GMC / MPTS Interim Orders (IOT) Hearings Representation

GMC IOT Hearings

The GMC / MPTS will convene an Interim Orders Tribunal (IOT) hearing where there is a concern that a doctor’s fitness to practise may be impaired by reason of ill-health, deficient performance (usually clinical performance), or misconduct.

Usually, the IOT hearing will take place prior to the any referral to a fitness to practise (FTP) Medical Practitioners Tribunal (MPT) hearing. The investigation stage of the GMC inquiry into a doctor’s fitness to practise can take many months, if not years, to complete. In that time a doctor would be able to practise without supervision, even if they were incompetent or a risk to others, unless restricted.

By Rule 6 of the General Medical Council (Fitness to Practise) Rules Order 2oo4, the GMC can refer concerns to the IOT at any time.

The IOT hearing is convened to look at the potential for a doctor’s fitness to practise being impaired, in light of the evidence and allegations that is available at the time, so as to determine whether a doctor is safe to practise without restrictions, or at all, while the investigation into their fitness to practise continues, and more evidence is gathered.

The interim orders tribunal may impose either: No Order, a Suspension Order, or a Conditions of Practice Order, for up to 18 months. The legislation setting out the tribunal’s powers are set out in the s.41 Medical Act (1983), as amended.

An Interim Order is reviewed after six months, and then at regular intervals. Where a doctor has obtained new information/evidence that may lead to a relaxation or the lifting of an Interim Order, the doctor may apply for an Early Review to request revocation or variation (no earlier three months after the IOT’s last decision).

The IOT tribunal does not make any factual findings. Instead, it assesses the weight of the evidence in favour of the doctor and against the doctor. The panel determines whether there is sufficient evidence to demonstrate that a doctor’s fitness to practise may be impaired.

The IOT panel may take expert evidence into account, whether it is obtained by the GMC or the doctor, when looking at the seriousness and strength of the allegations. The code of conduct for doctors, Good Medical Practice, will be of relevance in assessing whether a doctor has fallen below the standards expected of them.

The IOT looks at the risk of the doctor continuing to practise without restrictions. The tribunal should impose the minimum restrictions possible to meet the requirements of the case to take action, as they see it, if justified. In some cases that might mean suspension.

If the panel is of the view that it is in the public interest, in the doctor’s interest, or otherwise necessary to protect the public (or uphold public confidence in the profession or the GMC), to impose an Order, the panel will go on to determine the type of interim order that will balance the doctor’s interests and the overall public policy interests in the given circumstances of the case. In essence, the IOT panel is undertaking a risk assessment. Is the doctor going to be safe? Is there a risk of repetition? Would it undermine public confidence to allow the doctor to continue in unrestricted practice? Would the safety of the public or colleagues be at risk? Can carefully constructed conditions meet those risks?

Whether or not the IOT hearing panel imposes an interim Order, the GMC will continue to investigate the allegations against the doctor. This is an important point to note. An IOT hearing does not bring the GMC investigation to an end. See our guidance on GMC Investigations. and the way the GMC obtains and scrutinises evidence during an investigation.

The Interim Orders Tribunal procedure operates as set out in the following diagram:-

 GMC IOT Panel Procedural Flowchart

The above diagram can also be downloaded in PDF format: GMC IOT Procedural Flowchart

Where significant dishonesty or a serious sexual assault is alleged, by way of example, a suspension is likely to be imposed by the IOT panel. However each case turns on its own facts and doctors may well have Conditions (restrictions) imposed, or, no Order at all imposed, where they attend and make submissions and present evidence of their suitability to continue to practise medicine, while the GMC investigation continues.

Doctors Defence Service lawyers regularly present defence arguments on behalf of doctors who are invited to attend an IOT hearings. Our lawyers advise doctors on the evidence they will need so as to present a strong case that they are fit to practise. In many cases, where a strong defence is presented the GMC IOT panel imposes no order or only conditions-‘lite’ (as we colloquially call them), which most doctors could easily work to. More stringent conditions will be imposed in some cases, which may also restrict the doctor to working for the NHS only, until the conclusion of the GMC FTP process.

