Associates tribunal hearings

Step 2c: consider the impact of any relevant context

Text alternative: step 2c: consider the impact of any relevant context

What is the impact of any relevant context known about the PA or AA and/or their working environment?

Relevant context about a PA or AA and/or their working environment can have an impact on the assessment of whether a PA or AA poses any current and ongoing risk to one or more of the three parts of public protection. There are three types of relevant context: working environment context, role and experience, and personal context.
The associates tribunal (AT) should consider information known to it about relevant context and consider if, and how, it has impacted the PA or AA’s behaviour, performance, or health. The impact that relevant context might have on a PA or AA can be negative or positive so, where it does have an impact, it can increase or decrease the level of current and ongoing risk posed to public protection.
Where the AT identifies evidence of relevant context that relates to the facts found proved, the type should be specified. If the AT decides the type of relevant context identified has had an impact on the PA or AA’s behaviour, performance, or health, they should state how, decide what weight to attach to it and go on to consider what impact, if any, this has on their assessment of the level of current and ongoing risk to public protection posed by the PA or AA.
Where the AT considers that the type of relevant context has had an impact on the PA or AA and there has been no change to the specific setting or circumstances that created the context, this could give rise to a risk of the allegation being repeated. Depending on the weight given, this may increase the level of current and ongoing risk the PA or AA poses to public protection.
However, where the context is not ongoing, either because the circumstances have changed, or because steps are now in place to mitigate the impact that the type of context had on the PA or AA, the AT may consider that this reduces the likelihood of the allegation being repeated. This may in turn decrease the level of current and ongoing risk the PA or AA poses to one or more parts of public protection depending on the weight the AT decide to attach to it.
The impact that evidence of relevant context has on the assessment of risk, will depend on the nature of the allegation and individual circumstances of the case. However, evidence of relevant context that may decrease the level of risk to public protection posed by the PA or AA will usually carry less weight in cases that fall 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.
The ways in which each type of relevant context about a PA or AA and/or their working environment could increase or decrease the risk to public protection are set out below.

Working environment context

The environment in which a PA or AA is practising can influence their behaviour, performance, or health. There are two types of working environment context: systems factors and interpersonal factors.
Systems factors relate to the physical working environment where the PA or AA is practising. There are a range of systems factors which can directly or indirectly affect a PA or AA’s behaviour, performance, or health. These include, but are not limited to:
- 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 PA or AA 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 PA or AA has been unable to adequately prepare
- the impact of technologies or other physical influences
- a lack of, or conflicting, clinical practice guidance
- the availability or effectiveness of reasonable adjustments for disabled PA or AAs
- working in a setting or situation where the requirements of patient care are unpredictable or new to the PA or AA
Interpersonal factors relate to the values and interests of the organisation or team within which the PA or AA 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 PA or AA’s behaviour, performance, or health. These include, but are not limited to:
- 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 groups⁷ and addressing associated risks
- the support, supervision and learning experiences provided, or made available, to the PA or AA, including from more senior PA or AAs, other healthcare professionals or relevant staff
- the approach to giving and receiving effective, honest, and timely feedback to help the PA or AA address any concerns early and for them not to develop further

Assessing the impact of working environment context

The AT may have information available to them about systems factors or interpersonal factors that are outside a PA or AA’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 PA or AA 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 PA or AA. 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 PA or AA has improved support or supervision arrangements.
Where a PA or AA’s behaviour, performance or health was impacted by system or interpersonal factors that were outside of the PA or AA’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 PA or AA.
To comply with the professional duty of candour,⁸ all healthcare professionals are expected to raise and act on concerns about patient safety. Where a PA or AA failed to take reasonable steps to raise concerns about patient safety, this may increase the level of current and ongoing risk the PA or AA poses to public protection because of the potential risk to patient safety.
When the AT 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 PA or AA 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.
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.

Role and experience

PA or AAs work across a wide range of contexts and roles which require different skills, knowledge, and experience. The professional standards apply to all PA or AAs registered with the GMC, in all fields of practice, in NHS and independent care settings, whether or not a PA or AA routinely sees patients.
Practical experience of working in the relevant health and care system and setting plays a key role in a PA or AA’s development.
Where a concern arises about a PA or AA’s fitness to practise, their behaviour or performance will be judged against the standards expected of a reasonably competent PA or AA working within a similar setting and the same role. This includes grade and specialty.
PA or AAs 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 PA or AA 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

Failure to meet the professional standards expected is not acceptable simply because a PA or AA 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.
A PA or AA 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 PA or AA 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.
Where the PA or AA 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 PA or AA poses to public protection. The PA or AA 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.
In cases where there is evidence about the PA or AA’s role and experience which may decrease the level of risk the PA or AA 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.

A PA or AA's personal context

Personal context relates only to the individual PA or AA’s circumstances. It is distinct from information about the PA or AA’s good character and standing. Personal context can directly or indirectly affect a PA or AA’s behaviour, performance, or health condition and includes matters such as a personal emergency.
Where a PA or AA 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 PA or AA’s immediate control. This may present challenges that make it difficult for the PA or AA to deliver good practice.

Assessing the impact of personal context

For personal context to be relevant to the AT’s assessment of current and ongoing risk to public protection, there must be a direct link between it and the PA or AA’s behaviour, performance, or health.
If the personal context that directly influenced the PA or AA’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 PA or AA cope with those circumstances if they did arise again, this may decrease the level of current and ongoing risk posed by the PA or AA to one or more of the three parts of public protection because it reduces the likelihood of repetition.
Where the relevant personal context was out of the PA or AA’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 PA or AA’s personal context and steps are not in place to manage this, the AT 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.
In cases where there is evidence of personal context that may decrease the level of risk the PA or AA 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.

⁷ In groups and out groups exist in medicine including relating to qualifications (including by country and within the UK by medical school) and ethnicity (including within BME populations). Members of in groups can receive favourable treatment and those in out groups are at risk of bias and stereotyping. (Fair to Refer? June 2019).

⁸ The professional duty of candour - professional standards - GMC.

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