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Verification of employees’ professional registration

1 Introduction

It is mandatory that certain healthcare professionals, including temporary staff and agency workers, are appropriately registered with a regulatory body to practice. The purpose of undertaking registration checks is to ensure that, where appropriate, any prospective and or current employee within the trust are registered by the appropriate regulatory body and has the right qualification to do the job for which they have been employed. Such professional regulation is intended to protect the public, by assuring that anyone who is practising as a healthcare professional is doing so safely (NHS Employers, Professional Registration and Qualification Checks 2021).

Whilst it is the responsibility of individual employees to ensure that their professional registration remains current at all times, the trust is required to be able to verify such registrations for all its employees (permanent, temporary or bank) as well as being able to demonstrate that it has systems in place to monitor the registrations of employees on an ongoing basis. If an employee’s registration lapses, they will not contractually, and in many cases legally, be able to continue to carry out the duties of the post, if the post requires them to be registered.

In addition, the trust is required to have systems in place to ensure that any employment agency supplying workers to the trust (for example, NHS professionals and recruitment agencies) carries out professional registration checks on workers they supply to the trust as appropriate, and the trust should verify as soon as possible.

2 Purpose

The purpose of this policy is to ensure that the trust has adequate procedures to verify the professional registration status of clinical employees employed by the organisation who are required to hold a professional qualification and maintain registration with a professional regulatory body in accordance with their recommendations. Section 5.5 details the employees which are covered by the policy.

3 Scope

This policy applies to those employees for whom professional registration is a pre-requisite of employment and should be read in conjunction with the trust’s appointment of staff policy.

4 Responsibilities, accountabilities and duties

4.1 Head of workforce

It is the responsibility of the Head of Workforce to:

  • ensure that a professional registration policy and procedure is in place which sets out the verification procedure to be followed for clinical employees
  • ensure that a central record of professional registration is maintained on electronic staff record (ESR) and that processes are in place to monitor professional registration prior to commencement and during employment
  • ensure that a process is in place to monitor the compliance with and the effectiveness of this policy and procedure

4.2 Individual employees who are required to be professionally registered

  • It is the responsibility of each individual employee to ensure they maintain their professional registration during their employment, even if they are absent from work and fulfil their obligations set out in the procedure section below.
  • It is each individual employee’s responsibility to pay their own professional registration fees; ensure that they meet the ongoing registration requirements of the relevant professional body (for example, maintaining an adequate continuous professional development (CPD) portfolio and, where appropriate, to notify the relevant professional body of any further qualifications undertaken.
  • It is the duty of the individual employee to inform the trust if, at any point during their employment, they are subject to any form of proceedings initiated by their professional body. This duty applies irrespective of whether the matter is related to their employment with the trust.

4.3 Workforce systems

It is the responsibility of the trust’s Workforce Systems team to:

  • maintain and update a central system of the relevant employee’s professional registration details through the electronic staff record system (ESR)
  • utilise the central system to monitor renewal dates and to send a notification to employees and their line managers
  • monitor notifications from the electronic staff record system via professional registered body interface processes and ensure the Human Resources team and relevant line managers are notified immediately when a change to an employee’s registration status (amber or red alert) is received
  • where automated interface systems are not available within electronic staff record system (registered social workers) ensure renewal dates are updated
  • to generate a report from the electronic staff record system and correct any missing information monthly to identify any professional body registration numbers and expiry dates which have not been inputted for employees appointed to a clinical role which requires a professional registration

4.4 Recruitment team

The Recruitment team must ensure that professional registration is checked and recorded on the electronic recruitment system prior to confirming employment.

The sponsor management system must be updated with the details of disciplinary action taken for any employees who are being sponsored by the trust and where this may impact on their Right to Work status and must therefore be reported to the UK Visas and Immigration service, as outlined in the Home Office Workers and Temporary Workers: guidance for sponsors; Part 3: Sponsor duties and compliance.

4.5 Procurement team or agency

  • It is the responsibility of the purchasing department to ensure that the recruitment agencies used by the trust are registered on the appropriate framework under the NHS Workforce Alliance and that the associated agreement incorporates compliance with the NHS Employment Checks Standards.
  • This includes the requirement for the relevant agency to ensure appropriate checks on professional registration are undertaken.

4.6 Care group directors

Where the trust is working in partnership with external providers, for example, local authorities, it is the care group director’s responsibility to ensure the external provider has provided the trust with reassurance that they undertake appropriate checks on professional registration.

5 Procedure

Many healthcare professionals must renew their registration regularly (normally annually). The trust is unable to employ someone in a post for which they are not appropriately registered or are unable to provide evidence of registration. Failing to renew registration, or being removed or suspended from a professional register, is a serious matter and has an adverse effect on the trust’s ability to care for patients, clients or service users.