The GMC has published a IOT Conditions Bank document, which provides examples of Conditions that an IOT panel may impose. The Conditions Bank should be read in conjunction with the GMC’s publication Glossary of Terms, which defines the words used in Conditions of Practice Orders.

A doctor should identify the conditions that would likely be workable in practice. A doctor should consider talking with their employer to ensure that they can work to specific conditions. A letter to confirm that the employer is willing to work with the doctor pursuant to conditions being imposed, to enable them to continue to work, can sometimes be of assistance.

Conditions can be stringent and could make some doctors unemployable. It is therefore important to highlight to the tribunal the conditions that are deemed workable and unworkable.

Extensions to the length of an Interim Order

The GMC may apply to the High Court for a extension to an interim order, of up to 12 months. With power to make further applications thereafter. For more information see our Extension on Interim Orders page.

Preparing for an IOT hearing

The tribunal will be assisted by seeing at least three things:

One, general history of competence and reliability, including a CV and testimonials.

Two, a reply to the allegations (if appropriate). The latter must be done with great care, as the investigation is likely to be an an early stage and a doctor should not commit in absolute terms to a position without being satisfied that their recollection is correct. A doctor’s reply should be supported by evidence, where available. Where the police are investigating the doctor, it may be wiser to say little.

Three, evidence of taking steps to remediate any sub-optimal practice or alleged misconduct. Evidence of insight that demonstrates the risk of repetition is low.


If the GMC has yet to obtain or provide relevant documents, they should be requested at the earliest opportunity. Regrettably, IOT hearings are called on a short notice, and not all of the relevant documents will be available. A doctor will still be required to show that the risks of their continuing practice will not undermine public safety or public confidence in the profession.

Where a doctor has fallen into error, they may need to acknowledge this (if it is right to do so) and show that they have embarked on a suitable programme of remediation.

Some allegations might be considered to be very serious and will depend on or turn on the credibility of witness evidence. No live evidence is presented, usually, at IOT hearings. Instead, a doctor can comment on the weight that might be attached to the allegations and the defence case as it stands at the time of the IOT hearing.

Case Law

Case law holds that a conditions of practice order should not be made in terms that will in effect be a suspension in anything but name. The courts also accept, however, that a doctor will naturally find it more difficult to obtain work where conditions of practice are imposed. That in itself is not a sufficient reason for the GMC not to make an order of conditions, where it is in the public interest, necessary to protect patients (or the doctor) or otherwise uphold the public’s confidence in the profession. See our IOT Case Law page for more information. See, also, our IOT case law digests below.

If a doctor works or acts in breach of a Conditions of Practice Order, the GMC may take more draconian action, which could lead to suspension and/or erasure. A doctor must therefore ensure that they comply with the terms of any Conditions of Practice Order imposed upon them by the GMC.


In 2010 the IOT panels imposed 144 suspensions, 214 condition of practice orders, and made no order in a further 111 cases (totalling 469 cases). (Source: GMC Statistics 2010)

In 2011 the IOT panels imposed 158 suspensions, 236 conditions of practice orders, and made no order in a further 95 cases (totalling 489 cases). (Source: GMC Statistics 2011) Interim Orders Tribunal hearings were up by 4% in 2011, on 2010 figures.

In 2012 the IOT panels imposed 542 suspensions and conditions of practice orders  (the precise figures for each are not broken down in the 2012 annual report), and made no order in a further 242 cases (totalling 784 cases). (Source: GMC Statistics 2012) Interim Orders Tribunal hearings were up by 60% in 2012, on 2011 figures. This appears to be due to a policy shift on the part of the GMC to ask the independent MPTS panels to make the decision about borderline cases that they have hitherto not referred.

