Heard on: 28th
and 29th September, 19th October, 2nd
November,
7th December 2005 and 25th January
2006
Appeal Panel: Mrs
D Shaw Chairman
Dr D Kwan Professional Member
Ms S Brougham Member
BETWEEN
DR ATURU BHASKARA REDDY
(GMC Registration No: 3043815
and
REDBRIDGE PRIMARY CARE TRUST
Appeal against the decision of
the Respondent to remove the Appellant from its Performers List pursuant to
section 10 of The National Health Service (Performers Lists) Regulations 2004
1. The appeal was held at the Care Standards Tribunal, 18 Pocock Street, London
SE1 on all dates except 19th October 2005, when it was held at the NHS
Litigation Authority, Napier House, 24 High Holborn, London WC1.
2. Prior to the commencement of the hearing all three panel members had signed a
declaration confirming they had not had any prior interest or involvement in the
appeal which would preclude them from considering the evidence in an
independent and impartial manner.
3. The persons who appeared before the Appeal Panel were:
Dr Aturu Reddy - the Appellant
Ms Christina Lambert - Counsel for the Appellant
Mr George Dodd - Medical Protection Society
Ms Catherine Reynolds - Medical Protection Society
Mr David Stewart - Medico Legal Advisor
Dr Maurice Healy - Witness for the Appellant
Dr Chitriki Appa - Witness for the Appellant
Ms Margaret Bowron QC - Counsel for the Respondent
Mr James Reynolds - Capsticks Solicitors
Ms Jessica Hayman - Capsticks Solicitors
Ms Thirza Sawtell - Witness for the Respondent
Dr E Webster - Witness for the Respondent
Dr M Grenville - Witness for the Respondent
Dr H Spiteri - Witness for the Respondent
Ms Carol Hogg - Witness for the Respondent
Ms Jennifer Gosling - Witness for the Respondent
Ms Helen Hughes - Witness for the Respondent
(NB. Reference throughout to parties and
documents is as follows:
Dr
Reddy =
Dr Reddy /Appellant
Redbridge PCT =the
PCT /Respondent
Main bundle =
MB
Appellant’s Supplementary Bundle =
ASB
Respondent’s Supplementary Bundle = RSB
Medical records =
MR
Witness Statements = WS
GMC Performance Assessment
Report = GMC Report
File/Volume =
Vol
Page(s) = p(p))
1.
On 1st October 2003 Dr Reddy was suspended
from the Redbridge PCT’s Performers List pursuant to its powers under section
49(1) of the National Health Service Act 1977 (the NHS Act) (MB Vol 2 pp386-7).
2. On 9th February 2005 the PCT removed Dr Reddy from its Performers List on grounds of efficiency and unsuitability pursuant to Regulation 10 of the National Health Service (Performers List) Regulations 2004 (the Performers List Regulations) (MB Vol 2 pp529-537).
3. On 15th March 2005 Dr Reddy served Notice of Appeal on the PCT
disputing this decision pursuant to Rule 6 of the Family Health Services
Appeal Authority (Procedure)
Rules 2001 (the Procedure Rules) (FCP pp2-3) and annexed a copy of the disputed decision (FCP pp4-10)
and a concise statement of his grounds of appeal (FCP pp. 11-15).
3. The PCT responded to Dr Reddy’s grounds of appeal on 18th April 2005
(FCP pp35-39).
4. The appeal was scheduled to take place on 15th June 2005 but Dr Reddy
asked for it to be adjourned pending the outcome of a GMC Performance Assessment which he was required to undergo following his referral to the GMC after his suspension by the PCT. Although the appeal panel considered this to be a separate process which should not delay the appeal, when it became clear that the appeal would last several days, the listed date was used for a directions hearing and the substantive hearing was listed for the 28th and 29th September, 19th October and 2nd November and subsequently for the 7th December 2005 and 25th January 2006.
5. The GMC Performance Assessors’ Report was issued on 18th October 2005. It
concluded that Dr Reddy’s professional performance had not been deficient and that he was fit to practise medicine without conditions but that action needed to be taken for him to work with a mentor for a period of twelve months to supervise the development of his skills in IT and practice management. It also recommended it would be in Dr Reddy’s interest to approach the PCT and the Local Post-Graduate Tutor to address the issues highlighted in the report (GMC Report p105).
