the UK . We therefore had an interest in facilitating arrangements which would enable these doctors to revalidate. We did not anticipate high demand from other jurisdictions.

Gibraltar (a British Overseas Territory) 5 Gibraltar has decided that all doctors working there must be licensed with the GMC. In 2013, the Department of Health () requested that similar arrangements to those for Jersey and Isle of Man be extended to Gibraltar. At its meeting on 22 July 2014, the Board agreed for those doctors working for the Gibraltar Health Authority (publicly-funded healthcare). Gibraltese legislation is now in place creating a role analogous to that of a UK RO. We are now considering an application for GMC approval as a ‘suitable person’ for the purposes of making revalidation recommendations. We have no trainees in Gibraltar.

* The Crown Dependencies are the Bailiwick of Jersey, the and the Isle of Man. They are not part of the UK, but are self-governing dependencies of the Crown. Citizens of the Crown Dependencies hold British citizenship.

2 Strategy and Policy Board meeting, 22 March 2016 Agenda item 3 - GMC regulation in Crown Dependencies and other

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Other British Overseas Territories* 6 In late 2014, the Foreign and Commonwealth Office (FCO) enquired whether similar arrangements to those in the Crown Dependencies and Gibraltar could be applied to other British Overseas Territories. To date we have heard nothing further from FCO.

Principles, challenges and risks 7 Each of these three cases presents different grounds for extending GMC processes overseas. So far our decisions have been made ad-hoc, on a case by case basis. To enable us to handle future enquiries consistently it would be helpful to have a clear framework. We also need to understand the risks. These include:

a Our regulatory approach is UK-specific and not easily transplanted overseas. The further from the UK the weaker our regulatory levers.

b We have only limited assurance about the ongoing monitoring of doctors’ fitness to practise and the readiness of local systems to take action when concerns arise.

c Our regulatory approach has been developed to work with UK healthcare structures and systems, such as clinical governance. In other jurisdictions the same systems, and systems regulation, do not exist.

d We are not experts in systems regulation and cannot easily fill the gap to provide the assurance we require. Approving suitable persons overseas to fulfil the role of a UK RO exposes us to risk if those individuals are working within unsuitable environments.

e In regulating doctors working in other jurisdictions we take on the associated regulatory risk if things go wrong. This is different from our developing proposals for GMC services overseas where we would not be taking on a statutory regulatory risk, although other similar risks may arise.

f For GMC regulation to be effective overseas we require Governments and local systems to accept the implications of GMC standards, even though these are standards developed for a UK context.

* There are 14 British Overseas Territories: ; ; British Antarctic Territory; British Indian Ocean Territory (Chagos Archipelago); ; ; ; Gibraltar; ; ; St Helena, Ascension and ; South & The South Sandwich Islands; Sovereign Base Areas of and Dhekelia (); .

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g Politics, conflicts of interest and personal disputes can present challenges in small jurisdictions which would be diluted in larger environments in the UK.

h There is increased potential for challenges about the fairness of our policies and decision making as applied to doctors in other jurisdictions.

i We incur both actual and opportunity costs.

j GMC engagement with an overseas jurisdiction may bring reputational risks for us if that jurisdiction is subject to criticism.

k Our objective is to protect, promote and maintain the health and safety of the public in the UK and we may be subject to criticism if it is felt that we are devoting resources elsewhere without sufficient justification.

A framework for decision making 8 Based on the cases where we have so far been asked to regulate outside UK, we have developed a framework to help us decide whether providing GMC regulatory involvement (as distinct from GMC services) is appropriate.* The framework at Annex A simplifies the principles first considered by the Board in July 2015 so as to give us greater operational flexibility. It establishes just two fundamental principles:

a The full costs of GMC regulation overseas are borne by the host (including for example, staff time and Employer Liaison Service visits to the host territory).

b There is support for GMC involvement from both Department of Health and the government in the overseas jurisdiction.

9 However, in applying these principles the framework also requires consideration of a series of risk factors and the extent to which they can be mitigated.

10 In cases where GMC regulation overseas is not felt to be appropriate, there may nevertheless be options for us to provide other services.

* This framework does not apply in those cases (such as the quality assurance of UK primary medical education delivered overseas) where we have a statutory duty to exercise regulatory responsibility.

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Strategy and Policy Board meeting, 22 March 2016

3 – GMC regulation in Crown Dependencies and other overseas territories

3 – Annex A

Policy framework Risks would include, but need not be confined to one or more of the following:

a Our regulatory approach is UK-specific and not easily transplanted overseas. The further from the UK the weaker our regulatory levers.

b We have only limited assurance about the ongoing monitoring of doctors’ fitness to practise and the readiness of local systems to take action when concerns arise.

c Our regulatory approach has been developed to work with UK healthcare structures and systems, such as clinical governance. In other jurisdictions the same systems, and systems regulation, do not exist.

d We are not experts in systems regulation and cannot easily fill the gap to provide the assurance we require. Approving suitable persons overseas to fulfil the role of a UK RO exposes us to risk if those individuals are working within unsuitable environments.

e In regulating doctors working in other jurisdictions we take on the associated regulatory risk if things go wrong. This is different from our developing proposals for GMC services overseas where we would not be taking on regulatory risk.

f For GMC regulation to be effective overseas we require Governments and local systems to accept the implications of GMC standards, even though these are standards developed for a UK context.

g Politics, conflicts of interest and personal disputes can present challenges in small jurisdictions which would be diluted in larger environments in the UK.

h There is increased potential for challenges about the fairness of our policies and decision making as applied to doctors in other jurisdictions.

A1

Strategy and Policy Board meeting, 22 March 2016 Agenda item 3 - GMC regulation in Crown Dependencies and other overseas territories

i We incur both actual and opportunity costs.

j Our objective is to protect, promote and maintain the health and safety of the public in the UK and we may be subject to criticism if it is felt that we are devoting resources elsewhere without sufficient justification.

k GMC engagement with the overseas jurisdiction may bring reputational risks if the government or regulatory regime in that jurisdiction is subject to criticism (e.g. the LSE’s involvement with Colonel Gaddafi’s resulted in criticism when the relationship became public).

A2

Request for GMC involvement in regulation outside of UK

Is it an FTP issue YES relating to individual Send to FTP GMC registered doctors?

NO

Does the request require GMC to take statutory regulatory responsibility NO for doctors/systems Refer to GMC services overseas (e.g educational approvals, revalidation systems)?

YES YES

Does the requested GMC NO NO intervention have UK Is there a possible Government and role for GMC Close overseas Government services? support

YES YES

Is the overseas NO Could GMC NO jurisdiction willing to services be Close pay full cost of GMC interested on a intervention pro bono basis?

YES

Is there a strategic, tactical, diplomatic or financial interest for GMC becoming NO involved (for example: UK training programmes within Close overseas jurisdiction; regular flow of doctors into UK, close links with UK)

YES

Close NO Can risks associated with GMC invlvement be adequately mitigated? (see A3 footnotes below*) YES GMC engages regulatory role