Step 2c: consider the impact of any relevant context

52. The environment in which a doctor is practising can influence their behaviour, performance, or health. There are two types of working environment context; systems factors and interpersonal factors.
    
    
53. Systems factors relate to the physical working environment where the doctor is practising. There are a range of systems factors which can directly or indirectly affect a doctor’s behaviour, performance, or health. These include, but are not limited to:
    1. their immediate workplace, including the systems and processes that exist and the associated training they’ve received to understand their responsibilities within them, including:
       1. the quality of induction – this will be particularly relevant where the doctor is transitioning to new social, cultural and professional environments
       2. workload issues, such as unmitigated gaps in resources, a crisis or unexpected surge in demand
       3. service delivery requirements to work in unfamiliar roles, teams and/or environments at short notice so the doctor has been unable to adequately prepare
    2. the impact of technologies or other physical influences
    3. a lack of, or conflicting, clinical practice guidance
    4. the availability or effectiveness of reasonable adjustments for disabled doctors
    5. working in a setting or situation where the requirements of patient care are unpredictable or new to the doctor.

54. Interpersonal factors relate to the values and interests of the organisation or team within which the doctor is working, and the relationships between individuals in that working environment. There are a range of interpersonal factors which can directly or indirectly affect a doctor’s behaviour, performance, or health. These include, but are not limited to:
    1. the culture of the organisation, or the specific team or area of practice within the organisation, such as:
       1. how engaged, positive and accessible the leadership team is
       2. how they respond when things go wrong (blame versus learning culture)
       3. how they encourage an inclusive and fair working environment, including their approach to identifying insider/outsider groups⁴ and addressing associated risks
    2. the support, supervision and learning experiences provided, or made available, to the doctor, including from more senior doctors, other healthcare professionals or relevant staff
    3. the approach to giving and receiving effective, honest, and timely feedback to help the doctor address any concerns early and for them not to develop further.

Assessing the impact of working environment context

55. The medical practitioners tribunal (MPT) may have information available to them about systems factors or interpersonal factors that are outside a doctor’s control, and which had an impact on their behaviour, performance, or health at the time. Where this is the case, the relevant context may decrease the level of current and ongoing risk the doctor poses to one or more of the three parts of public protection where the likelihood of repetition has been removed or reduced, either because the working environment itself has now changed or because steps have been put in place to mitigate the impact on the doctor. This may include where there is evidence to show that workload issues, challenges with technologies or problems caused by poor team or organisational culture have now been addressed, or where the doctor has improved support or supervision arrangements.
    
    
56. Where a doctor’s behaviour, performance or health was impacted by system or interpersonal factors that were outside of the doctor’s control, the fact those factors have not been removed or mitigated by the organisation or individuals responsible for them may mean that the working environment itself poses an ongoing risk. However, this does not have the result of increasing the level of risk posed by the individual doctor. 
    
    
57. To comply with the professional duty of candour⁵, all medical professionals are expected to raise and act on concerns about patient safety. Where a doctor failed to take reasonable steps to raise concerns about patient safety, this may increase the level of current and ongoing risk the doctor poses to public protection because of the potential risk to patient safety.  
    
    
58. When the MPT is deciding what amounts to ‘reasonable’ steps, information available about the systems, processes, and culture in the working environment to support raising concerns should be considered. It’s unlikely a doctor will have failed to take reasonable steps in circumstances where they knew that another individual was raising the relevant concern(s), or the concern(s) were already known to management. 
    
    
59. In cases where there is evidence of working environment context that may decrease risk, this will usually have less impact, and therefore carry less weight, where the allegation falls at the higher end of the spectrum of seriousness. This is because the risk to public protection arising from these concerns is generally more difficult to mitigate. 

60. Doctors work across a wide range of contexts and roles which require different skills, knowledge, and experience. The professional standards apply to all doctors registered with the GMC, in all fields of practice, in NHS and independent care settings, whether or not a doctor routinely sees patients. 
    