(i) Jurisdiction
The National Health Service (Performers List) Regulations 2004
10(3) The Primary Care Trust may remove the performer from its
performers list where any of the conditions set out in paragraph (4) is
satisfied.
10(4) The conditions mentioned in paragraph (3) are that-
(a) his continued inclusion in its performers list would be prejudicial to
the efficiency of the services which those included in the performers list perform (“an efficiency case”);
(b) he is involved in a fraud case in relation to any health scheme; or
(c) he is unsuitable to be in that performers list (“an unsuitability case”)
15(1) A performer may appeal
(by way of redetermination) to the FHSAA
against a
decision of a Primary Care Trust mentioned in paragraph (2) by giving notice to the FHSAA.
(2) The Primary Care Trust decisions in question are
decisions – (inter alia) … (d) to remove the performer under
regulations 8(2), 10(3) or (6), 12(3)(c) or 15(6)(b);
(3) On appeal the FHSAA may make any decision
which the Primary Care Trust could have made.
(4)
Where the decision of the FHSAA on appeal is that the appellant's inclusion in a performers list is to be
subject to conditions, whether or not those conditions are identical with the
conditions imposed by the Primary Care Trust, the Trust shall ask him
to notify it within 28 days of the decision (or such longer period as the Trust may agree)
whether he wishes to be included in its performers
list subject to those conditions.
(5)
If the performer notifies the Primary Care Trust that he does wish to be included in its performers list subject
to the conditions, it shall so include him.
(6) Where the
FHSAA on appeal decides to impose a contingent removal - (a) the Primary
Care Trust and the performer may each apply to the FHSAA for the conditions imposed on the
performer to be varied, for different conditions to be imposed, or
for the contingent removal to be revoked; and (b) the Primary Care Trust may
remove the performer from its performers list if it determines that he has failed to comply
with any such condition.
(ii)
Preliminary issues
1. Burden and Standard of Proof
1.1 The parties agreed the burden of proof lay with the PCT.
1.2 Counsel for Dr Reddy submitted that the standard of proof should be the criminal standard of beyond reasonable doubt. Whilst she conceded that there was no established authority on this, she submitted this standard was usually accepted by PCTs when livelihood was at stake.
1.3 Counsel for the PCT submitted that whilst the standard of proof was high, it should be the civil standard of the balance of probabilities.
1.4 In her closing submissions she contended
that any issues of fact were to be determined applying the civil standard of
proof, in the manner described by Lord Nicholls in Re H and R [1996]
HL1FLR 80: “When assessing the probabilities the
court will have in mind as a factor, to whatever extent is appropriate in the
particular case, that the more serious the allegation the less likely it is that
the event occurred and, hence, the stronger should be the evidence before the
court concludes that the allegation is established on the balance
of probability.”
1.5 She also referred to the words of Ungoed-Thomas J in Re Dellow’s Will Trusts, Lloyd’s Bank v Institute of Cancer Research [1964]: “the more serious the allegation the more cogent is the evidence required to overcome the unlikelihood of what is alleged and thus to prove it.”
1.6 We were aware there are many other authorities on this issue which are by no means consistent. We noted there is some authority to support the application of the criminal standard in professional disciplinary proceedings before a tribunal. We were aware that if, notwithstanding, we were to accept the civil standard of proof, then the degree of probability would have to be high as livelihood was at stake. At the same time we were also aware we would have to consider patient safety.
1.7 We concluded that the best course to adopt would be to reach our decision bearing all of the above in mind, but that we should not feel constrained to reach our decision by reference to any one standard, particularly, as the PCT had pointed out in its closing submissions, there might be little in practical terms flowing from this point as this appeal turned more upon the interpretation of largely agreed facts than the resolution of disputed facts.
2. Appeal by way of review or redetermination
2.1 It was submitted in Dr Reddy’s skeleton argument that the appeal was by
way of review and no further or alternative grounds for the proposed removal could be permitted.
