CEL 4: Demonstrating Fitness to

Practise
This course unit supports Clinical Ethics and Law (CEL) Workshop 4, which will take place in the
Clinical School during R&I Week C. Students from the Standard Course (Year 4) and Graduate Entry
Course (Year 2) will all attend the same workshop. We will consider the standards of behaviour
expected of doctors, and the role of our professional regulator, the General Medical Council, in
ensuring that those standards are upheld. We will consider the reasons why medical students and
doctors sometimes depart from these standards, and how to prevent this from happening in the future.
As part of this workshop, you will be asked to consider some real examples of doctor behaviour, and
to consider whether or not you think the behaviour raises concerns about fitness to practice, and what
should be done about it.

OBJECTIVES
Students should be able to:
 Critically examine and apply General Medical Council guidance, principally relating to
o the need to promote best practice and respect for patients and colleagues (8b)
o professional standards expected of students
o respecting the different beliefs of patients, students and other HCPs (6a, 6b)
o duty of candour (2n) [see also CEL 11]
o maintaining professional boundaries with patients (5a)
o conscientious objection and its limits [see also CEL9]
o potential conflicts of interest and use of social media
 Discuss the importance of trust, integrity, honesty and accountability in all professional
relationships (2e)
 Recognise the limitations of their practical skills and knowledge, and to know how and where
to seek appropriate sources of support (including when working abroad or in resource-poor
environments -see also CEL6) (2h, 2u, 3, 13)
 Identify and appropriately respond when there is cause for concern, when things could be
improved, and when they go wrong - see also CEL 11 (2n, 2o, 5c, 5f, 5g)
 Apply professional guidance across all clinical contexts (including while working abroad and
in resource poor environments – see also CEL6) (2s)
 Consider the extent to which expected professional conduct extends into private life (2, 3)

These learning outcomes are from the Core Curriculum for Undergraduate Medical Ethics and Law
(Institute of Medical Ethics, 2019) and the numbers in brackets refer to the relevant sections of
Outcomes for Graduates (GMC, 2018).

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Medical students: standards of behaviour

Your studies will bring you into contact with patients and members of the public, who can be
physically and emotionally vulnerable. Because of this, and the fact that you’ll be joining a
trusted profession, we expect you to understand that there is a difference in the standard of
behaviour expected of students on courses that bring them into contact with patients and the
public.

Specifically, your behaviour at all times, both in the clinical environment and outside of your
studies, must justify the trust that patients and the public place in you as a future member of the
medical profession. We and your medical school will support you in your journey from student to
doctor, which includes teaching and assessment on professionalism.

As a medical graduate, you’ll need to register with the GMC and get a licence to practise before
you can begin work as a doctor if you wish to work in the UK. The GMC won’t register medical
graduates who are not fit to practise medicine.

General Medical Council: Achieving Good Medical Practice

What does the phrase ‘fitness to practise’ mean? - it’s about being able to demonstrate that you are a
fit and proper person for your role as a doctor-to-be. As we saw in the introductory course, the
privilege of learning in a clinical environment carries with it additional responsibilities and
expectations that don’t apply in the same way to students on purely academic courses. You have to be
able to demonstrate that you accept those responsibilities and can live up to those expectations.

We don’t want any of you to end up unable to get a licence to practice! Perhaps more importantly, we
want to support you to become excellent doctors who embody the values of our profession. That’s not
always easy, and few of us get it completely right all of the time; the mark of a good doctor is an
acceptance of this and a willingness to keep learning. The first step on this journey is to understand
what is expected of medical students and doctors who study and work in clinical settings.

The two main sources of guidance that you must follow are:
The University’s Medical Student Code of Conduct
The GMC’s Achieving good medical practice: guidance for medical students

You must make yourself aware of this guidance and keep following it as you progress through the
course. Not reading the guidance does not excuse you from the obligation to follow it, and behaviour
that you may believe to be acceptable (because you see students on other courses engaging in in) can
have serious consequences for medical students.