5.1 Appointment of staff

  • No person may be employed by the trust in any occupation requiring professional registration unless that person is included in the appropriate professional register and can demonstrate evidence of his or her registration.
  • The Recruitment team will ensure that the professional registration number provided by an applicant is valid, in date and appropriate for the role that they are being appointed to.
  • The pay services department will ensure that new starters will only be entered onto the appropriate pay band once confirmation has been received of their professional registration number.
  • Newly qualified employees will be paid according to their contract, for example, the rate of pay based on the post they have been offered, although they will not be permitted to carry out the duties of the post until they have received their registration. This only relates to employees who have been appointed pending their registration, and not to trainee staff who have been employed on training bands until they become registered.
  • In respect of all bank or agency workers, only recruitment agencies which are registered on the appropriate framework under the NHS Workforce Alliance may be used, which includes the requirement to check professional registration status.

5.2 During employment for existing staff

Each employee who is professionally registered must renew their registration before it lapses.

If there are circumstances which impact on the renewal of registration, for example, maternity, long term sickness, then a temporary extension must be sought and obtained from the professional body. This will be verified by the Workforce Systems team.

It is a breach of contract and a very serious matter to work in a role requiring registration in any circumstance whilst an employee is unregistered with their professional body.

In addition to the reminders which are sent directly from the relevant professional bodies, the Recruitment team will notify non-medical registered employees via email or phone to inform them of their registration renewal date (and revalidation date if appropriate). The Recruitment team will monitor the progress of re-registration via electronic staff record (ESR) and maintain contact with the employee and employee’s line manager as this deadline date approaches.

In the event that the Recruitment team receive a notification that a registration has lapsed, then this will be communicated to the People Experience team with immediate effect so that it can be investigated and actioned appropriately.

Where an employee is in a situation whereby, they believe that their professional registration may lapse for any reason they must immediately notify their line manager.

  • In the event that an employee allows their registration or their specialist registration to lapse for any reason they must immediately notify their line manager and will not be permitted to work until their registration has been renewed and verified (see section 5.3 below).
  • If an employee is paying their registration via direct debit and they fail to maintain their payments, the Nursing and Midwifery Council (NMC) and The Health and Care Professions Council (HCPC) will contact with the employee to pay the outstanding fee. If the Nursing and Midwifery Council or The Health and Care Professions Council do not receive payment the employee will be de-registered by the Nursing and Midwifery Council or The Health and Care Professions Council. The trust does not receive any notification of non-payment; therefore, it is imperative that employees ensure payments are kept up to date. In these circumstances the provisions of section 5.3 will be applied.
  • Medical employees are not de-registered by the General Medical Council (GMC) for non-payment for approximately 3 months after their annual retention date. The Medical Workforce team will check the information held on electronic staff record (ESR) immediately after the General Medical Council renewal date and advise those doctors that may be at risk of becoming unregistered. The relevant information is imported into electronic staff record from the General Medical Council system.

5.3 Action in the event of an employee’s professional registration lapsing

Where clinical employees are not registered, or have failed to maintain their specialist registration, immediate action must be taken to protect the interests of the public and patients. This will involve ensuring that the employee immediately ceases to practise and is suspended on no pay (unless there are extenuating circumstances, see point 5 below) For further information refer to the trust’s disciplinary policy.

  • The trust cannot employ an employee in a post for which they do not hold the requisite qualifications and registration. Accordingly, continuation in such a post beyond a due re-registration date is not permissible.
  • Where, on the day re-registration was due, the employee has not re-registered or maintained their specialist registration or licence to practise, the line manager, will initiate a period of unpaid leave for a maximum period of six weeks. The authority to initiate the period of unpaid leave rests with the appropriate senior employee on duty at the time; however, they should attempt to obtain advice from the Human Resources team or on-call director before initiating this leave. The deduction from payroll will be actioned the month following the incident, for example, unpaid leave in July will be deducted from the August salary.
  • During the period of unpaid leave, the employee may be permitted by the line manager to resume normal duties and customary pay if they are restored to the professional register or specialist register. However, in all instances the trust will formally investigate (at the time of the lapse) the lapse of registration in line with the disciplinary policy (or maintaining high professional standards for medical staff), which may result in a disciplinary hearing and ultimately the employee’s dismissal. The line manager must also notify the pay services department of the period unpaid leave.
  • During the period of unpaid leave regular contact with the employee should be maintained by their line manager, to offer support and assistance with any actions required to restore professional registration.
  • It is acknowledged that there may be occasions when for some employees there are reasons, known in advance, why re-registration by the due date will not be possible. In such situations the employee is responsible for advising their line manager before the due re-registration date so that the line manager can consider appropriate action including possible alternative duties which do not require professional registration.
  • In cases where there are extenuating circumstances which are beyond the employees’ control, these should be discussed with the line manager who may consider duties which do not require professional registration as an alternative to the unpaid leave. Where an employee fails to re-register by six weeks after the original renewal date, it will be deemed that the employee has invalidated their contract of employment with the trust which will result in a disciplinary hearing and may lead to the employee’s dismissal from the trust.