2.2 Counsel for the PCT submitted that it was common ground that the appeal
was a rehearing and that the appeal panel should have regard to all of the
evidence before it.
2.3 We noted the Performers List Regulations refer to appeal by way of redetermination and that whilst we could only consider removal on the grounds of efficiency or unsuitability, we considered that in reaching our determination, we should have regard to all of the written and oral evidence now before us.
3. The Respondent erred in law in failing to grant the Appellant’s application that
the oral hearing should be postponed pending the assessment by the GMC of
the Appellant’s clinical skills and performance
3.1 It was submitted in Dr Reddy’s concise statement of grounds of appeal that the most invaluable and objective appraisal of his competence would be that
generated by the assessment which was to be undertaken by the GMC in the
near future, and that the PCT had acted unreasonably and unfairly in rejecting
this submission prior to the oral hearing in February 2005.
3.2 In response, the PCT denied it had erred in law and submitted it had obtained
evidence over a number of years from a number of bodies, including the GMC
and the NCAA, which indicated serious concerns in respect of Dr Reddy’s
clinical performance and that he had failed to take any appropriate steps to
remedy the identified deficiencies within a reasonable period of time. The
PCT submitted it was not necessary to have details of the outcome of the
performance assessment in order to reach a decision and the continued
protracted nature of that assessment necessitated both the PCT oral hearing
and the appeal to proceed.
3.3 We accepted the PCT’s submissions. Although we considered that as and when the GMC reported the outcome of the performance assessment, its findings would be relevant and we should attach appropriate weight to them, we considered the GMC assessment was a separate procedure governed by separate regulations and the test it posed, namely whether a practitioner’s performance is so seriously deficient that his registration should be restricted or removed, is different to the test posed by regulation 10(4) of the Performers List Regulations.
4. Further procedural grounds of appeal
4.1 Some further procedural issues relating to the oral hearing held by the PCT
in February 2005 were listed in Dr Reddy’s concise statement of grounds of
appeal. However, as the determination of the appeal would be by way of a
re-hearing at which the function of the appeal panel would be to consider
matters entirely afresh, we considered such re-hearing would “cure” any
defects there may have been in the procedure undertaken at the oral hearing
and it was therefore unnecessary to express a view as to the fairness or
otherwise of that procedure.
(iii)
Evidence
1. Over the course of the hearing, which lasted for six days, we were presented
with a vast amount of written and oral evidence. There were over 2000 pages
of written evidence in the main and supplementary bundles plus extensive files
of medical records, witness statements and over 200 pages of notes of the oral
evidence. For the purposes of our consideration of the evidence and this
decision we agreed the best course to adopt would be to identify and then
summarize the most pertinent evidence for each of the different issues
which had been raised by the PCT in support of its allegations of unsuitability
and efficiency before fully considering those issues.
Grounds for removal (unsuitability and efficiency)
2. In its opening skeleton argument the PCT submitted Dr Reddy had shown
himself to be unsuitable on the following grounds:
·
examples of the failure to ensure 24 hour cover for his
patients
· inadequate care by reason of the lack of proper systems of chronic disease management and instances of poor actual care in Audits 3 and 4
· the lack of any signs of improvement in his personal or professional performance since 2000/2001 and despite the many efforts of the Respondent
· the concerning examples of the Appellant carrying out limited duties whilst suspended
3. The PCT further submitted in its opening skeleton argument that the past history
of Dr Reddy and the events of 2001 to 2003 were prejudicial to the efficiency of
services and that the inherent unsatisfactory nature of the premises, the poor
record keeping and management, the absence of proper systems for chronic
disease management etc all created potential risk to
patients.
4. The PCT requested we should determine that all of the allegations with regard
to practice issues or clinical management go to both issues of efficiency and
suitability and the overlap could not and should not be overlooked. We agreed
the allegations could go to both issues, but that we would first consider the
evidence relating to each of the grounds given by the PCT which it claimed
went to unsuitability before going on to considering whether or not they,
together with all of the other issues before us also went to efficiency.