Bear in mind that the following could place your registration at risk: disrespectful behaviour towards
patients, teachers or colleagues; inappropriate communication (e.g. discussing patients in a way that
enables others to identify them, inappropriate use of social media, unprofessional responses to
requests for feedback on the course, bullying or harassing fellow students); failure to abide by rules
and policies (e.g. failure to attend timetabled teaching sessions without good reason and without
discussing this with a member of staff, failure to adhere to safety guidelines such as those preventing
the spread of infection); dishonesty (e.g. forging signatures in log books or attendance sheets,

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engaging behaviour aimed at giving you an unfair advantage in examinations, concealing your
involvement in any form of unacceptable behaviour); misusing drugs or alcohol.

Nonetheless, anyone can make mistakes. This is especially likely when you are learning, getting used
to a new role, and maybe feeling under stress. The Medical School would always rather hear about
problems at an early stage and help you to put them right, rather than taking formal action which may
have serious consequences for your career. So, if you are having difficulty adhering to the
expectations outlined above, please get in contact with your college tutor, pastoral advisor or another
trusted member of staff and ask for help.

Be aware that police cautions have a lasting legal status. You should not accept a caution from the
police without taking legal advice. Please note that in Scotland a caution is known as a warning. If
you receive a caution, you should discuss this with the Clinical School. You will also need to declare
any police cautions when you register with the GMC (although this unlikely to prevent you from
joining the register – unlike attempting to conceal a police caution, which is considered to be a very
serious breach of professional standards).

Fitness to practise: Clinical School policies

We monitor for low level concerns and may contact you informally to express our concerns about
issues such as attendance, organization etc. We may ask you to reflect on what you will do to resolve
the issue and to let us know about any support you may need to do this.

Referral to Progress Panel is a more formal procedure but remains a supportive measure, not a
disciplinary procedure. The aim is to resolve concerns and support students to progress successfully
through the course.

Serious concerns about a student’s suitability to practice medicine are dealt with by the Fitness for
Medical Practice Adjudication Board (with separate procedures for cases where the student’s
problems appear to be caused by ill-health or disability). This is a three-stage process:

1. Preliminary stage (up to 3 months) – decision as to whether the concern can be dealt with
informally or is a health issue.
2. Investigation – the student, the person who raised the concern and anyone else with relevant
information are interviewed and a written report is prepared. A decision is taken as to whether
there is an issue requiring further action.
3. Adjudication – a panel of 3 members meet and hear evidence. The student is required to
attend and may choose to be accompanied by a supporter or representative

Outcome i – student is fit to practice and may continue on the course with no conditions.
Outcome ii – grounds for concerns about fitness to practice and the student may continue on the
course subject to conditions.
Outcome iii – unanimous decision that it is beyond reasonable doubt that the student is unfit to
practice – removal from the medical student register and from the course.

Going above and beyond – taking on the challenge of professional excellence

Hopefully, you will want to achieve more than the minimum standard expected of all medical
students. The GMC supports that too, stating, in Achieving good medical practice:

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‘This guidance explains the standards of professional behaviour expected of you during your studies.
True professionalism is about striving for excellence – to achieve this you’ll need to learn to:

 develop healthy ways to cope with stress and challenges (resilience)

 deal with doubt and uncertainty
 apply ethical and moral reasoning to your work
 work effectively in a team, including being able to give constructive and honest feedback
 manage your own learning and development
 be responsive to feedback
 prioritise your time well and ensure a good work-life balance
 promote patient safety and be able, where appropriate, to raise concerns
 work collaboratively with patients and other professionals
 deal with and mitigate against personal bias.

You may find many of these difficult or challenging to do well but, as with all elements of
professionalism, your medical school will help you to develop these skills. Being professional means
you’ll need to make time to reflect on your experiences, to learn continually and to apply your
learning in practice. You will need to seek out feedback, remain up to date with professional and
ethical guidance and be able to adapt to changing circumstances. Your teachers and trainers want
you to develop and become an excellent doctor, so you should look to them for guidance and
support’.

