Fitness to practise procedures

If your fitness to practise is ever investigated by the GMC, understanding what to expect can make all the difference. Our detailed guide to the process will tell you what you need to know.

  • There has been an overall decrease of 11% in fitness to practise enquiries between 2014 and 2018.
  • The great majority of complaints to the GMC are closed without action on the doctors' registration, but a GMC investigation is still a source of great anxiety to any doctor under scrutiny.
  • Understanding the process and knowing what to expect can help ease these fears, so here we give an overview of the GMC's fitness to practise (FTP) procedures.

Initial handling

Triage

An initial triage is carried out to consider whether a complaint or enquiry raises a question about a doctor's fitness to practise.

Those not relating to fitness to practise are closed immediately - for example, cases about late appointments or disagreements about content of medical reports.

Some complaints that don't raise serious concerns would not require a full investigation unless they formed part of a pattern of similar concerns. The GMC refers those complaints to the doctor's responsible officer (RO) or employer.

If you have any concerns about a complaint passed to your responsible officer, you're very welcome to seek MDU advice.

Provisional enquiries

Since 2014, the GMC has carried out provisional enquiries (PEs) at the triage stage in cases that meet certain criteria. These enquiries can be undertaken quickly, as the GMC needs only a few pieces of information to help it decide whether to close a complaint or open a full investigation.

Around 70% of such cases are closed without a full investigation.1

Complaints requiring full investigation

In 2018 most complaints to the GMC (66%) were made by members of the public. Complaints to the GMC are also made by employers, the police, doctors, other healthcare groups and organisations. The GMC also identifies potential concerns about doctors from other sources, such as the media. And doctors sometimes need to self-refer to the GMC.

The GMC does not usually investigate complaints relating to events that took place more than five years before the date of the complaint, unless it believes this would be in the public interest, in the exceptional circumstances of the case.

If a complaint is to be investigated, the GMC will write to the doctor with a copy of the complaint. At that stage, the doctor has an opportunity to respond but is not obliged to do so. There are pros and cons to responding, depending on the circumstances of each case.

If you have received a letter from the GMC about an investigation or provisional enquiry, please contact the MDU as soon as possible.

Investigation stage

GMC investigators gather information about the case, such as medical records and statements, and may obtain an expert report.

The GMC may make any enquiries needed to investigate whether the doctor's fitness to practise is impaired. It also has the power to order an assessment of a doctor's performance, health or knowledge of English. A doctor who fails to comply may be referred to an FTP tribunal for non-compliance.

Performance assessment

A team is selected from the panel of performance assessors to assess the standard of the doctor's professional performance. The assessment will normally include peer review - including a visit to the doctor's place of work and knowledge-based and practical assessments.

The doctor will have an opportunity to comment on information provided to the team by others, and on the outcome of the assessment.

The assessment team will report on the standard of the doctor's performance.

Health assessments

The GMC may also invite the doctor to be examined by two medical examiners. Their reports on the doctor's physical or mental condition will also state whether they believe the doctor is fit to practise, either generally or on a limited basis, and make recommendations for the management of the case.

English language assessments

If concerns relate to the doctor's knowledge of the English language, the GMC may direct the doctor to undertake an assessment of their knowledge of English.

Decision by case examiners

If, after initial investigation, the GMC believes there may be a case to answer, it will send the doctor a letter setting out the allegations it believes it needs to investigate further. It will ask the doctor to comment on these allegations and provide any additional information that may help the GMC with the investigation. The doctor has only 28 days to respond to this letter.

If you have received a letter setting out allegations but have not yet contacted the MDU, it is vital to do so as soon as possible so you can seek help with a response.

The GMC expects doctors to show insight into the gravity of what has happened and demonstrate they have taken action to remedy any deficiencies identified by the complaint. This is known as remediation and can have a positive influence on the outcome of the case.

The GMC invites some doctors to attend a meeting with a case examiner and GMC lawyer, to hear about the allegations and what sort of evidence the GMC might want to see in the doctor's response. The doctor can be accompanied to this meeting.

