01Principles and purposeThe professional or clinical skill and the decisions it supports.
Fitness to practise is contextual: can the doctor deliver safe, ethical care within their role, competence and any agreed safeguards? Concerns may arise from health, deficient performance, misconduct, dishonesty, substance use, fatigue, bullying, poor systems or a combination. Avoid diagnostic speculation and stigma. Describe the missed reviews, slurred speech, unexplained absence, prescribing pattern or refusal of supervision that creates risk. A well-managed condition with insight and adjustment may have no adverse effect on practice; conversely, risk can be serious without a diagnosis.
Immediate response should be proportionate to danger. If a colleague appears intoxicated before a procedure, prevent them practising, summon a senior and ensure the patient has an alternative clinician. If the concern is lower-level or developmental, speak directly when safe, use supervision and document an improvement plan. Do not investigate criminal or disciplinary allegations yourself, warn a person in a way that destroys evidence, or spread rumours. Preserve factual records and respect confidentiality while sharing enough with people able to act.
The GMC requires doctors to raise and act on concerns about patient safety and dignity. Follow local policy where it can work, but escalate to another appropriate body if the person responsible does not act, is part of the problem or risk is immediate. Speaking-up employment protections depend on statutory criteria and jurisdiction; not every personal grievance is a protected disclosure, and professional obligations are not contingent on qualifying for employment protection. For self-concern, obtain an independent treating clinician, occupational-health assessment and adjustments; restrict or stop practice when needed and notify employers or regulators when required. The aim is safe supported practice, not punishment for illness.
Key points
- Patient safety comes first: stop or modify unsafe activity, obtain urgent senior help and arrange continuity before debating blame or employment consequences.
- Raise an honestly held concern through an appropriate channel, stating observable facts, risk and prior action. You do not need proof of misconduct before protecting patients.
- A health condition or disability alone is not impaired fitness to practise. The relevant issue is its effect on safe performance, insight, support, adjustments and compliance with restrictions.
- If your own judgement or performance may be affected, seek independent medical and occupational-health advice, follow treatment and do not rely on self-assessment or informal corridor care.
- Escalate if the response is inadequate. Use a clinical lead, freedom-to-speak-up or equivalent guardian, regulator or external body according to urgency and jurisdiction.
- Employment whistleblowing law and GMC professional duties are related but distinct. The Public Interest Disclosure Act 1998 amends employment protections in Great Britain; Northern Ireland uses its own 1998 Order.
02Situations and prioritiesThe context, relevant information and actions that matter most.
Apparent intoxication, severe confusion, collapse, dangerous fatigue or acute mental distress requires removal from safety-critical duty, compassionate medical help and a senior-led continuity plan.
One error may need learning; repeated omitted checks, poor handover, refusal of feedback or concealment can indicate a wider competence or conduct concern. Use objective examples and assess system contribution.
Declining function, self-prescribing, missed occupational review or denial despite observed risk increases concern. Diagnosis is not the key threshold; current effect and engagement with safeguards are.
Pressure to falsify data, discourage incident reports or keep unsafe staffing invisible is itself a safety concern. Use an independent speaking-up route and preserve evidence.
Performance processes can be misused after a worker raises safety issues or because of protected characteristics. Maintain fair evidence, separate patient protection from punitive assumptions and seek appropriate advice.
03Assessment and interpretationHow to gather information, assess the situation and recognise uncertainty.
Consider the information, its meaning and its limitations before deciding what follows.
- 01
Immediate patient-risk assessment - Why
- Decide whether practice must stop or be modified now.
- Interpretation and limitations
- Consider role, task, acuity, supervision and available alternatives. Use the least restrictive measure that reliably protects patients, but do not negotiate with imminent danger.
- 02
Objective behaviour and performance record - Why
- Ground the concern in facts rather than diagnosis or reputation.
- Interpretation and limitations
- Record dates, tasks, observations, outcomes and actions. Distinguish firsthand knowledge from reports and preserve confidentiality and evidence.
- 03
Health, insight and safeguards review - Why
- Assess whether illness affects safe practice and whether risk is managed.
- Interpretation and limitations
- Use independent clinical and occupational assessment, not colleague gossip. Effective treatment, insight, supervision and restriction may permit safe work.
- 04
System-factor assessment - Why
- Identify workload, staffing, induction, equipment or culture that may cause or amplify risk.
- Interpretation and limitations
- Address system hazards while holding individuals to appropriate standards. A systems explanation does not excuse deliberate concealment or unsafe refusal of support.
