Fitness to Practise

 When talking to students I get one of three reactions: sheer terror that we (”The Medical School” spoken as if with capital letters) are lying in wait to catch people out and get rid of them from the course; “it’s not fair” we should be able to lead our lives like any other students or laughter – “I don’t think I’ve breathed in and out right – that’ll be fitness to practise then”.

I don’t think that many students have a problem with understanding why Fitness to Practise (FTP) is required.  If you look at the GMC’s very helpful document: Medical Students: professional values and fitness to practise (http://www.gmc-uk.org/static/documents/content/GMC_Medical_Students.pdf), it is easy to see that someone who is involved with child pornography or who is dishonest is not suitable to be entrusted with the responsibility of being a doctor.  Or that someone who has a health problem that an independent Occupational Health Physician says prevents him/her working safely in a clinical environment cannot therefore complete their training.  However, I think that sometimes what students do struggle with is the feeling that their every move is watched and that from the age of 18 they aren’t able to be like other students.  To a certain extent this is true and we have a lot of sympathy for the fact that you have to ‘grow up’ fast.  You certainly aren’t the only students to feel like this – research shows that many others do too 1.

Students in the later years of the programme tend to say that FTP isn’t actually something they need to think about very often – they manage to have a lot of fun without getting into fights, they turn up to their placements as expected, or keep the Medical School informed if they can’t (repeated, unexplained, very poor attendance is one of the most common reasons for getting to an FTP hearing – what the University calls lack of Reasonable Diligence) and they are honest.  Perhaps the trickiest area for some is avoiding getting so drunk that their judgement becomes impaired and without realising it they take risks or get into situations that when sober they would know to avoid.

In the last nine months The Dean, Sue Grant and I have done a lot of work at revising our FTP procedures, working with the GMC, the University and its legal services department.  Our intention is to make the procedures clearer and quicker.  At the start of the next academic year for each cohort we will be talking to you about the process and answering questions, but in this blog will introduce you to the ideas behind the changes.

The first thing to say is that up to now the University has required that any disciplinary matter involving a student on an full time professional course (Dentistry, Education, Medicine, Nursing, Physiotherapy, Social Work) has been dealt with as FTP.  In future if a student gets to a hearing it will be the job of the panel to decide whether the issue is either misconduct or FTP.  A way of thinking about this is to consider some possible incidents in the Guild.  If a student gets drunk and boisterous and pulls a door off its hinges that’s misconduct as this doesn’t bring into question the student’s fitness to practise.  If, for example, a student assaults another student by shoving a glass in his face following a perceived insult, that does bring into question the student’s fitness to practise as his response when angry is disproportionate and violent.

Secondly, in order to be sure that cases are not delayed when key staff are on leave a second Investigating Officer (IO) has been appointed.  The IO is the person who sees a student after it has been determined that the matter is disciplinary (see below).  Professor Janesh Gupta, who is Senior Tutor for Professional Behaviour, and Dr John Winer, who is Head of NHS Liaison, are the Investigating  Officers.

The third major change is that we have established a Professional Support Unit (PSU) for students.  This makes more formal a resource that the Year Tutors have used for a long time.  It builds on work that the Interactive Studies Unit (ISU), who are responsible for teaching you clinical communication skills, does with the West Midlands Postgraduate Deanery Doctors in Difficulty scheme.  The Unit is led by Professor John Skelton, and he and his team see doctors who run into problems during their career: ones who cannot pass exams (although their knowledge and skills are such that they should pass); or who get a lot of complaints; or who have difficulty working with colleagues.  The idea of the PSU is that we will be able to get help for students who seem to be running into trouble so that we can help with things like being terrified of taking OSCEs, or being so shy they cannot talk to patients, or where there seems to be a pattern of unprofessional behaviour developing.  Any of us can make a mistake, but what we are looking for are people who don’t seem to learn from that mistake and keep repeating the behaviour.  Our aim, through the PSU, is to help people understand why their behaviour gives cause for concern and learn to change it.  This, we hope, will prevent the issue ending up at FTP and, equally importantly, will mean that these people don’t end up in trouble at work.  The Unit is genuinely supportive and we estimate that 50 medical students will be referred each year – so if you ever do get referred don’t assume it’s because you are heading to FTP – it rarely will be, and take up the offer as people almost always benefit from it.

So, when we talk about FTP what do we mean?  Really we are talking about when a student gets to a hearing – this is very rare (in reality affecting 0.02% of the cohort in the last 5 years).  We know that teaching and administrative staff in the Medical School and the NHS sometimes misuse the term FTP for any minor indiscretion e.g. being late.  It is an unprofessional behaviour to be late for teaching, but alone it is certainly not an FTP matter.  We also know that a small number of staff use FTP as a threat and we will now work with staff to explain to them how unhelpful this is.  Educating everyone from staff to students, to understand exactly what we mean by FTP – and what we don’t will be a priority.  To get as far as a hearing a problem has to be very serious and there are a lot of steps before a student gets that far.  Unless it concerns a very serious matter, e.g. dealing drugs, no one can say whether something is a Fitness to Practise matter or not until they have investigated it.