The meeting is not mandatory. If you receive an invitation to one of these meetings, please let us know immediately.

Whether or not there has been a meeting, the case examiners will consider all the evidence, including the doctor's response, and will apply the 'realistic prospect' legal test. That means that only cases with a realistic prospect of establishing that the doctor's fitness to practise is sufficiently impaired to justify action on registration will be referred to an FTP tribunal hearing.

Outcome of the investigation

At the end of the investigation, the GMC case examiners may decide to conclude the case against the doctor with no further action or a letter of advice. Of investigations concluded in 2018, 58% were closed with no further action and 5.5% with a letter of advice.

Other possible outcomes at the case examiner decision stage are:

  • a warning
  • referral for adjudication before an FTP tribunal
  • undertakings (where an assessment of health or performance has been carried out).

In some cases where the case examiners believe the facts do amount to impaired fitness to practice, but an FTP tribunal would not erase the doctor, the case examiners may also offer undertakings.

Warnings

The GMC has power to issue warnings. It may do so where it decides the allegations don't justify referral to an FTP tribunal, but there is evidence to suggest the doctor's behaviour or performance has fallen below acceptable standards and warrants formal censure.

The doctor will be asked to give comments for the GMC to consider before it decides whether to issue a warning, and on what terms. Where the doctor chooses not to comment or does not dispute the allegations, and is taken to have accepted the warning, two case examiners may agree a warning is appropriate.

The complaint will proceed to an oral hearing of the investigation committee if:

  • the doctor does not accept the warning, or
  • the case examiners consider it appropriate to do so, or
  • they cannot agree on whether a warning is appropriate based on the evidence.

The investigation committee may decide:

  • to issue a warning
  • to conclude the case, or
  • where information provided to the investigation committee casts a fresh light that suggests the case is serious enough to be referred for adjudication by an FTP tribunal.

In practice, oral hearings are rare. They are held in public unless there is an overriding public interest reason to hold them in private - for example, if there are any health matters that must remain confidential.

Warnings will be disclosed to the person or body who brought the allegation to the GMC's attention, and to doctors' employers, or any person or body for whom they provide medical services.

Warnings are visible on the online register for two years. After that, the warnings will be removed from public view but will remain available to employers.

Reviews of decisions

In exceptional circumstances, the GMC registrar may decide it is in the public interest to review a decision by the GMC to conclude a case.

This happens rarely, and only when there is new information that casts a substantially different light on the allegation, or when an apparent error is discovered in the handling and/or consideration of an allegation that led the GMC to reach an inappropriate decision.

Interim orders

A case that raises serious concern about safety of patients or others can be referred to the interim orders tribunal (IOT) at any stage. The Medical Practitioners Tribunal Service (MPTS) is a separate body responsible for both IOT and FTP hearings.

The IOT may decide that a doctor should be suspended, or that conditions should be imposed on their registration on an interim basis (in order to protect patients, or in the interests of the public or the doctor), while an FTP investigation is underway. IOT hearings will generally be held in private.

There may be very short notice of a decision to refer a case to an IOT, so it is vital you tell the MDU immediately if you are being referred there.

Suspensions or conditions imposed by the IOT are reviewed every six months and will usually remain in place for up to 18 months if takes that long for the GMC to undertake a full investigation into the allegations. They may be extended by a high court order.

Adjudication stage and FTP tribunals: MPTS

FTP tribunals are held by the Medical Practitioners Tribunal Service (MPTS). This is an operationally separate part of the GMC, designed to provide separation between the investigation/prosecution of complaints, and adjudication.

Once a doctor is referred to an FTP tribunal, the case management stage begins. There is usually a case review, generally a telephone conference, between the GMC and the solicitor instructed by the MDU.

It will often take several months for a case to progress to an FTP tribunal hearing, during which time the GMC will investigate further and may seek expert evidence, as may the MDU.

