NHS Education South Central
Wessex School of General Practice

GP Retainer Scheme

APPLICATION FORM

Part A

PERSONAL DETAILS (please print)

Surname / Forenames
Home Address
Post Code / Email Address
Tel No / Mobile No

PRACTICE DETAILS (please complete one form per practice)

Proposed start date / / / No of sessions per week
(NB the Retainer scheme is always activated on the 1st of a month)
Educational Supervisor
Practice Manager
Practice Address
Tel No / Email Address
What induction is being planned for you within the practice?
What will your normal work pattern be?

(NB: Please note that variation is allowed. If there is a substantial change, please let your Patch Associate Director know and agree it with them.)

Retainer Scheme Application Form/Sep 08 1


NHS Education South Central
Wessex School of General Practice
NON-GENERAL MEDICAL SERVICES WORK

Please give details if applicable, to include number of hours per week and normal work pattern

(NB: Such work is undertaken subject to the approval of the Patch Associate Director. Approval will normally be given for work relevant to general practice, up to 2 extra sessions per week.)

EDUCATIONAL ARRANGEMENTS

Please give details of arrangements for your education within the practice

(NB: You will be required to produce a learning plan (education development plan) for the first year, within 6 weeks of your start date in the practice; the plan should be discussed with your Educational Supervisor and submitted to your local Patch Associate Director with copy to the Director of Postgraduate GP Education.)

ELIGIBILITY FOR SCHEME:

Please give personal reasons for limited, paid employment, noting ages of children if applicable

CAREER PLANS: including future plans to return to more substantial general practice work


Part B

THE SCHEME

This section is part of the process ensuring that Retained doctors receive a fair deal under the scheme and are points to consider and be prepared to discuss.

Will you have a BMA model Contract? / Yes No
Are you aware of your educational entitlement of 8 sessions per year? / Yes No
Have you thought about your Personal Development Plan for your CPD? / Yes No
Have you discussed your study leave entitlement with your practice? / Yes No
Have you agreed your pay? / Yes No
If yes, how much is your hourly rate?
Have you agreed your annual leave entitlement? / Yes No
Are you aware that you will need an annual appraisal? / Yes No
Are you on a Primary Medical Performers List? / Yes No
NB you are not able to start in the practice until you are on a list
Signature of applicant / Date

Part C

FOR COMPLETION BY THE EDUCATIONAL SUPERVISOR

I confirm that the information given in parts a) and b) are accurate and agree to current Deanery Retainee Guidelines on supervision. Please comment on how you plan to supervise over the first year.

Signature of Educational Supervisor ……………………………………… Date ……………………………………

Registrar: Please send this form to your Associate Director of Postgraduate General Practice Education attaching a copy of JCPTGP Certificate of Prescribed / Equivalent Experience for Part D to be completed.

Part D

To be completed by Associate Director of Postgraduate General Practice Education
Associate Director’s Recommendation
I recommend Dr

for membership of the GP Retainer Scheme.

Signature / Date

Associate Director - Please return form and JCPTGP certificate to:

Mrs Patricia Abbott

Wessex School of General Practice

Southern House

Otterbourne

Winchester SO21 2RU

Any queries, please contact

Tel: 01962 718441

Head of GP School Approval
I approve Dr

for membership of the GP Retainer Scheme.

Signature / Date

Retainer Scheme Application Form/Sep 08 1