- 05
Escalation and jurisdiction map - Why
- Choose a recipient able to protect patients and understand available legal routes.
- Interpretation and limitations
- Start locally when appropriate; bypass or escalate when urgency, conflict or inaction requires. Distinguish GMC duties from GB and NI employment-protection statutes.
04Worked approachesCases with ordered reasoning, an action and a check of the outcome.
01Worked caseColleague appears intoxicated before a procedureA trainee smells alcohol on a senior surgeon who is unsteady and intends to begin an emergency operation.+
- 1Prevent the surgeon entering safety-critical practice by summoning the theatre lead or another senior immediately. Arrange an alternative operator and continue urgent patient care; do not manage the confrontation alone if unsafe.
- 2Describe observable facts rather than labelling addiction. Encourage and facilitate urgent medical help, but do not let confidentiality or hierarchy override the immediate patient risk.
- 3Report through the clinical leadership and speaking-up route, preserve a contemporaneous record and cooperate with the appropriate occupational or employment process. Do not undertake personal testing or a covert investigation.
- 4Final action: ensure the clinician remains away from unsafe duty until appropriately assessed and authorised, with patients covered and the colleague offered support. Escalate externally if local leaders fail to protect patients.
- 5Verification: confirm the operation has safe staffing, the responsible leader accepted the concern and follow-up assessment occurred; record and re-escalate any attempted return before clearance.
02Practical approachDoctor recognises declining concentrationA doctor with worsening insomnia has made two near-miss prescribing errors and feels unable to judge whether work remains safe.+
- 1Stop high-risk unsupervised tasks and tell an appropriate senior so current patients are covered.
- 2Consult an independent GP or specialist and occupational health; do not self-diagnose, self-prescribe or rely only on family advice.
- 3Follow recommended treatment, adjustment, supervision or absence and make required declarations honestly.
- 4Agree criteria and review dates for safe return or progression, documenting work restrictions separately from unnecessary clinical detail.
03Escalation approachManagement ignores falsified safety dataA clinician reports that waiting-time records are being altered to conceal clinical delays, but the manager implicated dismisses the concern.+
- 1Preserve lawful factual evidence and assess whether any patient needs immediate review.
- 2Escalate outside the implicated line using the board, speaking-up guardian or designated executive route.
- 3Seek independent professional or legal advice about an external disclosure and jurisdiction-specific employment protections.
- 4Share proportionately with a body able to act, document the pathway and continue escalation if patients remain exposed.
05Feedback, follow-up and evidenceReview outcomes, seek feedback and identify what to improve.
- Confirm that immediate patient cover, restrictions and clinical review occurred; an acknowledgement email is not evidence that risk is controlled.
- Use named supervision goals, outcome evidence and scheduled review for performance concerns, while monitoring for system contributors and unfair treatment.
- For a health-related plan, review function, insight, adherence and agreed safeguards rather than demanding broad disclosure of diagnosis to colleagues who do not need it.
- Track retaliation, suppression or recurrence after speaking up and escalate with factual documentation if the organisation’s response remains inadequate.
- For WPBA, show proportionate escalation and reflection on hierarchy or bias, but do not include identifiable colleague health or disciplinary material.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Illness is not misconduct
Health concerns should trigger support and risk management. Dishonesty, refusal of necessary restriction or unsafe conduct may create separate issues, but diagnosis alone should not be stigmatised.
Facts travel better than labels
“Smelled of alcohol, speech slurred and twice lost balance” gives a decision-maker usable evidence; “is an alcoholic” is an unsupported diagnosis.
Local first is conditional
Normal escalation can preserve context and speed, but it is inappropriate when the responsible person is implicated, evidence may be destroyed or immediate danger demands another route.
Protection law is not the professional threshold
Whether an employment disclosure meets statutory conditions is a legal question. A doctor may still have a GMC duty to raise a patient-safety concern.
Self-care includes limiting practice
Seeking help is necessary but not sufficient if current work is unsafe. The doctor must act on advice and ensure patients are protected during assessment and recovery.
07Common pitfallsFrequent interpretation and management errors.
- 01
Allowing hierarchy or loyalty to delay removal of an apparently impaired clinician from immediate patient-facing risk.
- 02
Equating any mental or physical diagnosis with impaired fitness, rather than assessing function, insight and safeguards.
- 03
Trying to prove misconduct personally, spreading allegations or obtaining covert tests instead of using an authorised process.
- 04
Assuming every workplace grievance is protected whistleblowing or that lack of employment protection removes the GMC duty.
- 05
Raising a concern once and taking no further action when patients remain exposed and the response is inadequate.