Unsuitability
5. The
failure to ensure 24 hour cover for his patients
5.1 Thirza Sawtell, Director of Primary Care Services for the PCT, gave
evidence (WS pR15) that in January 2003 Dr Reddy failed to put in place adequate arrangements to cover his planned annual leave, having not made arrangements for the locum to undertake home visits and having failed to notify the out of hours service of his leave or cover arrangements, resulting in Jenny Gosling and Carol Hogg having to make arrangements in his absence.
5.2 Despite Carol Hogg writing to Dr Reddy to express the PCT’s concerns over
this incident, in September 2003 Dr Reddy again took leave without either securing locum arrangements to undertake home visits or informing the out of hours provider of the cover arrangements.
5.3 Helen Hughes, Deputy Director of Primary Care Services for the PCT, gave
evidence (Ws ppR37-38), that Dr Reddy had real difficulty in understanding his responsibilities as a GP to ensure adequate cover was in place when he was absent from the practice. Although Dr Reddy had been insistent on making his own arrangements, which were his responsibility anyway, they did not prove satisfactory.
5.4 Carol Hogg, Primary Care Development Manager for the PCT, and Jenny Gosling, Consultant Practice Manager, also gave evidence confirming Dr Reddy failed to arrange adequate cover on 15th September 2003, resulting in Jenny Gosling having to book a locum from an agency for one day where there was no cover at all.
5.5 Dr Appa, witness for Dr Reddy, gave evidence (WS pp A175-177) that he was the locum for part of the periods in question and that in December 2004.he had been in discussion with Dr Reddy about joining his practice as a partner
5.6 Counsel for the Respondent called Dr Appa as a witness to question whether he had agreed to cover Dr Reddy’s surgeries but not his out of hours work. Dr Appa gave evidence he had agreed to cover everything and disputed Jenny Gosling’s evidence to the contrary. He claimed his failure to undertake the out of hours work was due to a misunderstanding and that Jenny Gosling
was not telling the truth.
5.7 Dr Reddy gave evidence (WS ppA108-111) that it would appear there had been some kind of failure of communication between himself and Dr Appa regarding out of hours cover in January 2003 and again in September 2003 and that he had overlooked informing the out of hours service that he required cover between 7.00am and 9.00am, in addition to the usual cover between 7.00pm and 7.00am. He blamed this oversight on his being distracted by his uncle’s death and having to make arrangements at very short notice to visit India. The locum he had arranged for 15th September 2003 had an emergency commitment of which Dr Reddy submitted he was unaware prior to his departure. He accepted it was very important to ensure proper out of hours arrangements are in place at all times and he was concerned the arrangements had failed on these two occasions but he felt these were isolated incidents when he was distracted by family deaths.
5.8 We considered the evidence relating to this issue. We felt that whilst it was possible for there to have been a misunderstanding about out of hours work on one occasion, we were sceptical this could have occurred a second time and given the unfavourable impression we formed of Dr Appa as a witness and the fact that Dr Reddy had admitted he had been distracted at the time, it was more than likely Dr Reddy had not taken sufficient care with the arrangements.
5.9 However, we considered that Dr Reddy had made some attempts to arrange cover in his absence and we concluded that whilst his arrangements were slapdash they did not render him unsuitable to be included in the Performers List, although we might later consider them in the context of his efficiency.
6. Inadequate care by reason of the lack of proper systems
of chronic disease
management
and instances of poor actual care in Audits 3 and 4
6.1 One of the grounds which the PCT submitted indicated Dr Reddy’s
unsuitability for inclusion on the Performers List was the lack of proper
systems of chronic disease management at the practice. The PCT submitted
evidence that there were no chronic disease registers at the practice when Dr
Reddy joined and he proved unwilling to establish them. Subsequently, it
emerged that there were in existence some very basic disease registers
compiled by Dr Desai (ASB pp172-325) and also, that Dr Reddy had, with his
wife, attempted to commence compiling his own disease registers in July and
August 2003 (ASB pp347-379).
