Appendix 3: Government's Response - Annual
Accountability Hearing with the General Medical Council |
On 26 July 2011, the House of Commons Health Committee
(the Committee) published the report: Annual Accountability
Hearing with the General Medical Council (GMC).
The driver for the hearing was a recommendation made
in the Health Select Committee's Fourth Report on Revalidation
of Doctors, published on 8 February 2011, in which the Committee
said that it intended to exercise, on behalf of Parliament, the
power nominally held by the Privy Council to hold the General
Medical Council (GMC) to account.
The Department strongly believes that these hearings
are of great value in strengthening the accountability of the
professional regulatory bodies to Parliament and the wider public.
We welcome this report and have carefully considered
the Committee's recommendations and the issues it raises. The
Government's Command Paper, 'Enabling Excellence: Autonomy
and Accountability for Health and Social Care Staff', published
on 16 February 2011, set out a comprehensive strategy for ensuring
that professional regulation system is robust and proportionate.
The Government's response to each of the recommendations
made in relation to the GMC is shown below. Though many of the
Committee's recommendations were clearly for the GMC to take forward,
we have commented on all recommendations.
Recommendation Para 4
Although, therefore, the Committee recognises
that the GMC achieves a high level of operational competence,
it remains concerned that the leadership function of the GMC within
the medical profession, and within the wider health community,
remains underdeveloped particularly in the areas of fitness to
practise, revalidation, education and training and voluntary erasure.
We hope that the GMC will embrace more ambitious objectives for
professional leadership, some of which are described in this report.
The Government understands the comments of the Committee
on this issue and agrees that the GMC should take a strong lead
in carrying out its statutory duties. In doing so, however, it
needs to continue to see its primary purpose as public protection
and public service, and not as a body that represents the profession.
Recommendation Para 11
The work undertaken by the Society of Cardiothoracic
Surgery of Great Britain and Ireland in setting standards for
that part of the medical profession is commendable. Its transparency
will be welcomed by patients and should be a template (where clinically
relevant) for further refinement of the revalidation process.
The Government agrees that the work undertaken by
the Society of Cardiothoracic Surgery of Great Britain and Ireland
in publishing their outcomes data is commendable. The Society
has been collecting outcome data since 1977 and has continued
to develop sophisticated systems in line with technological advances,
with the patient being integral to the process.
This approach of patient-focussed care with open
publication of results sits comfortably within the aspiration
of the White Paper 'Equity and excellence: liberating the NHS.'
The Government is pleased to note that the GMC will
continue to have discussions with the Society of Cardiothoracic
Surgery of Great Britain and Ireland so that the regulator, employers
and the profession can benefit from their ongoing work.
In addition to this standard-setting for individual
practitioners, the Committee will wish to note that responsible
officers in England have a duty to ensure the robust, efficient
and reliable functioning of systems of clinical governance. The
focus on clinical governance systems should be on quality improvement,
in terms of the quality of care not only delivered by each doctor
but also by the entire team of which the doctor is part.
The Academy of Medical Royal Colleges is working
with the individual medical colleges to produce guidance on the
supporting information relevant for appraisal discussions and
revalidation for each specialty. It supports the White Paper's
vision for the NHS to focus on delivering improved health outcomes
for patients. The NHS Outcomes Framework 2011/12 sets out how
this will b e achieved. The Government's Transparency and Open
Data commitments for Health and Adult Social Care also support
the publication of clinical outcomes data across a range of healthcare
In future, the revalidation decision will be based
on a series of annual appraisals with doctors using supporting
information to demonstrate they are continuing to meet the principles
and values set out in the General Medical Council guidance, Good
The General Medical Council (GMC) has recently published
its expectations of doctors in terms of the six types of supporting
information that the doctor would be expected to provide and discuss
at appraisal. They include CPD, significant events, feedback from
colleagues, patients (where applicable), reviews of complaints
and compliments and quality improvement activity. Quality improvement
activities include evidence of effective participation in clinical
audit or an equivalent quality improvement exercise that measures
the care with which an individual doctor has been directly involved,
reviews of clinical outcomes where robust, attributable and validated
data are available. This could include morbidity and mortality
statistics or complication rates where these are routinely recorded
for local or national reports.