FTP tribunals have three members, including at least one medical and at least one non-medical member. Most hearings will have a legally qualified chair who sits as part of the tribunal and advises on points of law. Some cases may have a legal assessor to advise the tribunal on points of law.

Hearings before the FTP tribunal are intended to be 'holistic', in that allegations will be brought forward based on all the evidence obtained during the investigation stage. This may include health and performance assessment reports, and any allegations relating to the doctor's health, performance or conduct, or based on a caution, conviction or determination.

The FTP tribunal has three stages. First, the evidence is heard and the panel must determine whether or not the facts of the case are found proved. If the facts are not found proved, the case will not go to the second and third stages.

Second, if the facts are admitted or proved, the FTP tribunal must decide whether the doctor's fitness to practise is impaired. It is the doctor's fitness to practise at the time of the hearing that is relevant, though the nature of the original misconduct will be taken into account. The panel will have to take into account any evidence of remediation, including assessing the success of doctors' efforts to reform.

If fitness to practise is found to be impaired, the third stage would be for the FTP tribunal to decide what sanction (if any) should be applied to the doctor's registration. In doing so, the tribunal must take into account the protection of patients, public confidence in the medical profession and the need to uphold standards of medical practice. The tribunal may also take into account mitigating factors, such as a demonstration of insight by the doctor and any steps they have taken to address the problem.

Evidence of this may come from testimonials from colleagues, patients and others.

The FTP tribunal can take the following actions:

  • accept written undertakings from the doctor
  • impose a period of conditions on a doctor's registration
  • suspend the doctor's registration for a specified period
  • erase the doctor's name from the medical register. This will not happen where the allegations relate solely to the doctor's health.

If the doctor's fitness to practise is not found to be impaired, the FTP tribunal may decide to issue a warning, if appropriate.

Of 247 FTP tribunals completed in 2018, 101 resulted in suspension and 65 resulted in erasure of the doctor's name from the register.

The proportion of erasures is low. If erased, a doctor will be able to apply to have their name restored after five years.

However, a doctor must be able to demonstrate fitness to practise in order to be restored, and erasure usually marks the end of a medical career.

Attendance at hearings

Doctors are expected to attend hearings at the MPTS. If they don't, the committee or tribunal may proceed to hear the case in their absence.

Please contact the MDU as soon as possible if you are asked to attend a hearing.

Publication of decisions

The decision reached by an investigation committee, interim orders panel or FTP tribunal will be notified to doctors, their employer and any person or body who made the complaint, along with the reasons for that decision.

The decision itself will also be published. The sole exception is in relation to confidential information about the doctor's physical or mental health.

Information is published on the GMC and MPTS websites. Whereas information in relation to tribunals is published on the MPTS website for up to a year, the GMC online register includes information about decisions for much longer2.

Appeals: GMC and Professional Standards Authority for Health and Social Care

The GMC has power to appeal MPTS decisions to the High Court if they are considered to be unduly lenient and it is necessary for the protection of the public to do so. The Professional Standards Authority for Health and Social Care can also join such an action.

Insight and remediation

Demonstrations of insight into the causes of the incident that led to the complaint, and providing evidence of remediation to put things right, can be powerful ways for a doctor to demonstrate they are fit to practise.

A GMC study of cases that were considered by FTP tribunals (but not cases relating to health or convictions) showed that evidence of insight correlated with whether a doctor was erased or given a less serious sanction.

Doctors who showed insight and said sorry were ten times less likely to be erased than those who did not.

Last word

GMC FTP investigations are stressful for doctors, and we would encourage any MDU member receiving notification of a complaint to the GMC to make contact with us as soon as possible, and before responding. This applies even if the GMC is going to pass the complaint to the responsible officer or treat it as a provisional enquiry.

We are experts in assisting doctors at the GMC, and it is never too soon to ask for help.

References

  1. In 2018, just over 500 cases were investigated as provisional enquiries and around 70% of them were closed without further investigation. GMC statistical information about fitness to practise investigations is available here.
  2. The GMC publication and disclosure policy can be accessed here.

This guidance was correct at publication 10/01/2020. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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