For 2014 to 2020, see below:

Year 2014 2015 2016 2017 2018 2019 2020 2021
Suspension 102 49 58 43 48 52 40
Conditions  359 359 233 238 247 225 234
No Order Made 114 114 48 71 93 81 78
Total 571 522 339 352 388 358 352

IOT Review Hearings:

Interim order reviews take place six monthly or three months after an extension granted by the High Court, or where an early review has been convened. A doctor must evidence that they have complied with any conditions that have been imposed. They should carefully read the requirements of the conditions and provide the relevant evidence. This might be a supervisors report, a letter from a GP in health-related matters, or evidence of remediation.

Some IOT reviews are now held on paper (as of April 2016), where a continuation of the current interim order is not opposed by either the doctor or the GP. Where a review is held on paper, the doctor should still provide evidence of compliance with the current order and provide any other evidence that might be relevant. Where the Chair of an on-paper review is of the opinion that a IOT hearing should be convened (to consider matters in greater detail, because a variation or new order may be necessary based on the evidence available), they will direct that a hearing should take place. The doctor will be invited to attend.

A doctor should think carefully before deciding not to attend a review hearing in person, as there will be a risk of an adverse outcome if the doctor does not attend and does not send counsel. If, on balance, a doctor decides not to attend they should still write to the tribunal explaining why they are not attending and, if appropriate, put in a reply to the concerns and submissions. They could still send Counsel to represent their interests, and this is usually helpful to improve the understanding of the tribunal, when looking at proportional responses to the alleged concerns.

It should be borne in mind that it is the interim orders tribunal that will decide on the type of order to be imposed and so, even where the GMC and defence are in agreement about the current order continuing, there will be a risk that the tribunal will make changes to the order. In at least one case that we are aware of, a doctor who did not attend their IOT review hearing (even where there was not a significant material change) the tribunal imposed a suspension order in place of the conditions of practise order previously imposed. We recommend that a doctor always attends any IOT hearing that is convened.

Where there has been an adverse outcome (ie. an order has been imposed that the doctor does not like or the doctor considers will make them jobless) the doctor must wait until the next review or within a reasonable time bring an appeal to challenge the interim order.

Not being able to work (as a consequence of the impact of an order on the doctor’s practice) can be costly and reputationally damaging, but an appeal can be very costly too and will not necessarily be successful. There will be occasions where a doctor is unable to work because potential employers are unwilling to employ a doctor under such restrictions, on economic or other grounds. This is unfortunate but not in itself something that will be persuasive in most cases to alter an interim order on appeal or at an IOT review.

A doctor should put forward evidence, however, of jobs they have applied for where they have been unsuccessful at obtaining work, as this may influence the review tribunal’s thinking on the next occasion.

IOT Review on the Papers

Some cases are now reviewed on the papers (without the parties needing to attend), which can be time-saving and cost effective. By agreement between the GMC and the doctor, the current order of suspension or conditions will be extended for a further six months. Doctors will often have to provide evidence (as stipulated in the conditions) for this to take place.

Appeals from Interim Orders:

A doctor must lodge an appeal ‘within a reasonable time’ from the date the order is made. This is not defined. An appeal is brought by way of Part 8 of the Civil Procedure Rules (CPR). A GMC review hearing may actually be preferable because the appeal court has limited disposal powers, and will not interfere with an IOT decision where the assessment of risk has been properly balanced. New evidence would ordinarily have to be submitted to the interim orders tribunal at an early review, rather than on appeal.

On occasions, it can be useful to obtain the opinion of the appeal court on the continuation of an order. Where there has been significant delay some high court judges have relaxed the order imposed by the MPTS IOT.

Where a doctor finds that the conditions imposed are unworkable, it is often better to apply for an early review at the MPTS, rather than appeal to the High Court, but each case turns on its own facts. We can advise on the best approach, based on the merits and prospects of success in the case. A review can be requested after three months has passed since the last order (or extension) was imposed. Where new evidence comes to light that would impact on the order granted no time-period is stated in the Act. If, by way of example, new evidence came to light that showed that a doctor was in no way at fault, a review might be justified.