Recommendation Para 12
The GMC clearly has a considerable amount of work
to undertake between now and the implementation of revalidation
in 2012. Although we agree that all disciplines will not have
developed their standards to an advanced level by that date, the
GMC needs to accelerate its work with the medical royal colleges
to further refine the standards for revalidation in specialist
areas and to ensure that the process is meaningful to clinicians
and transparent to the public.
The Department recognises that the GMC has made significant
progress in driving forward revalidation since the last Health
Select Committee report on the 'Revalidation of Doctors'
published 8 February 2011. Revalidation remains the number one
priority in the GMC Business Plan for 2011.
The GMC has confirmed to its Council and the Health
Select Committee that it continues to develop its own internal
processes and governance arrangements so that it can be ready
to accept recommendations and make revalidation decisions from
the end of 2012.
The GMC has also confirmed to the Health Select Committee
that it has accelerated its work with the Academy of Medical Royal
Colleges and individual colleges to define the speciality specific
guidance for each item of supporting information. A number of
the medical colleges have produced draft guidance and consultations
are currently underway.
The GMC has recently published guidance on developing,
administering and implementing patient and colleague questionnaires
for revalidation. The Government welcomes patient and colleague
involvement in the revalidation process. In England, the NHS White
Paper Equity and excellence: liberating the NHS aims to
put patients at the heart of the NHS and to strengthen the collective
voice of patients.
Recommendation Para 14
As the GMC states, some doctors may decide to
retire rather than undergo the process of revalidation; of those
who pursue revalidation, some may require retraining and some
may fail to meet the required standards. The GMC needs to ensure
that it monitors the number of doctors who retire, leave the profession,
have conditions placed on their practice or fail revalidation.
It must develop and share this evidence with employers to ensure
that future workforce planning includes the developing outcome
of the revalidation process.
The Government agrees with the Health Select Committee's
recommendation. We will look to the GMC to develop and share this
evidence to inform future workforce planning.
Recommendation Para 15
Of the Officers who will have to make recommendations
about revalidating doctors, only a minority feel that the process
will help with the early identification of doctors with performance
issues. Early identification of problem doctors is a core task
of the professional regulatory system, and the GMC needs to ensure
that its systems of appraisal and revalidation achieve this task.
The introduction of responsible officers in January
2011 has been an important change in clinical governance and key
to putting in place the building blocks for introducing medical
The Department's view is that dealing with doctors
whose conduct and performance is a cause for concern is primarily
a clinical governance issue and is usually best dealt with at
a local level. For the small proportion of doctors about whom
there may be concerns, the strengthening of local clinical governance
and a more objective annual appraisal provides the means for identifying
problems earlier and either putting in place remediation or, if
not possible, taking steps to remove them from clinical practice.
The clinical governance functions of responsible
officers in England are set out in Part III of the Medical Profession
(Responsible Officers) Regulations 2010. These include monitoring
conduct and performance of doctors, reviewing performance information
and identifying any issues which emerge from that, as well as
ensuring the organisation concerned takes steps to address any
such issues. Where concerns arise in relation to individual practitioners,
the responsible officer has powers to initiate investigations
and ensure that suitable action is taken.
Training for those doctors appointed as responsible
officers is underway and covers the statutory responsibilities
and provisions of the role, obligations on a designated body to
resource the responsible officers' work and how to deal with potential
conflicts of interest or appearance of bias. Training also addresses
monitoring of clinical quality and performance, identifying concerns
and quality assurance processes to support appraisal systems and
organisational governance. The training will be completed for
all responsible officers by the end of the year.
Responsible officer networks are established to ensure
ongoing support is available, local expertise is shared and that
thresholds for intervention and management of conflicts of interest
In addition, the GMC has also appointed Employment
Liaison Advisers who will work with responsible officers and organisations
to provide advice and guidance on specific cases of poor conduct
and performance to ensure that issues are managed at the most
We understand that the GMC is in the process of developing
guidance for responsible officers, which will build on existing
advice for Medical Directors and other health professionals about
the types of concerns that should be referred to the GMC.