5.4 Requirements of registration

Each professional registration body has its own requirements in relation to matters such as lapsed registrations, career breaks and continual professional development. Where these factors complicate the basic employment question of whether the employee is registered or not, advice must be sought from a human resources advisor.

5.5 Professionally registered trust employees and the professional bodies with which they must be registered

5.5.1 General medical council (GMC)

Doctors (all grades) to practice medicine all doctors are required by law to be both registered and hold a licence to practise.

For some doctors it is a condition of their employment that they have and maintain appropriate Mental Health Act approval, that is, section 12 and or approved clinician status

5.5.2 Nursing and midwifery council (NMC)

Registered nursing staff (all grades).

5.5.3 Health and care professions council (HCPC)

  • Occupational therapists.
  • Arts therapists.
  • Dieticians.
  • Physiotherapists.
  • Podiatrists.
  • Social workers.
  • Speech and language therapists.
  • Practitioner psychologists.

5.5.4 General pharmaceutical council

Pharmacists and pharmacy technicians.

5.6 Unregulated practitioners

There are some unregulated roles which require registration with a specific Accredited Register as a condition of employment.

This is the case for some psychological professional roles that are not regulated by law. These posts will be checked during the recruitment process via the Accredited Registers which is managed by the Professional Standards Authority (PSA)

The Accredited Registers include:

  • Association of Child Psychotherapists (ACP)
  • British Association for Counselling and Psychotherapy (BACP)
  • UK Council for Psychotherapy (UKCP)

6 Monitoring arrangements

6.1 How the organisation checks registration with the relevant professional body

In accordance with their recommendations for all directly employed clinical staff, both on initial appointment and on an ongoing basis.

6.1.1 Initial appointment checks

  • How: initial appointment checks undertaken via Trac electronic recruitment system.
  • Who by: Recruitment team.
  • Frequency: as required.

6.1.2 Electronic staff record (ESR) interface with professional regulatory body with alert system for changes in status

  • How: electronic staff record (ESR) interface with professional regulatory body (Nursing and Midwifery Council, The Health and Care Professions Council, General Medical Council) with alert system for changes in status.
  • Who by: Workforce Systems team
  • Frequency: daily.

6.1.3 Ongoing checking undertaken each month to ensure compliance

  • How: ongoing checking undertaken each month to ensure compliance.
  • Who by: Workforce Systems team
  • Frequency: monthly.

6.2 How the organisation makes sure that registration checks are being carried out by all external agencies used by the organisation on respect of all clinical staff

  • How: procurement limited to those approved by the Government Procurement Service.
  • Who by: procurement
  • Frequency: as required. 

6.3 How the organisation follows up those directly employed clinical staff who do not satisfy the validation of registration process

  • How: review of human resources data through the monitoring of investigations and disciplinary cases.
  • Who by: Workforce Systems team and Human Resources team.
  • Frequency: as required.

7 Equality impact assessment screening

To access the equality impact assessment for this policy, please see the overarching equality impact assessment.

7.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence, the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

7.1.1 How this will be met

Policy does not relate to patients.

7.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason, all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible.

8.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

9 References

  • NHS Employers NHS Employment Check Standards: Professional registration and qualification checks 2021, as updated.
  • NHS Workforce Alliance Framework.
  • Home Office Workers and Temporary Workers: guidance for sponsors; Part 3: Sponsor duties and compliance.

10 Appendices

10.1 Appendix A professional bodies information and contact details

10.1.1 General Medical Council (GMC)

  • Who they support: registered doctors (all grades).
  • Date for registration: 3 years for provisionally registered doctors, every 5 years for fully registered doctors.
  • Data they can release: name, sex, General Medical Council (GMC) reference number, registration status, registered address, licence to practise, qualifications, dates of registration, and due date for retention fee.

10.1.2 Nursing and Midwifery Council (NMC)

  • Who they support: registered nursing staff (all grades).
  • Date for registration: every 3 years.
  • Data they can release: can provide details on registration such as if registration has been: removed, restored, suspended, lapsed, conditions of practice, cautioned, and effective date.

10.1.3 Health and Care Professionals Council (HCPC)

  • Who they support: art therapists, occupational therapists, dieticians, physiotherapists, podiatrists, social workers, speech and language therapists, practitioner psychologists.
  • Date for registration: every 2 years.
  • Data they can release: fitness to practice cases are uploading on their website.

10.1.4 General Pharmaceutical Council

  • Who they support: pharmacists and pharmacy technicians.
  • Date for registration: every 2 years.
  • Data they can release: general registration details and fitness to practice inquiries.

Document control

  • Version: 8.
  • Unique reference number: 260.
  • Approved by: people and teams group.
  • Date approved: 9 December
  • Name of originator or author: head of workforce.
  • Name of responsible individual: director of people and organisational development.
  • Date issued: 22 December 2025.
  • Review date: 31 December 2028.

Page last reviewed: December 22, 2025
Next review due: December 22, 2026

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