Step 1a: consider what has happened since the previous MPT's decision

25. The previous medical practitioners tribunal (MPT) will have decided that the doctor’s fitness to practise was impaired, considering the assessment of current and ongoing risk to public protection they made at that time. The MPT should not reconsider or go behind those findings. Their role is to decide whether the doctor’s fitness to practise remains impaired at the time of the review. 
    
    
26. To understand the previous MPT’s assessment of risk, the MPT should note: 
• the seriousness of the allegations which resulted in the finding of impairment
• the impact of any relevant context known about the doctor and/or their working environment and
• how the doctor has responded to the allegations which resulted in the first finding of impairment and how they responded to, if relevant, any subsequent findings made by previous MPTs.  

27. The MPT should also be mindful of which parts of the three parts of public protection were engaged and note this along with the level of risk that the previous MPT identified as part of their finding of impairment (low, medium or high). 

28. Once the MPT has noted the previous MPT’s assessment of risk and reasons for it, they should go on to consider what new evidence has been received and assess what impact this has. This will help inform their assessment of the current and ongoing risk the doctor poses to public protection.
    
    
29. The MPT should consider any relevant new evidence provided by the parties (the General Medical Council (GMC) and the doctor) about what has happened since the last impairment decision and assessment of risk was made.
    
    
30. In many cases the GMC will have been monitoring the doctor’s compliance with the current sanction of conditions or suspension and/or may have received information relevant to considering the doctor’s current fitness to practise from another source. The doctor may also provide their own evidence of what has occurred since the last impairment decision and assessment of risk was made.
    
    
31. The MPT may need to consider new evidence, including evidence:
• regarding the doctor’s health, performance or knowledge of English language 
• relating to any change to relevant context known about the doctor and/or their working environment 
• about a material change in the doctor’s circumstances that needs to be considered
• relevant to the doctor’s compliance with the current sanction, including the relevance of any facts found proved in relation to a new allegation.

32. Further guidance about each of these is below.

33. When assessing new evidence and deciding the weight to attach to it, the MPT should consider its source, relevance and the extent to which they have been able to adequately test it at the hearing.
    
    
34. If the MPT is not able to reach a fair decision based on the evidence before them, they may wish to consider whether to adjourn in order to direct an assessment or for further information or reports to be provided. Before doing so, the MPT should invite submissions from the parties on whether this is appropriate. For further guidance on this issue, the MPT should refer to Adjourning to direct an assessment or for further information or reports to be obtained  in Part B of Section two: Procedural matters relating to tribunal hearings of the Guidance for MPTS tribunals.

Evidence regarding the doctor’s health, performance or knowledge of English language

35. Evidence provided to the MPT about the doctor’s health, performance or knowledge of English language may include:
• a GMC health, performance or assurance assessment or an English language assessment 
• reports provided by the doctor’s own treating healthcare practitioner
• witness statements that provide an up to date position on the doctor’s health, performance or knowledge of English Language.

36. The MPT should consider the weight to be given to any new evidence received about the doctor’s health, performance or knowledge of English language with reference to the source of the information and their awareness of the circumstances that led to the original findings about the doctor’s fitness to practise. 
    
    
37. Where there is evidence that demonstrates an improvement in the doctor’s health, performance, or knowledge of English language, this may indicate that either (a) the doctor no longer continues to pose a current and ongoing risk to public protection requiring restrictive action in response, or (b) that any risk they do still pose has decreased. 
    
    
38. Evidence of improvement in a doctor’s health may be trigged by a full recovery. As many health conditions are remitting and relapsing in nature, it may also be triggered by a doctor developing insight that enables them to recognise any warning signs and/or where the impact of the doctor’s health condition is being appropriately managed. 
    
    
39. When deciding how much weight to attach to evidence of improvement, more weight can usually be attached to objective evidence that demonstrates improvement over a sustained period.  
    
    
40. Evidence that demonstrates a deterioration in the doctor’s health, performance or knowledge of English language, is likely to suggest that the doctor continues to pose a current and ongoing risk to public protection requiring restrictive action in response and may indicate that the risk to one or more parts of public protection has increased. 
    