In Cambridge, we have developed the Professional Responsibilities Course to support you to develop
the skills and attributes listed above by the GMC. This year, you have begun to work on learning to
apply ethical and moral reasoning to your work, through the CEL programme, and to manage your
own learning and development and be responsive to feedback, through the PPG programme (which is
designed to help you to develop the skills needed for effective reflective learning). As the course
continues, you will continue to participate in these programmes. Next year (year 5 Standard
Course/Year 3 CGC) you will have the opportunity to work on all of the skills and attributes listed
above, through active participation in the ‘How to be a successful doctor’ workshops (which focus on
personal development), the Teaching Course and the Clinical School Leadership Programme
(certificated programmes which you can use to demonstrate your experience in teaching others and in
working collaboratively as part of a team to deliver improvements in patient care and safety).

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Doctors: Standards of behaviour

If you only remember one thing from this Unit – make it this!

The guidance for medical students discussed in the previous section is based closely upon the Code of
Conduct that you will be expected to adhere to once you qualify: this is outlined in the GMC’s Good
Medical Practice and summarised in Duties of a Doctor:

‘Patients must be able to trust doctors with their lives and health. To justify that trust you must show
respect for human life and make sure your practice meets the standards expected of you in four
domains.

Knowledge, skills and performance

 Make the care of your patient your first concern.
 Provide a good standard of practice and care.
o Keep your professional knowledge and skills up to date.
o Recognise and work within the limits of your competence.

Safety and quality

 Take prompt action if you think that patient safety, dignity or comfort is being compromised.
 Protect and promote the health of patients and the public.

Communication, partnership and teamwork

 Treat patients as individuals and respect their dignity.
o Treat patients politely and considerately.
o Respect patients' right to confidentiality.
 Work in partnership with patients.
o Listen to, and respond to, their concerns and preferences.
o Give patients the information they want or need in a way they can understand.
o Respect patients' right to reach decisions with you about their treatment and care.
o Support patients in caring for themselves to improve and maintain their health.
 Work with colleagues in the ways that best serve patients' interests.

Maintaining trust
 Be honest and open and act with integrity.
 Never discriminate unfairly against patients or colleagues.
 Never abuse your patients' trust in you or the public's trust in the profession.

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The GMC’s role in protecting the public

The Medical Act 1983 gives the GMC four main functions:

 keeping up-to-date registers of qualified doctors

 fostering good medical practice
 promoting high standards of medical education and training
 dealing firmly and fairly with doctors whose fitness to practise is in doubt.

The General Medical Council is the independent regulator for doctors in the UK. Its statutory purpose
is to protect, promote and maintain the health and safety of the public by ensuring proper standards in
the practice of medicine.

It achieves this by controlling entry to the medical register and setting the standards for medical
schools and postgraduate education and training. It also determines the principles and values that
underpin good medical practice and takes firm but fair action where those standards have not been
met.

The GMC has strong and effective legal powers designed to maintain the standards the public have a
right to expect of doctors. Its role is not to protect the medical profession - our interests are protected
by others. The GMC’s job is to protect patients.

Source: GMC website (www.gmc-uk.org)

For the remainder of this course unit, we will focus on the procedures used to deal with doctors whose
fitness to practise is in doubt.

Formal or informal action?

Concerns about a doctor will not necessarily go straight to the GMC. Informal local procedures will
be followed first, wherever this is appropriate.

‘Cases involving minor misconduct or early indications of unsatisfactory performance may be

handled informally. For example, additional training, coaching or advice may resolve the concern. If
informal action does not bring about sufficient improvement, or if the matter is considered too serious
to be classed as minor, then employers should make it clear that formal action will be necessary.

Informal resolution should ideally be a two-way discussion of those aspects of performance or

conduct which are causing concern and suggesting ways of sustained improvement. Where
improvement is required, the employer needs to make it clear to the employee what needs to be done,
over what timescale and how their performance or conduct will be reviewed. The employer should
keep notes of any agreed informal action and consider sharing these with the employee. This ensures
that informal action is more than just a passing comment or casual aside and is designed to achieve an
agreed outcome.

