The General Medical Council (GMC) are responsible for the registering and licensing of Doctors practicing in the UK. When concerns are raised about a Doctors performance, the GMC may investigate whether that Doctor is considered ‘fit to practice’ in their current role. Sometimes this is called into consideration after a single incident, as in the case of Dr Bawa Garba. The fairness of this has been widely questioned by the profession.

Charlie Massey and colleagues from the Fitness to Practice Directorate were invited to the University of Oxford’s Patient Safety Research Group in March this year to discuss how Human Factors might change the approach to investigating individual fitness to practice concerns.

This led to a series of meetings and workshops to study the process of investigation, and to identify where there are opportunities for systems issues to be taken into account. This work is producing changes to the investigation processes, and will be paired with training and coaching for Fitness to Practice staff on interpreting systems issues (e.g. the role of technology and task design) in an investigation. We are also working with the Employer Liaison Service, a GMC division who hold discussions with the Responsible Officer (often the Medical Director) in individual Trusts, to ascertain how human factors should be used in evaluating performance concerns about individual doctors.
The work is being led by Dr Lauren Morgan (Chartered Human Factors Lecturer), Prof Peter McCulloch (Professor of Surgery) and Dr Dawn Benson (Sociologist in healthcare investigations) from the Patient Safety Academy at the University of Oxford.

Charlie Massey (Chief Exec and Registrar GMC) said of the collaboration:
“This collaboration will make sure that Human Factors are hardwired into our investigations so that the role systems and workplaces play in events is fully and evenly evaluated in assessing context following serious failings.” (

This commitment to incorporate Human Factors in investigations by a key player in UK healthcare signifies a huge step forward in recognising the importance of Clinical Human Factors.  We hope it will improve patient safety by diminishing the climate of fear amongst staff, which has been recognized as a major barrier to an open learning culture in the NHS

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