Introduction

The General Medical Council, or GMC, is the regulatory body for doctors in the UK and, from late 2024, will become the regulatory body for Physician Associates and Anaesthesia Associates too. The GMC’s purpose, as set out in the Medical Act 1983, is (a) to protect, promote and maintain the health, safety and well-being of the public, (b) promote and maintain public confidence in the medical profession, and (c) promote and maintain proper professional standards and conduct for members of the medical profession. It’s this final function – fitness to practise – for which the GMC is most well-known. The GMC spends some 55% of its £102.2 million annual budget just on doctors’ fitness to practise matters.

 

How Does A Fitness To Practise Case Start?

Fitness to practise (FtP) cases commence either via complaints made to the GMC by third parties such as patients, employers or police, or via self-referral by a doctor, or via the GMC itself deciding to open an investigation – for example, because of the GMC seeing a media report regarding a doctor’s activities. Members of the public (mainly patients) consistently make the largest number of FtP complaints about doctors. For example, in 2020 the GMC received 5,165 FtP complaints from members of the public, but only 250 FTP complaints from doctors’ employers.

 

Triage & Investigation

Each complaint submitted to the GMC goes through a triage assessment process. Following triage, complaints are either closed, referred to the doctor’s employer for local-level action, or referred onwards for a provisional or full GMC investigation. It is only those complaints which are sufficiently serious to raise a concern about the doctor’s fitness to practise which progress to a GMC investigation. Investigations by the GMC can include:

  • obtaining independent expert evidence (in relation to clinical and other matters – we have encountered expert evidence on everything from handwriting to IT and forensic accounting);
  • taking witness statements;
  • commissioning an assessment of the doctor’s health, performance or knowledge of the English language;
  • acquiring evidence from other proceedings, such as a transcript of an Inquest.

 

Rule 7

When the GMC has concluded its investigation, it will provide the doctor with fully particularised allegations, supported by a bundle of the GMC’s evidence which supports those allegations. This is known as Rule 7 stage and is a crucial point in the GMC FtP process, because it is the final opportunity for a doctor’s case to be resolved without a formal (and likely public) hearing before the Medical Practitioners Tribunal Service, or MPTS.

It is essential, in our experience, for the doctor to fully engage at Rule 7 stage. This will involve working with a medical defence organisation, insurer or solicitor to prepare a detailed response, supported by a bundle of defence material. The Rule 7 response will commonly include items such as the doctor’s factual account and reflections, legal arguments, references and testimonials, relevant CPD and expert evidence to counter any obtained by the GMC.

 

Case Examiners

Once the doctor has submitted their Rule 7 response, the entire case will be considered by two GMC Case Examiners. Case Examiners are senior GMC decision-makers and each case is considered by one medically-qualified Case Examiner and one non-medical Case Examiner.

Essentially, the Case Examiners must grapple with what is known as ‘the realistic prospect test’. The realistic prospect test means that there must be a genuine (not remote or fanciful) prospect that both the factual allegations in the case and impairment of the doctor’s fitness to practise will be found proved if the case is referred forward for a hearing before the MPTS.

The six categories of fitness to practise impairment comprise:

  • Misconduct;
  • Deficient professional performance;
  • Adverse physical or mental health;
  • Lack of English language;
  • Conviction or caution;
  • Determination by another regulatory body.

When deciding what to do with a case, the Case Examiners have a broad range of powers. Their options include:

  • Concluding the case with no action;
  • Issuing a Warning, which will be published against the doctor’s medical register entry;
  • Agreeing Undertakings, for example in a health case the doctor might undertake to abstain from the consumption of alcohol;
  • Referring the case forward for a hearing before the MPTS.

A minority, rather than majority, of FtP cases progress to the final stage of a MPTS hearing.

 

MPTS Hearings

The MPTS is the independent adjudication limb of the GMC and hears all FtP cases against doctors. FtP hearings are divided into three stages:

  • Facts – Which, if any, of the factual allegations against the doctor are found proved?
  • Impairment – As a result of the facts found proved, is the doctor’s fitness to practise impaired by reason of one of the categories of impairment (e.g. misconduct)?
  • Sanction – If the doctor’s fitness to practise is impaired, what sanction should be imposed?

At each stage of a MPTS hearing, both the GMC and doctor have an opportunity to present their evidence, examine witnesses and make legal submissions to the Tribunal. Not infrequently, the doctor’s evidence in chief is the most important point in the defence case

If a case progresses through to sanction stage, the sanctions available to the Tribunal range from taking no action, to imposing conditions of practice on the doctor’s GMC registration, to the ultimate sanction of erasure from the medical register. On average, just over one doctor per week is erased from the medical register.

 

Conclusion

The GMC’s Head of Operations was once heard to say to a group of doctors that she knew “receiving a letter from the GMC acts as an excellent laxative”. Sadly, this joke is entirely accurate. In a recent survey of 197 doctors investigated by the GMC, 91% reported that their case triggered stress and anxiety, with 31% reporting that they experienced suicidal ideation.

In view of the catastrophic impact of FtP cases on doctors, it’s essential to have the right support in place should you need it. We can provide assistance from the legal perspective, but there is now also a wide range of expert, confidential wellbeing support. For example, we highly recommend Practitioner Support to any doctor in distress: https://www.practitionerhealth.nhs.uk/

It is also important to bear in mind that the risk of a GMC FtP case is ultimately small. In 2020, the GMC received 8,197 complaints against 300,687 doctors on the medical register, which equates to a complaint rate of just 2.72%.