Case Law on Interim Orders

In Hussain v GMC [2012] EWHC 2991 (Admin) an interim order (imposed on public protection grounds) could not continue once the GMC determined to no longer pursue allegations that touched sufficiently on public protection matters. In doing so, the court reviewed the cases of Hiew v GMC [2007] EWCA Civ 369  and Sandler v GMC [2010] EWHC 1029 (Admin) relating to the test for granting conditional registration. The court was of the view that a fresh merits assessment could be undertaken by the appeal judge.

In CRHP v GDC and Fleischmann [2005] EWHC 87 Admin – the court held that a clinician should not usually be permitted to practise medicine while still serving a sentence (February 2005). This principle might therefore have an impact on whether an order of suspension ought to be imposed. So, by way of example, where a notional doctor is given a suspended sentence, and is placed on the sex offenders register for a period of five years, policy would require that some form of regulatory order be in place for the duration of the sentence. An interim order will be put in place, in circumstances, pending a fitness to practise hearing (that would look at the disposal of the case), as to do otherwise would offend against the principle in Fleischmann.

In Dr Kalaf v Interim Orders Panel of the General Medical Council [2016] EWHC 982 (Admin) – the court dismissed a doctor’s appeal against an interim order of conditions and a subsequent interim order of suspension. At [para 51] the appeal judge averred:

“I have listened attentively to the claimant as he has explained his case to me. I agree with the IOT in its reasoning and its conclusion. The claimant does not seem to understand that risk to patients is and must be a key concern for the IOT, and indeed for me. Of course that risk has to be balanced against his own personal interests, in order to arrive at a proportionate outcome, but the claimant appears to give little credence to the existence of that risk. I am satisfied that there are very serious concerns about the claimant’s performance. There may be impairment of his fitness to practise, and if impairment is established that impairment may be of a nature and extent which poses a real risk to members of the public and may adversely affect the public interest.” per Whipple J

The doctor was also ordered to pay the GMC’s costs in the sum of £6000, despite submitting that he was impecunious. (February 2016)

GMC v Dr Anyuam-Osigwe [2012] EWHC 3884 (Admin) – sets out the scope of the appeal provisions (referred to in Kalaf. The quoted part is as follows (para 34):

“[…] the powers of the court that the court exercises are properly to be regarded as ‘original’ powers. However, since the application is to terminate an extant order made by a professional disciplinary body charged by statute to discharge its function in support of the General Medical Council’s role to protect, promote and maintain the health and safety of the public, then the discretionary power to terminate an interim order should only be exercised where the court considers that the Panel was wrong to make and maintain such orders. In exercising its powers the court necessarily undertakes a review, even if it is not purporting to judicially review the decision making process and similarly, in reaching a conclusion that the Panel was wrong in reaching its own determination, the court is exercising similar and familiar powers to those exercisable when hearing an appeal.”

In short, the review powers of the court are more than mere JR review powers, akin to the statutory appeals from sanctions imposed at substantive FTP hearings. Where an appeal is successful, the appeal court can quash the current order if it is a suspension. The case may need to be remitted to a tribunal in order for conditions to be put in place in such an instance. Where a doctor had conditions in place, the appeal court may vary them.

In NH v General Medical Council [2016] EWHC 2348 (Admin) the appeal court upheld an interim order of suspension, imposed on a doctor who faced a criminal charge. The appeal judge stated that:

[at para 12]…

“The question can be stated simply – would an average member of the public be shocked or troubled to learn, if there is a conviction in this case, that the doctor had continued to practice whilst on bail awaiting trial? In my view the answer would be in the affirmative and it is therefore necessary that he remains suspended in the interim.” 

And at [Para 13]…

“The  allegations in this case involve serious criminal offences. As an adult and a trainee doctor the Claimant is said to have lent himself to a joint enterprise in which his younger sister, a minor, was held captive for a substantial period of time and was assaulted by others in the family group. All it is said because she had behaved in a way which the family found to be inappropriate and likely to cause them dishonour. In addition, this claimant is said to have obtained for her and given to her the morning after pill which he ordered that she should take. In my view these allegations are of such a nature and are sufficiently serious to warrant interim suspension better to maintain public confidence in the medical profession.“per McGowan J (September 2016).