Recommendation Para 18
The Committee notes the negative media reports
about the time taken to undertake revalidation and hopes that
the GMC will ensure that lessons are learned from the revalidation
pilots, particularly in how it can support locum doctors. It also
needs to ensure that the underlying processes that doctors are
expected to undertake are not unwieldy and overly time-consuming,
and that they are an effective means of gathering the required
The Revalidation Pathfinder Pilots concluded in March
2011. The independent evaluation report was published in July
2011 and has provided significant data for partners to take forward
to ensure that the final model for revalidation is proportionate,
affordable and streamlined, whilst adding value for both patients
The report noted a number of areas that need further
exploration and testing but the overriding message was that pilot
organisations recognise the importance of appraisal and revalidation
in delivering high standards of care. The report revealed that
96 per cent of pilot organisations expect revalidation to lead
to improved quality of care, 82 per cent expect improvements to
patient safety and 80 per cent expect improvements to patient
Eighty-six per cent of doctors appraised in the pilot
felt that their appraiser performed their appraisal well and 91
per cent felt that their appraisal was objective.
The GMC's consultation findings on revalidation (published
18 Oct 2010) demonstrate that doctors value a common approach
to appraisal and one that is both clear and straightforward. In
response, the GMC published in April 2011, 'Good Medical Practice
Framework for appraisal and revalidation' setting out the broad
areas which should be covered in medical appraisal and on which
recommendations to revalidate doctors will be based. The Framework
is based on Good Medical Practice.
At the same time the GMC also published 'Supporting
information for appraisal and revalidation', which sets out its
expectations of doctors in terms of the six types of supporting
information that the doctor would be expected to provide and discuss
at appraisal. The medical Royal Colleges, Faculties, and many
of the specialty associations are providing guidance on how this
supporting information applies in specialist practice.
The Revalidation Support Team (RST) has produced
clear and effective appraisal guidance in the form of a draft
Medical Appraisal Guide (MAG). It underpins the two GMC guidance
documents described above. In response to requests from the medical
community, the RST has published the MAG on its website and is
seeking feedback. It is available for all organisations to use,
should they wish, but will also be formally tested during this
year. A final version will be published in early 2012, taking
account the evaluation findings and feedback from employers and
the profession. The guide will lie at the centre of appraisal
and revalidation, ensuring a consistent approach for all doctors,
regardless of where they work.
The additional year of testing announced by the Secretary
of State in his letter of June 2010 to the GMC, in response to
the revalidation consultation will widen the scope to test whether
the model is applicable to doctors working across different environments,
specialties and with varied work patterns. It will test the proposed
model with SAS doctors, doctors in training, locums in secondary
care and clinical academics.
It will provide the robust data to determine a model
that is straightforward and proportionate, applicable for all
doctors and not place excessive burdens on doctors or employers.
Recommendation Para 21, 22 and 23
Doctors from the European Economic Area and Switzerland
seeking to practice in the UK cannot routinely be language and
competence tested by the GMC.
The GMC along with the Government is working towards
resolution of this with partner organisations across Europe. The
Committee takes the view that current legal framework is at odds
with good clinical practice, which is clearly unacceptable. The
GMC has plans, within the boundaries of UK law and the EU Directive,
to manage the constraints on language and competence testing by
using the Responsible Officer role to establish that EEA (the
EU plus several other European countries) doctors are fit to practise
in the UK. The Committee accepts this way forward as a short term
Although this short term measure is welcome, the
committee believes that public confidence in the medical profession
requires the issue to be addressed authoritatively. It is clearly
unsatisfactory that the competence to practise of health professionals
should be assured by a work-around, and we look to the government,
GMC and the relevant European bodies to work as a matter of urgency
to produce a long-term solution to this problem.
Employers and those contracting with healthcare workers
can and should verify the language knowledge of any person they
appoint, but we recognise the need for a stronger, more effective,
system of checks on all doctors.
The Department has worked closely with the GMC to
produce a proposal for a strengthened system of local checks on
the suitability of doctors, which will include consideration of
their communication skills.
We have already taken steps to strengthen the current
system and as of 1 January 2011, all designated bodies must nominate
or appoint a responsible officer.
Responsible officers in England have a duty to ensure
that medical practitioners have qualifications and experience
appropriate to the work to be performed and that appropriate references
are obtained and checked.
Our intention now is to work with a wide range of
partners including the European Commission and the Devolved Administrations
to develop a proportionate new system of checks through enhanced
duties on responsible officers to ensure that any person appointed
to a medical post has the necessary skills for the role, before
they take up post.
The European Commission has consulted on the possibility
of a change in the relevant European law in a recent Green Paper,
with firm proposals due before the end of 2011. The Government
sought evidence of the extent of concerns about the issue as part
of the consultation and the UK's response to the consultation
will be published shortly.