Most problems come to the Medical Schools’ attention through a Concern Form or a report of an issue.  Plagiarism, for example, is dealt with by staff involved with the relevant module and is only referred on if it is clear that the student intended to be dishonest.  Once the Student Development and Support Office receives notification of a concern the student is asked to see their Year Tutor to explain what happened from their side of the story.  Some things are clearly not serious and the matter rests there.  Sometimes it is not clear whether a matter should be pursued or not – often this is when a student has had several concerns reported and a pattern of unprofessional behaviour seems to be forming.  Some things are so serious that a referral to the Investigating Officer is needed, e.g. forging a Consultant’s signature on a logbook or cheating in an exam.  Whichever of these it is the Year Tutor who will discuss the case at a meeting of the Student Welfare and Development Advisory Group (SWADAG), which consists of the Year Tutors, myself, the Investigating Officers, Professor Skelton and relevant administrative staff.  This means that no one person makes a decision without a discussion with senior colleagues.  This group of people, by virtue of their interest in student welfare, can be thought of as “pro-student”, and generally we will look to find a way to help students improve their behaviour.  However, there are times that the student’s behaviour is such that a referral to the Investigating Officer is needed.

If a concern about a student is serious or of a nature to be investigated further this is what happens:

  • The student will be informed in writing of the detail of the concern and invited to attend a meeting with the Investigating Officer.  This letter is very formal and marks the fact that it is not something to be taken lightly.
  • S/he will be invited to provide a written response to the detail of the concern.  The student will also be invited to bring a friend to the meeting.  [In University “speak” a “friend” must either be a student or member of staff of the University].
  •  The student (and his/her friend) will meet with the Investigating Officer to discuss and agree the facts.
  • S/he will receive a summary report of the meeting and be given the opportunity to review it and agree its accuracy.
  • The Investigating Officer will decide on further action based on the balance of probabilities that the student’s fitness to practise is impaired – options are:
    • no case to answer / case not proven – dismissed
    • refer back through the welfare system if further support is appropriate
    • refer to the Professional Support Unit for further assistance – e.g. behaviour / attitude
    • request that the student accepts an undertaking (e.g. remedial teaching)
    • award a summary penalty – e.g. warning or reprimand (to be declared to   the GMC)
    • referral to a College Misconduct and Fitness to Practise Committee to decide whether the student’s  fitness to practise is impaired
    • referral to a College Misconduct and Fitness to Practise Committee to decide whether the concern raises a disciplinary issue but there are no concerns about the student’s  fitness to practise
  • The student will be advised in writing of the Investigating Officer’s decision. 
  • If the student does not accept the decision of the Investigating Officer the issue will be referred to a College Misconduct and Fitness to Practise Committee for further consideration.
  • If the Investigating Officer’s decision is to refer to a College Misconduct and Fitness to Practise Committee, the student will receive a comprehensive report detailing the concern or allegation and will have 10 working days in which to provide a response.  S/he will also be invited to object to any of the committee members on reasonable grounds.
  • The student will be invited to bring a friend to the College Misconduct and Fitness to Practise Committee.  S/he may also bring witnesses but s/he must inform the Committee Secretary of his/her intention to do so before the hearing.
  • After the hearing, the student will be informed of the Committee’s decision within 2 working days.  Support will be made available to him/her as s/he receives the decision.
  •  The student will be provided with information on how to appeal against the Committee’s decision as s/he has the right to do so.


We strongly advise students who have to see the IO or go to a hearing to contact the Advice and Representation Centre (ARC) in the Guild for help and support in preparing documentation, as they are expert in understanding the workings of the process.  They can also arrange for one of the Guild Sabbatical Officers to attend as the student’s friend, which is something that students who have been to a hearing have found very helpful.  Sue Grant, who is the College of Medical and Dental Sciences’ Student Services Manager, is responsible for the process of FTP and she is incredibly helpful and supportive of students who are involved at any stage.  I also offer to support students through the process, which, as you can imagine, they find highly stressful.

Students have to inform the GMC of any disciplinary or Fitness to Practise matters – so anything that is a summary penalty or more serious (in the list above it’s summary penalty or below).  The GMC deals with all the UK Medical Schools, so is used to reading about problems from all over the UK.  The key thing in any dealings with the GMC is to be absolutely honest and transparent – never tell a partial truth and never try to conceal anything.  If you follow that advice there should be no problems.  It is a myth that you cannot register if you have been to an FTP hearing.  At a GMC meeting in May they compared the number of FTP cases each Medical School deals with in a year and the way in which Medical Schools deal with them.  Reassuringly the numbers and outcomes were very similar across the all Schools, with Birmingham being very average.

I hope that this has been helpful in enabling you to understand what Fitness to Practise really is and that it seems less scary.  Getting to a hearing is rare and being required to leave because of Fitness to Practise is even rarer.  For the vast majority of students their Fitness to Practise will never be questioned.

1.  Finn G, Garner J, Sawdon M.  ‘You’re judged all the time!’ Students’ views on professionalism: a multicentre study.  Medical Education 2010;44:814-825.

Professor Kate Thomas. 

With thanks to Mrs Sue Grant for her invaluable contribution.

1 comment

  1. Anne Marie Cunningham says:

    Thank you for sharing this. I have just written a very short blog post about medical students perceptions of fitness to practice and will link to this.

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