The appeal judge also expressed the view that an IOT review hearing would have been the better forum to bring a challenge to the suspension order. The doctor was ordered to pay the GMC’s costs as his appeal was dismissed.

In Otto Ijsselmuiden v General Medical Council [2018] EWHC 1199 (Admin), the appeal court refused to interfere with an interim order of suspension that had been imposed on a doctor by an interim orders tribunal, in circumstances where the doctor had declined to undergo a health assessment. The court also determined that any ‘new evidence’ must be considered at an IOT Review hearing rather than on appeal. (April 2018)

In Dr Belinda Agoe and Dr Kausar Ali v General Medical Council [2020] EWHC 39 (Admin); [2020] 1 WLUK 77an interim suspension of 12 months was upheld by the High Court. The two doctors were said to have carried on providing care despite a suspension of their practice by the Care Quality Commission. The case had also been examined by the First Tier Tribunal (FTT) of the Care Standards Tribunal (CST). Of particular note was the judge’s comments on refusing the doctors’ applications to adjourn the IOT hearing. He determined:

The refusal to adjourn was a case management decision by the IOT which fell well within the generous discretion it enjoys in such matters. It was entitled not to adjourn the hearing for the reasons that it gave, namely, that the Applicants had had sufficient time to arrange for representation, balancing the relevant interests, the balance came down in hearing the matter as soon as possible. Both Applicants would have been fully familiar with the subject matter, given the earlier FTT proceedings.

(January 2020)

In Jooste v General Medical Council [2010] EWHC 2558 (Admin) the appellant doctor asked that the interim order be quashed. the court held that the interim order was appropriate and declined to quash it (October 2010)

In Patel v GMC [2012] EWHC 3688 the High Court held (at para 30) that:

“In all the circumstances, it is my judgment that no reasonable and properly informed member of the public, in Brent or elsewhere, would be offended or surprised to learn, even following a hypothetical conviction at some point next year, that the Applicant has been permitted to go on serving his patients in the interim. There is no evidence of any threat at all to their welfare. I do not believe that such a decision would undermine confidence in the medical profession. I consider that most citizens well understand the notion that a person is to be treated as innocent until proved guilty – and its practical implications. Nor can it be said, for any other reason, that the public interest requires his registration to be suspended. In my opinion, the balancing exercise comes down clearly against that. That is why I informed the parties at the conclusion of their submissions that I would terminate the suspension.” (December 2012)

This case is often cited to justify in other IOTs the need for an interim order. The above case also cited: Houshian v General Medical Council [2012] EWHC 3458 (QB) in which a High Court judge overturned an interim order in a case that included an allegation of dishonesty. This case surveys the case law at the time and is a useful reference point. In particular, it talks in terms of decisions being proportionate (at para 13):

“The importance of the principle of proportionality in determining whether an interim order should be made pending the resolution of as yet unproven allegations faced by the practitioner, cannot be overstated. A suspension has potentially three very important consequences for a practitioner. First there is the impact upon the person’s right to earn a living: in this case the Applicant’s pre-suspension salary was in the region of £150,000. Secondly, there is the obvious detriment to him in terms of his reputation. Thirdly it deprives the practitioner of showing that during the relevant period he has conducted himself well and competently and ‘so as it were enhanced his prospects in front of the panel undertaking a final hearing‘ (per Davis J, in Sheikh at paragraph 18). I note that in Sandler Nicol J. agreed that ‘the Panel must consider very carefully the proportionality of their measure (weighing the significance of any harm to the public interest in not suspending the doctor against the damage to him by preventing him from practising)‘.”

(December 2012)

In Dr MXM v General Medical Council [2022] EWHC 817 (Admin) the High Court directed that an interim order of suspension was not appropriate. The judge criticised the IOT for its approach to weighting risk, and the length of the order, as well as the inadequacy of the reasons given.  The case concerned alleged sexual conduct that was in a private capacity but with an alleged connection to professional practice (allegedly having sex on clinical premises; allegedly, briefly, treating his sexual partner in the capacity of patient, and dis outraging her from having counselling; allegedly treating the sexual partner’s husband in the capacity of patient while conducting an affair with his wife). As the appeal court did not have the power to impose an order of conditions, it encouraged the GMC to hold a further interim orders tribunal hearing to impose an order of conditions.