6.2 Thirza Sawtell gave evidence (WS ppR25-26) that
the PCT was aware of and had
documented the difficulties Jenny Gosling had experienced trying to work with Dr
Reddy to establish a chronic disease register
6.3 At the hearing she told us that Dr
Reddy’s filing system for notes – in boxes by ethnicity, sex
and age rather than alphabetically- meant that even his opportunistic management of patients with chronic diseases was
compromised by reason of his often being
unable to locate the notes to file test results, consultants’ letters etc. Although Dr Reddy had not instigated
this system, he did nothing to improve
it, even when Dr Desai had retired and he had the time and financial input from the PCT to commence improvements.
6.4 Helen Hughes explained (WS ppR35-26) that Audit 3 was specifically
focussed on the management of patients with chronic diseases and patients on long-term medication. She submitted that Dr Grenville’s findings were clear and that she had advised the PCT there was no evidence of systematic reviews, no clinics held, no evidence of chronic disease registers and a lack of appropriate medication reviews was also a concern. The PCT had shared an interim findings report with Dr Reddy in April 2003 and discussed it with him at a meeting that month. As Dr Reddy then had additional GP and
management support in place, the PCT encouraged him to use that support and, as a first step, to establish chronic disease registers and undertake
audits. She submitted Jenny Gosling had worked with Dr Reddy on a diabetic audit in February 2003 but encountered problems completing it and that from April to October 2003 she was not aware of any positive steps Dr Reddy took to improve chronic disease management. Again, she was aware that Jenny Gosling had started work on registers but could not engage Dr Reddy’s help to complete them.
6.5 Carol Hogg’s evidence (WS ppR95-96) was that the practice did not have any reliable chronic disease registers in place; different coloured stickers were stuck on the front of medical records to identify hypertensive, diabetic patients etc. She submitted that she and Jenny Gosling had discussed with Dr Reddy the need for reliable disease registers as a priority for the practice.
At the hearing she gave evidence that Dr Reddy had never indicated there
were any disease registers at the practice. He had asked Jenny Gosling to
ask a member of staff to do a drug search on the computer but he had been
unwilling to provide a list of drugs for each disease which they could search
against and they did not have the clinical knowledge to set up accurate
registers without his assistance. She submitted Dr Reddy showed no interest
in setting up the disease registers and expected Jenny and the staff to do all the work
6.6 Jenny Gosling gave evidence (WS pR102) that Dr Reddy’s lack of support made it very hard to produce chronic disease registers or to carry out audits. She was unable to produce them without his assistance partly because data was not held efficiently so it was very difficult to search for data.
6.7 At the hearing she submitted that she had never seen the disease registers
which Dr Reddy had commenced compiling in July and August 2003.She
noted they had been printed out outside surgery hours when no member of
staff would have been there and said she could not understand why Dr
Reddy had done this because she and Lucky (another member of staff)
had made it clear they would compile disease registers if Dr Reddy gave
them the information they had asked him for.
6.8 Dr Spiteri, Clinical Governance Lead for the PCT, gave
evidence (WS pR110)
that follow up was haphazard and happening on an opportunistic basis if and
when the patient turned up for other reasons. There were no consistent
protocols, which he submitted indicated a lack of a consistent approach which
meant patients who did not turn up were not receiving appropriate follow up
care and different patients were receiving different types of management for the
same chronic disease.
6.9 With regard to the disease registers compiled by Dr Desai which Dr Reddy
introduced as late evidence, Dr Spiteri considered these to be very rudimentary
and not very functional. He considered they were simply lists of patients with no
evidence as to if and how they were updated or else lists of patients on particular
drugs rather than proper chronic disease registers which did not make it clear
which disease the drug was treating.
6.10 Dr Michal Grenville, a GP principal and Associate Director of the London
Deanery, who carried out Audits 1, 2 and 3 for the PCT, gave evidence
(WS ppR112-117) in relation to Audit 3 and concluded that whilst it demonstrated
some of Dr Reddy’s prescribing was appropriate, he failed to take
appropriate medication reviews, monitor patients appropriately and to keep
adequate records.
6.11 Dr Elizabeth Webster, a GP principal and a medical advisor to the PCT and a
member of its Performance Panel at the time in question, carried out Audit 4 on behalf of the PCT. The audit related to patients with chronic disease, mainly diabetes and hypertension. Her evidence (WSp pR121-127) was that Dr Reddy’s care for many of the patients included in that audit was not acceptable, with instances where he had failed to follow up, record blood pressure, take blood tests, regularly monitor or review, actively manage the condition or the medication, or to maintain appropriate clinical records.