Fitness to Practise
Recommendation Para 27
The Committee notes that there is an increase
in referrals of doctors to the GMC, and of nurses to the NMC,
as well as an increase in the number of general NHS complaints.
The Committee welcomes the fact the GMC has commissioned research
into this phenomenon in order to better understand what is driving
this increase, and to ensure that their systems and processes
are adequate for meeting the future needs of the public. We look
forward to reviewing the preliminary findings of this with the
GMC at our next accountability hearing.
The Department supports the GMC's ongoing research
to understand the increase in fitness to practise referrals. The
Department looks forward to learning of the GMC's findings, and
any associated action plan. We are conscious that the causes of
the rise in fitness to practise referrals are not yet fully understood,
are likely to be being influenced by complex and multiple factors,
and so the work which the GMC is doing to understand the causes
is very important.
Recommendation Para 29
The Committee welcomes the ongoing good performance
of the General Medical Council (GMC) in resolving 90% fitness
to practise cases within fifteen months. However, we agree with
the GMC that fifteen months is indeed too long to conclude such
cases and we recommend that the Council for Healthcare Regulatory
Excellence (CHRE) their regulatory body should set the GMC a more
demanding target for future years.
The statutory role of the Council for Healthcare
Regulatory Excellence (CHRE) is to scrutinise and oversee the
work of nine regulatory bodies, including the GMC. In undertaking
this function, CHRE reviews whether the regulatory bodies meet
their statutory functions and provide best practice guidance for
the regulators. CHRE does not have the powers to set targets as
such in relation to the regulators' performance of their statutory
functions. We understand that the target referred to by the GMC
is an internal performance measure.
CHRE are, however, in the process of working with
all the regulatory bodies in the development of a common data
set of key performance indicators, in order to allow the comparative
performance of the regulators across a range of areas to be more
The Department is collaborating with the GMC to produce revised
legislation that will enable more efficient handling of fitness
to practise cases at hearing stage. Following full, public consultation,
the GMC Council reviewed proposals for changes to the GMC's fitness
to practise adjudication function, on 19 July 2011. These proposals
include changes to procedures, including changes to pre-hearing
case management, which should help reduce the time a case takes
to reach a hearing and the time each hearing takes.
Recommendation Para 35
Some of the decisions made by fitness to practise
panels of the GMC defy logic and go against the core task of the
GMC in maintaining the confidence of its stakeholders. Furthermore,
they put the public at risk of poor medical practice.
The Department notes the findings of the Committee
regarding the GMC's decisions in fitness to practise cases.
A number of proposals to strengthen the independence
and quality of the GMC's fitness to practise panels - by setting
up a Medical Practitioners' Tribunal Service (MPTS) - were subject
to full public consultation conducted by the GMC from March-June
2011, and subsequently agreed by the GMC Council. Departmental
officials are working with the GMC to take this work forward through
changes to legislation.
As part of the CHRE function in overseeing the performance
of the regulators, including the GMC, it reviews all final decisions
made by the regulators' fitness to practise committees. CHRE has
the power to refer those decisions to court if they consider them
to be unduly lenient or if the decisions do not protect the public.
Available statistics show that very few cases decided by GMC panels
present such concerns.
Recommendation Para 36
The GMC holds the dual but potentially conflicting
roles of prosecutor and adjudicator in fitness to practise cases.
The GMC proposes to establish an Independent Medical Practitioner
Tribunal Service to create a greater separation between these
functions, and the Committee supports this proposal. We also urge
that performance management of fitness to practise panellists
commence as soon as is practicable.
Departmental officials are working with the GMC to
take forward the proposed move towards the MPTS to separate further
the GMC's investigation and adjudication functions.
A number of proposals concerning the setting up of the MPTS were
subject to full public consultation from March-June 2011, and
subsequently agreed by the GMC Council. Departmental officials
are working with the GMC to take this work forward.
Many proposals under consultation fall squarely within
the GMC's remit to implement through changes to secondary legislation.
It is right that the GMC should make changes in order to improve
Where proposals require a change to primary legislation,
the Department will seek approval from the Privy Council and Parliament
under section 60 of the Health Act 1999, which would be subject
to a separate consultation exercise and Parliamentary debate.