    
41. It may be appropriate for the MPT to conclude that the deterioration demonstrates an increase in risk where:
• the deterioration is significant
• the deterioration or impact of the doctor’s health condition is not being, or cannot be, managed locally
• patient safety has been compromised as a result
• the doctor has continually not engaged with the GMC about the deterioration
• the doctor does not accept that there has been a deterioration, has not demonstrated insight into the impact and potential consequences of the deterioration and has not taken steps towards recovery and/or to remediate, and/or
• the deterioration occurred in conjunction with a breach of restrictions. 

42. It may be appropriate for the MPT to conclude that the deterioration does not impact on the present assessment of the current and ongoing risk to public protection posed by the doctor where several of the following factors are seen: 
• the deterioration is not considered to be significant  
• the deterioration is being managed, or can be, managed locally  
• patient safety has not been compromised as a result  
• the doctor engaged with the GMC regarding the deterioration and continues to engage and/or 
• the doctor accepts that there has been a deterioration, demonstrates insight into the impact and potential consequences of the deterioration and has taken any relevant steps towards recovery and/or to remediate. 

Evidence relating to any change to relevant context known about the doctor and/or their working environment that was relevant to the previous MPT’s assessment of risk

43. When the previous MPT decided the doctor posed a current and ongoing risk to public protection requiring restrictive action in response, they may have taken into account evidence of relevant context known about the doctor and/or their working environment. Where the previous MPT considered that the type of relevant context identified had an impact on the doctor, they may have concluded that it could give rise to a risk of the matter being repeated.  
    
    
44. The MPT should consider whether there has been a change to the relevant context previously identified. If there has been no change, this is unlikely to impact on the present assessment of current and ongoing risk posed by the doctor. However, if the likelihood of repetition has now been removed or reduced, either because the specific setting or circumstances that created the context have changed or because steps have been put in place to mitigate the impact on the doctor, this may decrease the level of current and ongoing risk the doctor poses to public protection.  
    
    
45. The MPT should refer to the section What is the impact of any relevant context known about the doctor and/or their working environment?  in Part B of Section three: MPT hearings of the Guidance for MPT tribunals for further guidance on how to decide the impact any relevant context has on their assessment of risk.

Evidence relating to a material change in the doctor’s circumstances that needs to be considered 

46. Where there is evidence that demonstrates a material change in the doctor’s circumstances, the MPT should consider what impact this has on their assessment of the current and ongoing risk the doctor poses to public protection. 
    
    
47. In some cases, such evidence may suggest that the risk the doctor poses to public protection requiring restrictive action in response has not changed, but that any current conditions are no longer appropriate, workable and/or measurable in their existing format.  In these circumstances, provided there are no other matters that increase risk requiring consideration of a more restrictive sanction, the MPT should consider if alternative conditions are appropriate, workable and measurable, achieve the overall aim of conditions and adequately address the current and ongoing risk to public protection posed by the doctor.

Evidence relevant to the doctor’s compliance with the current sanction, including the  relevance of any facts found proved in relation to a new allegation

48. Where the evidence demonstrates the doctor is complying with the current sanction of conditions or suspension this could indicate that either the level of risk has decreased or that the doctor no longer continues to pose a current and ongoing risk to public protection requiring restrictive action in response. However, in some cases, the fact of compliance in and of itself may not be directly relevant to the assessment of risk but may indicate that the conditions or sanction remain suitable to address the level of risk currently posed by the doctor. 
    
    
49. More weight can be attached to evidence of compliance where there is a range of objective evidence that demonstrates the doctor’s compliance over a sustained period.  However, the fact of compliance alone is unlikely to be sufficient for the MPT to conclude the doctor no longer continues to pose a risk to one of more of the three parts of public protection. The impact of compliance will need to be considered alongside other information including the doctor’s response to the previous MPT’s findings. 
    
    
50. If there is evidence suggesting that a breach of the current sanction has occurred, the MPT will need to decide whether they are satisfied, on the balance of probabilities, that a breach has in fact occurred.
    
    
51. The MPT should give clear and adequate reasons for its conclusion as to whether there has been a breach to enable the doctor, profession and members of the public to understand their decision. 
    