6.12 At the hearing she submitted that even when patients are under specialist
care the GP still has a shared responsibility to ensure the patient has been seen and appropriate care given even if it is not necessary to duplicate that care. She considered there were both clinical and management issues and that Dr Reddy did not fully understand the role of a GP principal.
6.13 Dr Maurice Healy was an expert witness for Dr Reddy. He compiled a
lengthy report on Dr Reddy’s practice (WS ppA1-87) and his clinical management
of patients the subject Audits 3 and 4. Whilst he acknowledged Dr Reddy’s
experience of running a GP practice was not as complete as it should have been
prior to taking over from Dr Desai and that Dr Reddy’s chronic disease
management was opportunistic, he came to far more favourable conclusions than
Dr Webster regarding the quality of Dr Reddy’s care. He pointed out that Dr
Reddy had not had the benefit of having undertaken a vocational training course
prior to qualifying as a GP. He felt Dr Reddy had now recognised his deficiencies
and drawn up protocols for chronic disease management that appeared to be
perfectly adequate. He had given Dr Reddy advice about note taking and the need
for efficient staff and an up to date computer system.
6.14 However, at the appeal when cross-examined on the care of a sample of three
patients, he withdrew his findings of acceptable care in two cases and qualified
the acceptability of care for the third patient.
6.15 Dr Reddy ‘s evidence (WS ppA114-117) was that chronic disease management was
entirely opportunistic when he joined the practice and things were not going to
change whilst Dr Desai was in control. Once Dr Desai retired, Dr Reddy
submitted he proposed a number of clinics to the PCT but his proposals were
ignored. He also confirmed he had prepared his own protocols for, inter alia,
chronic disease management. He submitted Jenny Gosling did nothing to
improve chronic disease management at the practice and that he would have
expected her, as a practice manager, to set up proper recall systems but that
there was no attempt on her part to do so.
6.16 Dr Reddy also submitted that he did not have access to a practice nurse who
would have been able to assist in the management of chronic diseases and the running of special clinics, that he was isolated by Jenny Gosling and had none of the freedom that one would expect as a self-employed GP principal, the absence of a computer system made it very difficult to introduce effective patient recall management and that his workload following Dr Desai’s suspension made it very difficult to initiate any new systems, particularly in the absence of a permanent team of staff.
6.17 He also submitted that if he was permitted to return to practice he would expect to make very significant improvements to his chronic disease management and he was confident these improvements would be successful in a practice with the appropriate sources in terms of staffing and IT support.
6.18 At the hearing Dr Reddy submitted that he had not been aware of Dr Desai’s
disease registers as Dr Desai would keep a lot of things to himself.
6.19 He contended that having given information to Lucky on medicines to extract from the computer database for eleven types of chronic disease registers which
he wished to compile, nothing happened between March and July 2003. When he asked Lucky what was happening she told him that Jenny Gosling was too busy to assist so he went to another practice to see what to do and he and his wife then compiled the registers. They had prepared them when Jenny Gosling was not there because she hated his wife.
6.20 Dr Reddy had hoped to set up special clinics, for example for asthma and
diabetes, but Thirza Sawtell had told him not to change the way the practice was run and the PCT never approved his proposals.
6.21 We considered the evidence relating to this issue of chronic disease
management and were concerned at the lack of appropriate procedures for monitoring and review. Although we did not consider Dr Reddy had made serious or realistic attempts to improve matters during his time at the practice, we accepted that he was not entirely responsible for the situation, which was both a clinical and managerial issue. Accordingly, we preferred to consider it along with the numerous other management issues which the PCT had raised as going to efficiency rather than unsuitability
6.22 In relation to the instances of poor clinical care indicated in Audits 3 and 4 we
had the evidence of Drs Webster, Grenville and Spiteri on the one hand and the
evidence of Dr Healy on the other. We noted that Dr Healy’s support was
qualified in several instances and that on questioning, he withdrew his
conclusion that care was acceptable in three further cases
6.23 However, we were also aware of the conclusions in Dr Reddy’s recent GMC
Performance Assessment, which indicated that in the right conditions Dr
Reddy’s performance was clinically acceptable although it acknowledged he
lacked knowledge in practice management. The Assessors concluded
(GMC Report pp100-101):
“ Dr Reddy is a polite, courteous and sympathetic
doctor who cared for his
patients and
had a good relationship with them” and that he …communicated well with
his patients and treated them with respect, respected their confidentiality and
dignity, assessed his patients appropriately, carried out appropriate
investigations prior to making a diagnosis and made appropriate referrals.”