This piece of work is scheduled for completion by the end of 2013.
Matters relating to the performance management of
fitness to practise panellists are for the GMC.
Recommendation Para 40
The GMC currently has no right of appeal over
decisions made by independent fitness to practise panels. The
Committee does not seek to undermine the existing power of appeal
held by the Commission for Healthcare Regulatory Excellence, but
agrees that the GMC needs also to have a right of appeal in cases
where it thinks panellists have been too lenient. We urge the
Government to move quickly to make the necessary legislative amendments.
The Department notes the Committee's recommendation
that the GMC should have a right of appeal.
Following full public consultation by the GMC, and
subsequent agreement by the GMC Council, Departmental officials
are working with both the GMC and CHRE to consider the potential
for the GMC to be given such a right of appeal in legislation.
Recommendation Para 43
Doctors from Mid Staffordshire NHS Foundation
Trust whose practice was in itself blameless but who failed to
act and raise concerns about colleagues are now also under investigation
by the GMC. A clear signal needs to be sent by the GMC to doctors
that they are at as much risk of being investigated by their regulator
for failing to report concerns about a fellow registrant as they
are from poor practice on their own part.
There is a current and long standing professional
duty upon doctors to act upon/report any concerns they have about
a colleague's practice. Paragraphs 43-45 of Good Medical Practice
"Conduct and performance of colleagues" provides details
about how the GMC expects its registrants to behave where they
It would also be open to doctors to refer concerns
about NHS organisations or management through a public interest
disclosure to the Care Quality Commission (CQC) or Monitor.
The NHS Constitution draws attention to the protection
available to staff and the handbook to the constitution specifically
cites the Public Interest Disclosure Act 1998 and staff rights
to "protection from detriment in employment and the
right not to be unfairly dismissed" under the Act.
Recommendation Para 44
The Committee recognises, however that doctors
and other practitioners who have raised concerns by other staff
have sometimes been subject to suspension, dismissal or other
sanctions. The Committee therefore intends to examine this issue
in more detail in due course.
There is a long standing professional duty where
a doctor has good reason to think that patient safety is or may
be seriously compromised by inadequate premises, equipment, or
other resources, policies or systems, to put the matter right
if that is possible.
In all other cases, they should draw the matter to
the attention of their employing or contracting body. If that
body does not take adequate action, the doctor raising the concern
should take independent advice on how to take the matter further.
The doctor must record their concerns and the steps they have
taken to try to resolve them. This is set out in Good Medical
Practice at paragraph 6.
The Public Interest Disclosure Act 1998 inserted
provisions into the Employment Rights Act 1996 (sections 43A-L)
which is owned by the Department for Business, Innovation and
Skills. It forms part of the wider employment rights legislation
and gives the legal protection to all staff (employees and workers
as defined in the Act) who make qualifying disclosures in the
public interest, providing they follow the procedures set out
in the Act. It therefore applies to all staff working in the NHS.
Although PIDA does not require organisations to set
up whistleblowing policies and procedures, it does provide an
impetus for doing so. Guidance issued in 2003 made clear that
NHS organisations should put in place local policies and procedures
that comply with the Act and set out minimum requirements for
The Department of Health also provides funding to
the charity Public Concern at Work, which provides an independent
source of advice for NHS workers seeking to raise concerns in
the public interest.
In all cases, professionals must consider the wider
implications of failing to report such concerns and the risks
to patient safety, which is their primary responsibility. In March
2011, the GMC began a process of consultation on additional guidance
to supplement Good Medical Practice, for doctors (as individuals
or managers/employers) about raising concerns about patient safety.
This additional guidance also includes information on how to make
a concern public - i.e. how to whistleblow.
To help all employers (including doctors) to build
a culture where staff feel able to raise concerns about poor practice
or potential risks to patient safety Speak up for a healthy
NHS was commissioned by the Social Partnership Forum. The
guide, written by the independent whistleblowing charity Public Concern at Work,
was launched at the NHS Confederation conference on 25 June 2010.
It sets out simple steps to help employers ensure their whistleblowing
The reasons for suspension (exclusion) or dismissal
of NHS staff are varied. The Department would therefore be interested
in giving evidence to the Committee should they examine in more
detail consequences that some individuals experience when they
have raised concerns.