The court also ordered that the name of the doctor should be anonymised. The judge stated (at paragraph 5 of the judgement):

“5. At the outset of the hearing I granted the Applicant’s application for an anonymity order and gave reasons for that decision. In summary, the application was made on the grounds that certain matters raised in the complaints made against the Applicant regarding the nature of the sexual practices in which he and ‘ER’ engaged are liable to attract negative and potentially sensationalist publicity, which would be likely to have a detrimental impact on the mental health and welfare of his four children (of whom the younger three are between the ages of 10 and 16). The GMC took a neutral position on the anonymity application; and no member of the press or public made any representations on it.” per Mrs Justice Steyne DBE.

(April 2022)

In Shiekh, R (on the application of) v General Dental Council [2007] EWHC 2972 (Admin) the High Court held that there is a threshold for an interim order of suspension had not been met in conviction case. Then case also touches on the issues of public policy, in particular the the public interest test. The judge observed (paras 15-16):

15. As a matter of strict language, no grammatical interpolation of the word “necessary” falls to be applied to the phrase “or is otherwise in the public interest”. But that is not the end of the matter because it does seem to me that if “the public interest” is to be invoked in this context, under the statute, then that, to my mind, does at least carry some implication of necessity; and certainly it at least carries with it the implication of desirability. I think it is of some note in this context that the statute was amended, as I gather, to introduce a power to impose interim suspension or conditions where it was in the public interest in the aftermath of the Shipman case. It seems to have been the case that the General Dental Council, and indeed the General Medical Council, did not feel the need for such a public interest power before that happened; although Mr Bradly did make the point that it may be that they simply had been prepared to tolerate a not very satisfactory position.

16. At all events, in the context of imposing an interim suspension order, on this particular basis, it does seem to me, adopting the words of Mr Winter, that the bar is set high; and I think that, in the ordinary case at least, necessity is an appropriate yardstick. That is so because of reasons of proportionality. It is a very serious thing indeed for a dentist or a doctor to be suspended. It is serious in many cases just because of the impact on that person’s right to earn a living. It is serious in all cases because of the detriment to him in reputational terms. Accordingly, it is, in my view, likely to be a relatively rare case where a suspension order will be made on an interim basis on the ground that it is in the public interest. I do not use the words “an exceptional case” because such language is easily capable of being twisted and exploited in subsequent cases; but I do think, as I say, it is likely to be a relatively rare case. Ultimately, of course, all these things have to be decided on the facts of each particular case. (November 2007)

Freedom of Speech

Regulators are having to wrestle with when free speech crosses a line and becomes misconduct in a professional capacity, even when the words spoken or written were outside of work. In White v General Medical Council [2021] EWHC 3286 (Admin) the High Court set aside an interim order of conditions, holding that the correct legal test had not been applied. The doctor had allegedly published inappropriate comment via Youtube on Covid-19.  The appeal judge did not determine whether the utterances of the doctor were appropriate or not. The judge restricted the appeal court’s focus to the legal test that should be applied in freedom of speech cases (s.12(3) of the Human Rights Act, and Freedom of Expression, a convention right under the European Convention on Human Rights). Any consideration of prior restraint (i.e. prior to trial of the issues) of a publication should adopt such a legal test. The IOT failed to do so. The judge also observed:

28. … Amongst other matters, any condition proposing to curtail freedom of expression on an interim footing, in order to be proportionate, is likely to need to be specific as to what views or opinions the person subject to the order is precluded from expressing.

(December 2021)

Further information on Anonymity in GMC Cases

See also the case law on: GMC Interim Order Extension Applications in the High Court

See also our page on further IOT case law cases.

And our page on appeals from interim orders.

If you are a doctor who would like to talk with a specialist lawyer about the GMC IOT procedure or you seek legal representation, telephone us on 0800 10 88 739

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