Interim Retained GP Scheme July 2016 to March 2017

Interim Retained GP Scheme July 2016 to March 2017

APPLICATION FORM HEE WESSEX

PART A: PERSONAL DETAILS (please print)

Surname / First Names
Home Address / Post Code
Home Telephone and or Mobile / Email
GMC Number
Qualifications and Dates
Please attach a brief CV (1 side of A4 should be adequate)

PART B: Scheme application

Criterion / Please tick all that apply
1 / Take a career break such as for carer responsibilities. (as per the 1999 scheme)
2 / Salaried GP intending to leave practice or retire
3 / GP partner intending to leave practice or retire
4 / Locum GP intending to take up a salaried role
5 / GP currently on the Retained Doctor Scheme (1999) transferring to new RDS from 1st July 2016 / Please complete details of current or past scheme in box below
6 / GP previously been on the Retained Doctor Scheme, re-joining the new scheme, as long as eligible
Location Practice (and HEE area or Deanery if different) / Reason on scheme / Start Date / Finish Date / Years on scheme / Number of sessions
(If varied please complete a separate line for each change)
ELIGIBILITY FOR SCHEME:
a.  Please give a detailed explanation for your application, and where appropriate, supporting evidence should be included. E.g. Letters of resignation, appraisal documents, health records etc.
b.  If already on an approved (1999) Scheme please give details and supporting documentation of approval
Please list any attachments below

PART C: PRACTICE DETAILS (please complete one form for each practice)

Proposed Start Date / Number of Sessions per week / ( Normally 2-4 per week)
The Retainer Scheme starts on the 1st of a month / Total duration on the scheme is 5 years
Name of Educational supervisor / Approved as a GP Trainer / YES
NO / Last
Approval
Date
Practice Address / Approved as a Retained Doctor Educational Supervisor / YES
NO / Last Approval Date
Practice Code / Practice type / GMS or PMS
Practice Telephone / Mobile of ES
Name of Practice Manager / Tel Direct Dial
Email for Educational Supervisor / Email for
Practice Manager

Part D: Work and Educational Arrangements

1.  What induction is planned (or has already taken place) for you within the practice?
2.  What will your normal work pattern be?
3.  NON-GENERAL MEDICAL SERVICES WORK
Please give details if applicable, to include number of hours per week and normal work pattern
Such work is undertaken subject to the advice of the Patch Associate Dean.
Approval will normally be given for work relevant to general practice, up to a maximum of 2 extra sessions per week.
4.  EDUCATIONAL ARRANGEMENTS
Please give details of arrangements for your education within the practice
You will be required to produce a learning plan (education development plan) for the first year, within 6 weeks of your start date; the plan should be discussed with your Educational Supervisor and submitted to your local HEE I&R Lead
5.  CAREER PLANS: including future plans to return to more substantial general practice work
The duration of the scheme is for a maximum of 5 years

Part E: SCHEME REQUIREMENTS

This section is part of the process ensuring that Retained doctors receive a fair deal under the scheme and are required for approval of a funded place.
These are requirements for Deanery approval of the Retained Doctor Scheme, regardless of Practice type / YES / NO
Will you have a BMA model Contract?
Are you aware of your educational entitlement per year? / See Appendix A
Have you thought about your Personal Development Plan for your CPD?
Have you discussed your study leave entitlement with your practice?
Have you agreed your pay?
If yes, how much is your hourly rate?
Have you agreed your annual leave entitlement?
Have you planned your annual appraisal?
Are you on a Primary Medical Performers List?
NB you are not able to start in the practice until you are on a MPL and have an Enhanced CRB check
Signature of Applicant / Date

Part F: FOR COMPLETION BY THE EDUCATIONAL SUPERVISOR

I confirm that the information given in parts B) and C) are accurate and agree to the current National and Health Education Retained GP Guidelines. Please comment on how you plan to supervise over the first year.
I confirm that I am aware that the Doctor employed by the practice under the Retained Doctor Scheme retains full employment rights as an employee of the practice when the scheme ends at 5 years under UK Employment Law
Signature of Educational Supervisor / Date

Part G: RECOMMENDATION TO be completed by THE HEE RGP Scheme Lead

The scheme is subject to annual re-approval by the HEE RGP Lead and is for a maximum duration of 5 years
Please send this form to your Area Associate Dean of Postgraduate General Practice Education attaching a copy of the Retained Doctors CCT or JCPTGP Certificate and a brief CV to the appropriate Patch office as listed below.
Dorset:
Associate Dean:
Prof Clare Wedderburn
Address:
Dorset GP Centre (R507)
Bournemouth University
Royal London House
Christchuch Road
BOURNEMOUTH
Dorset
BH1 3LT
Email: / Mid-Wessex:
Associate Dean:
Dr Heidi Penrose
Address:
Mid-Wessex GP Education
University of Winchester
WINCHESTER
SO22 4NR
Email: / Portsmouth:
Associate Dean:
Dr Rachel Elliott
Address:
The Centre for Primary Care Education,
Goddard Centre,
St James’ Hospital
Locksway Road
PORTSMOUTH
PO4 8DL
Email: / Southampton:
Associate Dean:
Prof Johnny Lyon-Maris
Address:
The Education Centre
Mailpoint 10, Level C,
South Academic Block,
Southampton General Hospital
Tremona Road
SOUTHAMPTON
SO16 6YD
Email:
amanda.o’
I Recommend
Dr………………………………………………………………………………………………………………………………
For membership of the Interim 2016 Retained Doctor Scheme
Signature of Associate Dean / Date
When Sections A – E have been completed, please send this form to: GP Programme Administrator, GP School, Health Education Wessex
Part H: Approval TO be completed Health Edcuation england
I Approve Dr
…………………………………………………………………………………………………………………………………..
For membership of one year of the Interim 2016 Retained Doctor Scheme
Signature of Director of GP Education or Head of School / Date
The Retained GP may not commence in post until approval has been confirmed by the
Director of GP Education of Health Education England and the Practice have been notified in writing following approval by NHS England

PART I: For completion by NHS England local team DCO

Name of NHS England DCO checking there are no concerns with the GP/practice and supporting the application for funding.
Date of decision
Decision / Agreed
Declined
Referred for further information
Proposed date funding to commence
Signature of DCO
Date forwarded to NHS England central team
Name of NHS England central team officer determining funding place
Funding decision / Agreed
Declined
Referred for further information

The funding will be paid from NHS England local teams to the practices as it is now via the SFEs.

Please forward approved form to NHS England

6 | Page