    
52. If the MPT decides there has been a breach, they will then need to decide what impact this has on the level of current and ongoing risk the doctor poses to public protection. A breach of a sanction is likely to suggest that the doctor continues to pose a current and ongoing risk to public protection requiring restrictive action in response and may indicate that the risk to one or more parts of public protection has increased. 
    
    
53. It may be appropriate for the MPT to conclude that the breach demonstrates an increase in risk where: 
• the breach was significant in nature or repeated 
• patient safety was compromised as a result 
• the circumstances of the breach, including the reasons for it, were completely within the doctor’s control 
• the breach demonstrates a wilful or deliberate disregard of instructions issued by the previous MPT 
• recurrence of the breach is likely 
• the doctor does not accept the breach occurred, does not understand the reasons for it, and has not demonstrated insight into the impact and potential consequences and/or 
• the breach occurred in conjunction with a deterioration in the doctor’s health or performance. 

54. If this is not the first review and it has been found previously that the doctor has breached their sanction, then the fact of repetition will usually increase the risk they pose to public protection as they have shown disregard to the purpose and reason for the sanction being imposed. 
    
    
55. It may be appropriate for the MPT to conclude that the breach does not impact on their present assessment of the current and ongoing risk to public protection posed by the doctor where several of the following factors are present: 
• the breach was not significant in nature or was isolated or a one off 
• patient safety was not compromised as a result 
• the circumstances of the breach, including the reasons for it, were outside of the doctor’s control 
• recurrence of the breach is unlikely
• the doctor accepts that a breach has occurred, understands the reasons for it, has demonstrated insight into the impact and potential consequences of the breach and taken any relevant steps to remediate it. 

56. The MPT should be mindful that where the review has been directed by the GMC registrar¹⁰ on the basis the GMC considers the doctor has failed to comply with any requirement imposed as a condition, and the MPT finds there has been a breach of conditions, the MPT cannot vary any specific conditions or direct a further period of conditions. The MPT may:
• suspend the doctor for up to 12 months, or 
• erase the doctor, except in a health or language case.¹¹

57. If any new allegations have been considered by the MPT with facts found proved, these will need to be considered to inform the MPT’s decision on impairment. Although an assessment of current and ongoing risk to public protection will need to be made in relation to the new allegations, any facts found proved can also be taken into consideration when assessing current risk in relation to the review matter. 
    
    
58. Where there are facts found proved that demonstrate additional similar concerns or allegations have arisen, this is likely to suggest that the doctor continues to pose a current and ongoing risk to public protection requiring restrictive action in response and may indicate that the risk to one or more parts of public protection has increased. This is because repeated similar concerns or allegations may suggest that the doctor lacks insight into their own practice and behaviour and has not taken steps that effectively or sufficiently reduce the risk of similar matters occurring again.  
    
    
59. The impact of, and weight to be given to, additional similar concerns or allegations having arisen will need to be considered alongside other factors including the doctor’s insight and remediation, response to the previous MPT’s findings, the timings of the new allegations and any other information that may be relevant as to why further additional allegations have been referred to a hearing. 

60. To demonstrate insight the doctor will need to show they understand and accept any previous MPT’s findings, including the original MPT’s findings on facts and impairment. The doctor will also need to demonstrate they understand what happened and accept how they could have acted differently. The MPT will need to consider how complete or developed the doctor’s insight is.
    
    
61. When considering evidence of insight and the impact it has on the present assessment of current and ongoing risk the doctor poses to public protection, the MPT should consider and apply the guidance in the section Insight and remediation  in Part B of Section three: MPT hearings of the Guidance for MPTS tribunals. When doing so, the MPT should remind itself that it must not revisit the decision made by the previous MPT but should consider evidence of the insight that has developed since the previous assessment of risk.
    
    
62. When assessing insight, the MPT should consider how the doctor has responded to the findings made by the previous MPT.
    
    
63. When assessing the impact the doctor’s response has on the present assessment of the current and ongoing risk the doctor poses to public protection, the MPT should examine the evidence available to them from all sources to reach a view on whether the doctor has shown insight into their own practice and behaviour.
    