Employers should take care that informal action does not turn, without notice to the doctor, into
formal disciplinary action as this may inadvertently deprive the doctor of certain rights under the

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formal procedure (such as the right to be accompanied). If, during an informal discussion it becomes
clear that the matter may be more serious, then the meeting should be adjourned and the employee
should be told that the matter will be continued under formal procedures.

Any concern about the capability or conduct of a doctor in training should initially be considered as a
training issue and the involvement of the postgraduate dean should be sought. Deaneries must be
informed of any concerns and actions taken to allow the dean to carry out his or her role as
responsible officer.’

Source: ‘Staying on course – supporting doctors in difficulty through early and effective action’ NHS
Employers June 2012

Referral to the GMC

If local measures do not resolve the concern, a doctor may be referred to the GMC by their employer
or colleagues. Members of the public may also make a referral.

The GMC is independent of the NHS and can also take action if it believes that the doctor's fitness to
practise is impaired. This may be for a number of reasons:
 misconduct;
 deficient performance;
 physical or mental ill-health;
 a criminal conviction or caution in the British Isles (or elsewhere for an offence which would
be a criminal offence if committed in England or Wales);
 a determination (decision) by a regulatory body either in the British Isles or overseas
 lack of the necessary knowledge of English language to be able to practise medicine safely in
the UK.

The GMC investigates the allegations and, if there are serious concerns about the doctor’s fitness to
practice, the case is passed onto the Medical Practitioners Tribunal Service (MPTS) for adjudication.

If the MPTS finds that a doctor's fitness to practise is impaired they can:

a. take no action (this would be unusual)

b. Impose conditions on the doctor’s registration for a period up to three years (renewable).
This sanction allows a doctor to practise subject to certain restrictions (eg restriction to NHS
posts or no longer carrying out a particular procedure).
c. Direct that the doctor’s registration be suspended for up to 12 months;
d. Direct erasure of the doctor’s name from the register, except in cases that relate solely to a
doctor’s health.

If they believe a doctor’s fitness to practise is not impaired but there has been a significant departure
from the principles set out in Good medical practice, a warning can be issued to the doctor.

The MPTS will impose the least serious sanction that is compatible with maintain the public’s safety
and trust in the medical profession.

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Source: GMC State of Medical Education and Practice in the UK 2014
Circumstances under which fitness to practice is likely to be questioned

The GMC’s guidance for decision makers states: All human beings make mistakes from time to time.
Doctors are no different. While occasional one-off mistakes need to be thoroughly investigated by
those immediately involved where the incident occurred and any harm put right, they are unlikely in
themselves to indicate a fitness to practise problem.

A question of fitness to practise is likely to arise if:

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A doctor’s performance has harmed patients or put patients at risk of harm
A risk of harm will usually be demonstrated by a series of incidents that cause concern locally. These
incidents will indicate persistent technical failings or other repeated departures from good practice
which are not being, or cannot be, safely managed locally or local management has been tried and has
failed.

A doctor has shown a deliberate or reckless disregard of clinical responsibilities towards

patients
An isolated lapse from high standards of conduct – such as an atypical rude outburst– would not in
itself suggest that the doctor’s fitness to practise was in question. But the sort of misconduct, whether
criminal or not, which indicates a lack of integrity on the part of the doctor, an unwillingness to
practise ethically or responsibly or a serious lack of insight into obvious problems of poor practice
will bring a doctor’s registration into question.

A doctor’s health is compromising patient safety

The GMC does not need to be involved merely because a doctor is unwell, even if the illness is
serious. However, a doctor’s fitness to practise is brought into question if it appears that the doctor
has a serious medical condition (including an addiction to drugs or alcohol); AND the doctor does not
appear to be following appropriate medical advice about modifying his or her practice as necessary in
order to minimise the risk to patients.

A doctor has abused a patient’s trust or violated a patient’s autonomy or other fundamental
rights
Conduct which shows that a doctor has acted without regard for patients’ rights or feelings, or has
abused their professional position as a doctor, will usually give rise to questions about a doctor’s
fitness to practise.

