If a consultant shouldn't have been practising, your hospital owns that liability
Independent hospitals are directly accountable when a credentialling gap leads to a clinical negligence claim. With settlement costs that can run into significant sums, and reputational exposure far beyond that, an inconsistent privileges process is a material risk, not a paperwork problem.
- steps
- 7
- steps
- to start
- 2 to 4 weeks
- to start
The short answer
You are accountable for every consultant who works under your roof, and after the Paterson Inquiry that accountability is closely examined. The industry standard is the IHPN Medical Practitioners Assurance Framework (MPAF), currently the 2022 version, with a refresh expected in autumn 2026. Use it as your written policy, audit every consultant file against one checklist, and put renewal dates for GMC status, indemnity, appraisal and scope of practice into a tracker that your Medical Advisory Committee reviews.
7 steps
Do it yourself: step by step
0 of 7 done
Download the IHPN MPAF and write or update your practising privileges policy to match it: application, scope of practice, appraisal, information sharing with the NHS, review and suspension. Check whether the autumn 2026 refresh has been published.
- Time
- 2 to 4 weeks
- Typical cost
- Staff time, or £1,000 to £5,000 for a governance supplier or lawyer to review (Solvable estimate: 1 to 3 days of specialist time)
- Who does it
- Registered manager with the Medical Advisory Committee chair
Done when: Policy approved by the MAC and the board, with a review date.
This problem is Solvable.
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Practising privileges file checklist
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Practising privileges file checklist
Consultant: [name] GMC number: [number] Specialty: [specialty] Date of audit: [date] Audited by: [name]
Identity and registration
- Photo ID seen and copied
- GMC registration with licence to practise, checked on the GMC register on [date]
- Specialist register entry for [specialty]
- No conditions, undertakings or warnings, or details recorded and reviewed by the MAC
- Revalidation date: [date]
- Responsible Officer and designated body: [name, organisation]
Indemnity
- Indemnity certificate covering private practice, dated [from] to [to]
- Cover matches the scope of practice (for example includes surgical procedures performed here)
Checks
- Enhanced DBS check, dated [date], or update service checked
- Occupational health clearance including immunisation status
- Right to work confirmed where needed
- Two references, including one from current Responsible Officer or clinical director
Practice
- Signed scope of practice listing procedures permitted at this hospital
- Most recent annual appraisal, including private practice (whole practice appraisal)
- Information shared with Responsible Officer this year
- Activity and outcome data reviewed in the last 12 months
- Complaints and incidents reviewed in the last 12 months
- Declarations of financial interests (for example shareholdings in the hospital or equipment) on file
Training and induction
- Hospital induction completed
- Mandatory training as required by hospital policy: [list]
Decision
- Approved by MAC on [date]
- Next review date: [date]
Gaps found: [list] Action owner: [name] Due: [date]
Avoid these
Common mistakes
- Accepting a copy of an indemnity certificate from a CV without checking dates and scope.
- Agreeing privileges for a specialty rather than a written list of procedures.
- Never sending information to the consultant's NHS Responsible Officer.
- No system to stop a consultant being booked once a document expires.
- MAC meetings that note privileges but record no decisions.
Free personal check
Done by Paul Robinson, not software
Answer nine quick questions and I'll show you where your practising privileges process is exposed
What I need from you
- Nine tap answers about your privileges process
- Roughly how many consultants hold privileges
What you get
- How you compare with the Medical Practitioners Assurance Framework
- The three gaps that create most liability
- What to put in your renewals tracker
Within 2 working days
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Paul Robinson
14 years in UK private healthcare
I solve this one for hospitals
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Questions
Frequently asked questions
Is MPAF mandatory?
It is an industry framework, not law. CQC committed to including it in its Well-led assessment of relevant providers, so following it is the simplest way to show good governance. IHPN is refreshing MPAF, with the new version expected in autumn 2026; check for it before you rewrite your policy.
How often should privileges be reviewed?
Many hospitals review every two years with annual checks of indemnity, appraisal and registration (Solvable observation; we have not found a single required interval). Set the frequency in your policy and stick to it.
Can we rely on the consultant's NHS trust to have checked them?
No. You must check for yourself and share information with their Responsible Officer.
What if a consultant does not provide documents?
Your policy should say privileges are suspended until they do. Apply it consistently.
Who should hold the files?
A named medical staffing or governance lead, with access for the registered manager and medical director.
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