    
64. To be relevant to the current assessment of risk, evidence of insight shown from the doctor participating in training or professional development, requires the training or professional development to be relevant to the MPT’s findings. Where it is, this should assist in demonstrating to the MPT that the doctor has accepted the previous MPT’s findings.
    
    
65. Where the doctor has made statements about how they’ve responded to the findings made by the previous MPT, the MPT will need to consider the objectivity of the statements. If the only source of the information is the doctor themselves, it will usually be appropriate for the MPT to test the evidence during the hearing before deciding the impact it has on the present assessment of current and ongoing risk to public protection. 

66. Where a doctor has shown insight and taken steps to avoid the risk of similar concerns occurring again, this can have a significant impact on the present assessment of the current and ongoing risk the doctor poses to public protection. However, the actual impact that evidence of the doctor’s response to the allegation and previous MPT’s findings has on the assessment of risk, will depend on the individual circumstances of the case. 
    
    
67. To demonstrate remediation the doctor will need to show that they have taken, or are taking, steps aimed at reducing the risk of similar concerns occurring again. The MPT will therefore need to consider the quality of the steps taken, or put in place, by the doctor since the previous assessment of risk.  
    
    
68. When assessing the impact of remediation, the MPT should examine the evidence available to them to reach a view on whether the doctor has remediated i.e. taken steps to reduce the risk of similar concerns occurring again, such as participating in training, supervision, coaching or mentoring relevant to the concern raised.  
    
    
69. When considering evidence of remediation and the impact it has on the present assessment of the current and ongoing risk the doctor poses to public protection, the MPT should consider and apply the guidance in the section Insight and remediation  in Part B of Section three: MPT hearings of the Guidance for MPTS tribunals.  When doing so, the MPT should remind itself that it is not to revisit the decision made by the previous MPT but should consider evidence of the remediation that has taken place since the previous assessment of risk. 
    
    
70. The MPT should be mindful that if the original MPT considered the allegation was remediable, it is not for them to review that decision. Their role on review is to assess whether the allegation has now been sufficiently remedied or could still be remedied if there is further insight to be developed and additional remediation to undertake.

71. While a sanction of conditions or suspension are in place, a doctor must keep their knowledge and skills up to date and be aware of relevant guidelines and developments that affect their work. This is to ensure they are competent in all aspects of their work, including, where applicable, formal leadership or management roles, research and teaching.  
    
    
72. Where a doctor has not been working for a significant period of time, the MPT may consider that this creates a risk that the doctor’s knowledge and skills may have deteriorated. It is therefore important that the doctor can evidence they have taken steps to mitigate this.  
    
    
73. When considering evidence of the doctor’s knowledge and skills and the impact it has on the present assessment of the current and ongoing risk the doctor poses to public protection, the MPT should consider and apply the guidance in the section Has the doctor kept their knowledge and skills up to date?  in Part B of Section three: MPT hearings of the Guidance for MPTS tribunals.
    
    
74. Where the doctor has been suspended from practising in the UK, at the review the MPT may be provided with a certificate of good standing ‘CGS’ from another regulatory body.¹² A CGS confirms that a doctor is in good standing with that organisation at the time of issuing and says whether there are any restrictions on their practice. This may therefore support any assertion by the doctor that they have kept their knowledge and skills up to date through practising in a different country. However, when deciding what weight to attach to such evidence, the MPT should give careful consideration to the date of issue and the nature of the restrictions, if any, on the CGS.
    
    
75. The doctor may also provide the MPT with testimonials from any clinical attachments or other work that has been carried out that has not required GMC registration. Where the content relates to the doctor’s knowledge and skills, the weight to be applied is a matter for the MPT. Otherwise, references and testimonials relating to the doctor’s character should only be considered when deciding what action is a proportionate response to the MPT’s decision on impairment.

76. When considering whether the previous assessment of risk to public protection requiring restrictive action in response has,¹³ the MPT should refer to the conclusions they reached on questions (i) – (v) above.
    
    
77. The MPT may reach a view that the present assessment of current and ongoing risk to one or more of the three parts of public protection indicates the risk posed by the doctor has: 
• decreased
• not materially changed
• increased.