A doctor has behaved dishonestly, fraudulently or in a way designed to mislead or harm others
The doctor’s behaviour was such that public confidence in doctors generally might be undermined if
the GMC did not take action.
The advice above is only illustrative of the sort of behaviour which could call registration into
question.

If these, or similar, factors are involved, the case is likely to be referred to a Panel of the Medical
Practitioners Tribunal Service.

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Factors that the Panel must consider

The panel has to decide in turn:

a. Whether the facts alleged have been found proved;
b. Whether, on the basis of the facts found proved, the doctor’s fitness to practise is impaired;
c. If so, whether any action should be taken against the doctor’s registration; if the panel has
not found the doctor’s fitness to practise impaired, whether a warning should be issued.

In the interests of fairness to both parties, the panel should invite evidence and/or submissions from
the GMC and the doctor at each stage of the proceedings.

The Merrison Report stated that ‘the GMC should be able to take action in relation to the registration
of a doctor… in the interests of the public’, and that the public interest had ‘two closely woven
strands’, namely the particular need to protect the individual patient, and the collective need to
maintain the confidence of the public in their doctors.

Since then a number of judgments have made it clear that the public interest includes, amongst other
things:
a. Protection of patients
b. Maintenance of public confidence in the profession
c. Declaring and upholding proper standards of conduct and behaviour.

Determining appropriate sanctions

The purpose of the sanctions is therefore not to be punitive but to protect patients and the wider public
interest, although they may have a punitive effect. This was confirmed in the judgment of Laws LJ in
the case of Raschid and Fatnani v The General Medical Council [2007] 1 WLR 1460 in which he
stated:

“The panel then is centrally concerned with the reputation or standing of the profession rather than
the punishment of the doctor.”

The Principle of Proportionality:

In deciding what sanction, if any, to impose the panel should have regard to the principle of
proportionality, weighing the interests of the public with those of the practitioner. The panel should
consider the sanctions available starting with the least restrictive.
Whilst there may be a public interest in enabling a doctor’s return to safe practice, and panellists
should facilitate this where appropriate in the decisions they reach, they should bear in mind that the
protection of patients and the wider public interest (i.e. maintenance of public confidence in the
profession and declaring and upholding proper standards of conduct and behaviour) is their primary
concern.

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Mitigating and aggravating factors:
In any case before them, the panel will need to have due regard to any evidence presented by way of
mitigation by the doctor. Mitigation might be considered in two categories:

a. Evidence of the doctor’s understanding of the problem, and his/her attempts to address it. This
could include admission of the facts relating to the case, any apologies by the doctor to the
complainant/person in question, his/her efforts to prevent such behaviour recurring or efforts made to
correct any deficiencies in performance;

b. Evidence of the doctor’s overall adherence to important principles of good practice (i.e. keeping up
to date, working within his/her area of competence etc.). Mitigation could also relate to the
circumstances leading up to the incidents as well as the character and previous history of the doctor.
This could also include evidence that the doctor has not previously had a finding made against him or
her by a previous panel or by any of the Council’s previous committees.

The panel should also take into account matters of personal and professional mitigation which may be
advanced such as testimonials, personal hardship and work related stress. Without purporting in any
way to be exhaustive, other factors might include matters such as lapse of time since an incident
occurred, inexperience or a lack of training and supervision at work. Features such as these should be
considered and balanced carefully against the central aim of sanctions, that is the protection of the
public and the maintenance of standards and public confidence in the profession.

The GMC may wish to draw attention to aggravating factors relating to the facts found proved by the
panel, for example the circumstances surrounding the events that took place, eg whether the doctor
has abused their position of trust by taking advantage of a vulnerable person (breaching paragraphs 32
and 33 of Good Medical Practice). The panel should also take into account any previous findings and
sanctions imposed on the doctor’s registration either by the GMC or any other regulator.

The principles in Good Medical Practice emphasise that doctors should take a mature and responsible
approach to their career; being personally accountable for problems that arise, learning from mistakes,
and working as a team. Panellists may wish to see evidence to support a doctor’s contention that
he/she has taken steps to mitigate his/her actions or to prevent problems arising.