    
61. Practical experience of working in the relevant health and care system and setting plays a key role in a doctor’s development. 
    
    
62. Where a concern arises about a doctor’s fitness to practise, their behaviour or performance will be judged against the standards expected of a reasonably competent doctor working within a similar setting and the same role. This includes grade and specialty. 
    
    
63. Doctors in leadership positions have specific standards set out in Good medical practice and other detailed professional guidance that they’re expected to practice in line with. Where a doctor is in a senior or leading role, the additional impact their poor behaviour or performance has had, or could have had, can be considered. 

Assessing the impact of role and experience  

64. Failure to meet the professional standards expected is not acceptable simply because a doctor is newly qualified or new to UK practice. However, where they are inexperienced at the time the behaviour or poor performance occurred and can demonstrate that since then they have developed their skills or gained a better understanding of the UK healthcare system, this may decrease the level of current and ongoing risk they pose to public protection because it reduces the likelihood of repetition. 
    
    
65. A doctor in a senior or leading role is more likely to be capable of influencing others and having an impact on workplace culture. Therefore, where a doctor that is in a senior or leading role frequently demonstrates inappropriate behaviour or poor performance, a departure from the professional standards expected has an additional impact.
    
    
66. Where the doctor was in a leadership position at the time the circumstances giving rise to the allegation arose and the behaviour or poor performance had, or could reasonably have had, a negative impact on others in the working environment, this may, depending on the facts of the case, increase the level of current and ongoing risk the doctor poses to public protection. The doctor no longer being in that role will not usually have the effect of reducing the level of current and ongoing risk posed to public protection because it is possible they will return to that, or a similar, position in the future. 
    
    
67. In cases where there is evidence about the doctor’s role and experience which may decrease the level of risk the doctor poses to one or more of the three parts of public protection, this will usually have less impact, and therefore carry less weight, where the allegation falls at the higher end of the spectrum of seriousness and therefore the starting point for assessing current and ongoing risk to public protection is high. This is because the risk to public protection arising from these concerns is generally more difficult to mitigate. 

68. Personal context relates only to the individual doctor’s circumstances. It is distinct from information about the doctor’s good character and standing. Personal context can directly or indirectly affect a doctor’s behaviour, performance, or health condition and includes matters such as a personal emergency. 
    
    
69. Where a doctor is aware of personal context that may impact on their behaviour, performance, or health at work, they should raise this and seek appropriate support. However, some types of personal context can arise suddenly or cannot be predicted, which may put them outside the doctor’s immediate control. This may present challenges that make it difficult for the doctor to deliver good medical practice. 

Assessing the impact of personal context 

1. For personal context to be relevant to the medical practitioners tribunals (MPT’s) assessment of current and ongoing risk to public protection, there must be a direct link between it and the doctor’s behaviour, performance, or health.  
   
   
2. If the personal context that directly influenced the doctor’s behaviour, performance or health at the time of the allegation has since resolved, or steps have been put in place to avoid the circumstances arising again and/or to help the doctor cope with those circumstances if they did arise again, this may decrease the level of current and ongoing risk posed by the doctor to one or more of the three parts of public protection because it reduces the likelihood of repetition. 
   
   
3. Where the relevant personal context was out of the doctor’s control, or where they were taking reasonable steps to minimise the impact, this will usually have more of an impact on the assessment of risk. However, where there is an ongoing impact arising from the doctor’s personal context and steps are not in place to manage this, the MPT might conclude, depending on the facts of the case, that there may be a risk of repetition which means the level of current and ongoing risk to public protection may be increased.
   
   
4. In cases where there is evidence of personal context that may decrease the level of risk the doctor poses to one or more of the three parts of public protection, this will usually have less impact, and therefore carry less weight, where the allegation falls at the higher end of the spectrum of seriousness and therefore the starting point for assessing current and ongoing risk to public protection is high. This is because the risk to public protection arising from these concerns is generally more difficult to mitigate.