Further to my article on the importance and significance of refection in fitness to practise, in this article I will focus on doctors and the GMC.

GMC & MPTS Guidance and Standards

General Medical Council (GMC)

Reflection is a core feature of medical practice and an ethical duty as outlined in the GMC’s Good medical practice.  Paragraph 24 onwards of the guidance requires of doctors to “take part in systems of quality assurance and quality improvement to promote patient safety” including:

• taking part in regular reviews and audits of your own work and that of your team, responding constructively to the outcomes, taking steps to address any problems and carrying out further training where necessary
• regularly reflecting on your standards of practice and the care you provide
• reviewing patient feedback where it is available.

Reflective Practice

The GMC has also published “The Practitioner Guidance” for doctors and medical students on reflective practise.  Whilst specifically in the context of revalidation, the principles are nonetheless relevant to other circumstances such as when things go wrong in practice.

The Academy of Medical Royal Colleges and COPMeD define reflective practice as:

“the process whereby an individual thinks analytically about anything relating to their professional practice with the intention of gaining insight and using the lessons learned to maintain good practice or make improvements where possible.”

MPTS Sanctions guidance

The Medical Practitioners Tribunal Service’s (MPTS) “Sanctions guidance for medical practitioners tribunal members and the GMC decision makers” provides the following guidance on mitigating and aggravating factors to consider when deciding on a sanction:

Evidence that the doctor understands the problem and has insight, and of their attempts to address or remediate it. This could include the doctor admitting facts relating to the case, apologising to the patient, making efforts to prevent behaviour recurring, or correcting deficiencies in performance or knowledge of English.

The guidance goes on to deal with a number of specific issues:

• Presenting evidence that they have attempted to address or remediate;
• Remediation of the concerns
• Expressions of regret and apology
• The doctor’s insight into the concerns
• Lack of insight

The guidance states that a doctor is likely to have insight if they:

• accept they should have behaved differently (showing empathy and understanding)
• take timely steps to remediate; and
• apologise at an early stage before the hearing demonstrate the timely development of insight during the investigation and hearing.

Reflection and the GMC’s fitness to practise process

The GMC’s fitness to practise process provides doctors with a number of opportunities to provide evidence of reflection, insight gained and remediation steps.  These opportunities are important because it offers doctors the potential for an early resolution to fitness to practise investigations and proceedings.

Preliminary Enquiries (Rule 4)

The GMC’s provisional enquiry process exists to close cases early without a full investigation, under certain circumstances.  As part of this process, a GMC case officer will send a doctor an initial Rule 4 letter which outlines the complaint or allegations.  Whether to respond to a Rule 4 letter is at a doctor’s discretion and, whilst under certain circumstances, a response might not be necessary, a doctor should consider this carefully and seek advice.

In any event, following the receipt of a Rule 4 letter, a doctor should reflect on the circumstances that might have led to the complaint and take remedial steps.  The insight gained and remedial steps taken might form part of a Rule 4 letter’s response and doctors are advised to seek legal advice as soon as is reasonably possible.

Case Examiners (Rule 7)

Should the complaint progress past the provisional enquiry stage, GMC case examiners also have the discretion to close cases without the need for a full fitness to practise hearing.  Case examiners will write to the doctor, outlining the evidence and allegations in a GMC Rule 7 letter.  The doctor will be invited to respond within 28 days.

Whist the case examiner stage provides another opportunity for a doctor to provide evidence of insight and remediation, the timescales are short.  As mentioned above, doctors are advised to seek legal advice as soon as is reasonably possible because genuine insight and remediation often requires time to achieve to meet the GMC’s standards.  In my article “Fitness to Practise – Reflection, Insight & Remediation” are a number of case studies that doctors might find helpful to refer to.

Fitness to Practise hearings before the MPTS

Finally, as is evident in the MPTS sanctions guidance that “Evidence that the doctor understands the problem and has insight, and of their attempts to address or remediate it” carries substantial weight before a fitness to practise panel.

The process of reflection, insight gained and remediation steps should not be rushed.  Early engagement with expert legal advice is essential to ensure the best potential for an early and positive resolution for doctors.

Further GMC guidance

• GMC – The reflective practitioner
• GMC – The reflective practitioner – guidance for doctors and medical students
• GMC – Good medical practice
• MPTS – Sanctions guidance for medical practitioners tribunal members and the GMC decision makers