Source: MPTS Guidelines

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What is remediation?
In broad terms, remediation refers to rectifying or correcting a certain behaviour that has generated
concerns. More specifically, in the context of fitness to practise, remediation is where a student or
graduate addresses concerns about their conduct, behaviour or health. Remediation can take a number
of forms, including volunteering, expressions of regret or apology (reparations), coaching, mentoring,
training, and rehabilitation (this list is not exhaustive). Where fully successful, it is less likely the
individual's fitness to practise is impaired.

What are the key principles?

In general, demonstrating remediation is difficult to do, especially in the case of certain concerns such
as probity or misconduct. This is because once the individual has acted in a certain way (for example
being dishonest), it is difficult to present convincing evidence that the behaviour was an exception or
a one-time occurrence. Nevertheless, when we look at fitness to practise concerns, these are the key
principles to consider.
 It is not possible for someone to remediate if they do not have insight into their actions. It is
crucial for students to reflect on their actions and try and understand why these were deemed
unprofessional in the first place.
 Being referred to student fitness to practise often means the student has not followed the
principles of Achieving good medical practice (and, by extension, Good medical practice).
Students should look at those principles, to see where they have deviated from the guidance,
and think what they could do to demonstrate remediation for those specific principles.
 Similarly, if a graduate has been refused provisional registration on the grounds of fitness to
practise, they should consider the reasons given for refusal and the actions that generated
those concerns. Any efforts towards remediation should be centred on these.
 There isn't a set way to demonstrate remediation. Each case is different and the way in which
a student can show they have remediated will depend on the specific circumstances. But
regardless of the nature of the case, key elements are:
o reflection and self-assessment
o sincerely expressing remorse
o taking steps to improve by learning from mistakes
o putting measures in place to prevent similar events from recurring
o having evidence of the steps taken and measures put in place.
 Any efforts to remediate should be driven by the student. The GMC and the student's medical
school can give support and some direction but cannot tell the student what they have to do.
The student should decide on the best plan of action and use their initiative to carry that out.
 In addition to evidence of how they have remediated for their actions, students can consider
providing references or testimonials about their character, and how representative of their
character the actions that raised concerns were.
 Remediation as a process is continuous and can require a significant investment of time and
resources. Students and graduates will need to be aware of this and ensure they are dedicated
to demonstrating remediation for their actions. But in the long-term, when successful, it helps
the individual in becoming a better doctor in the future.

Source: Remediation in Student Fitness to Practise (GMC)

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When would a particular sanction be appropriate?

No action might be appropriate in cases where

 the doctor has demonstrated considerable insight into his/her behaviour and
 has already embarked on, and completed, any remedial action the panel would otherwise require
him/her to undertake.

Conditions are likely to be appropriate where

 the concerns about the doctor’s practice are such that a period of retraining and/or supervision is
likely to be the most appropriate way of addressing them
 in cases involving the doctor’s health, or performance or following a single clinical incident or
where there is evidence of shortcomings in a specific area or areas of the doctor’s practice.

Suspension may be appropriate when some or all of the following factors are apparent:

 A serious breach of Good Medical Practice where the misconduct is not fundamentally
incompatible with continued registration and where therefore complete removal from the
register would not be in the public interest, but which is so serious that any sanction lower than a
suspension would not be sufficient to serve the need to protect the public interest.
 In cases involving deficient performance where there is a risk to patient safety if the doctor’s
registration were not suspended and where the doctor demonstrates potential for remediation or
retraining.
 In cases which relate to the doctor’s health, where the doctor’s judgement may be impaired and
where there is a risk to patient safety if the doctor were allowed to continue to practise even under
conditions. [suspension may be indefinite in such cases]
 No evidence of harmful, deep-seated personality or attitudinal problems.
 No evidence of repetition of similar behaviour since incident.
 Panel is satisfied doctor has insight and does not pose a significant risk of repeating behaviour.

Erasure from the register will be appropriate in any case where:

 this is the only means of protecting patients and the wider public interest, which includes
maintaining public trust and confidence in the profession
 except in a case which relates solely to the doctor’s health

Source: MPTS Guidelines

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