Recommendation Para 45
In contrast to the approach of the Nursing and
Midwifery Council, the GMC has put its fitness to practise cases
relating to Mid Staffordshire "on hold" until the inquiry
has concluded. The Committee believes that this is neither fair
to the public, or to the registrants under investigation. We urge
the GMC to set out its rationale for this, publicly and clearly.
The Department acknowledges the Committee's view.
This is a matter for the GMC as the independent regulator for
Recommendation Para 49
We suggest that the GMC further considers risk-based
approaches to proactive regulation and how these could be developed
with its employer liaison services.
The Department welcomes the Committee's suggestions
in this regard.
Recommendation Para 53
The Committee appreciates the seriousness with
which the GMC has treated the suggestion that doctors from black
and minority ethnic backgrounds are overrepresented in fitness
to practise cases. The finding that this relates to overseas trained
doctors and not ethnicity per se does not alter the fact that
a problem exists.
The Department supports the Committee's comments
on this, and welcomes the GMC's previous and ongoing work to understand
whether and why black and minority ethnic doctors might be overrepresented
in fitness to practise cases.
Recommendation Para 54
The GMC needs, as matter of urgency, to do more
to understand the risks associated with overseas-qualified doctors.
It should offer timely induction and needs to assure itself that
those doctors in peripatetic locum positions are adequately supervised
and supported. If a doctor is not safe to practise in the UK then
the GMC must ensure that they do not do so.
The GMC does not have the statutory ability to impose
standards of supervision and support upon those engaging overseas
doctors in peripatetic locum positions and it is the Department's
belief that they should not. Similarly, matters relating to induction
arrangements are the responsibility of employing and contracting
organisations addressing the needs of the work the doctor will
be doing within and for their organisation.
The GMC has a robust process for establishing the
suitability for registration of migrants from third countries
relying on third country qualifications. (EEA migrants have been
Under the Health and Social Care Act 2008, providers
of regulated activities (which would include NHS trusts and locum
agencies that also provide regulated activities) must register
with the Care Quality Commission (CQC) in England. As such, they
must ensure that they meet the registration requirements set by
the CQC, which include requirements around staffing skills, experience
and fitness. The responsibility for ensuring that staff employed
to carry out a regulated activity are fit to practise rests with
the provider, and CQC can take enforcement action against the
provider if it does not meet the requirements.
Recommendation Para 61, 62 and 64
Several cases have been brought to the attention
of the Committee of doctors applying to remove themselves from
the register during an ongoing investigation into their practice
by the GMC (so called voluntary erasure). The Committee has no
objection to the principle of voluntary erasure as it can be a
useful tool to protect the public. However, in some cases, interested
parties have been given little or no time to raise an objection
to applications for voluntary erasure, and the GMC was not able
to offer a clear explanation of this.
Applications for voluntary erasure must not be
granted by the GMC unless interested parties have been given adequate
notice of an application and have been offered an opportunity
to voice an opinion on the matter.
The Committee fully supports the publication of
the facts of any case of voluntary erasure where there is a fitness
to practise allegation about the doctor concerned. The GMC needs
to ensure that turning voluntary erasure into an admission of
guilt does not have a perverse impact in reducing the numbers
seeking it and therefore erode public protection.
The purpose of fitness to practise action is to ensure
that the public are appropriately protected from the activities
of poorly performing professionals. Its purpose is not to provide
a means of direct redress for the victim of the actions of a poorly
performing professional. Whilst sanctions such as suspension,
removal from the register or conditions on practice may have a
punitive effect, that is not their primary purpose.
As the Committee has highlighted, voluntary erasure
is a valuable tool for protecting the public. The GMC has a published
a transparent process (underpinned by legislation) for the handling
of voluntary erasure applications. Current GMC guidance on these
matters makes it clear that decision makers on applications for
voluntary erasure should balance the interests of complainants
against the interests of doctors, before deciding whether voluntary
erasure is appropriate in all the circumstances. This guidance
also makes clear that there will be cases where the public interest
dictates that it is appropriate to refuse such applications, and
pursue fitness to practise action against the doctor concerned.
The guidance recognises the importance that, in the
event of a voluntary erasure application being granted, details
of the allegations admitted should be made available to relevant
enquirers (including potential employers and overseas medical
authorities). The guidance makes clear that allegations admitted
would also be considered if the doctor subsequently applies for
restoration to the register.