6.24 Given these findings, together with our concerns as to how the patients in
Audits 3 and 4 had been chosen and whether they were representative
samples, we concluded that whilst these issues were of serious concern, they
did not render Dr Reddy unsuitable to be included in the Performers
List, although we might later consider them in the context of his efficiency.
7. The lack of any signs of improvement in his personal or
professional
performance since 2000/2001 and despite the many efforts of the Respondent
7.1 Another of the grounds which the PCT submitted indicated Dr Reddy’s
unsuitability for inclusion on the Performers List was the lack of any signs of
improvement in his personal or professional performance since 2000/2001 and
despite the many efforts of the PCT.
7.2 We considered this ground encompassed a multitude of the issues raised and
allegations made by the PCT but that they should more properly be considered in the context of efficiency. That is not to say that we did not consider them to be extremely serious issues and allegations or that we were unaware that the term “unsuitability” provided us with a broad area of discretion and of the possible overlap with efficiency; it was simply that in Dr Reddy’s case, where we were principally considering clinical and organisational failures due to a variety of difficult and unfortunate circumstances, rather than allegations of a criminal or sexual nature, we considered it was more appropriate to consider them in the context of efficiency
8. The concerning examples of the Appellant carrying out
limited duties whilst
suspended
8.1 Thirza Sawtell gave evidence (WS pR22) that whilst suspended, Dr Reddy had
amended repeat prescription forms. The locum GP had refused to act on the
amendments and saw the patients to clinically review their case. He wrote a
statement that the patients had told him they had seen Dr Reddy at his home a
few days earlier but they had no knowledge he had amended their medication.
When the PCT wrote to Dr Reddy for his comments, his MPS representative
replied on his behalf that Dr Reddy had admitted he had added Co-proxamol to
the prescription request form when the patients, who were personal friends of
his, had visited him at home, because they were going abroad and needed
urgent medication. As this was not the medication which had been added to the
forms, Thirza Sawtell wrote to the MPS in January 2004 setting out the
amendments on the prescription forms, one of which showed altered dosage
and added some non- oral items and the other had Ramipril added, which is
used for treating hypertension and should not be prescribed without
undertaking a physical assessment of the patient or having sight of their
medical records. Dr Reddy had also written “For repeat pr. To collect
personally.” She
submitted that if the repeat prescribing practices had been in
place at the time, she believed the repeat prescription would
have been
generated automatically
by the administrative staff.
8.2
The MPS took
over six months to respond and again referred only to
Co-proxamol being added. When Thirza Sawtell
wrote back stating this was
factually incorrect
and enclosed copies of the amended forms she did not
receive a reply.
8.3
The evidence
of Helen Hughes and Jenny Gosling supported this version of events.
8.4 Dr Reddy gave
evidence (WS
p A123-126) that he had not
written on the
prescriptions but on
the tear off repeat prescription request forms. From
memory, he believed he
had only added Co-proxamol and advised the MPS
accordingly, but when
he finally saw the forms he confirmed he had altered the
dosage on one form to
last for the duration of the patient’s holiday and added
non-oral items that
the patient was already using. He had added Ramipril to the
other form as he was
aware the patient had been started on this drug by her
consultant, who the
patient told him she had seen two days previously and he
had advised increasing
the dosage. He submitted he was simply adding an
existing medication.
8.5 Dr Reddy also submitted that he made it clear to the patients
that it would be
entirely up to the locum GP at the practice
whether or not he actually prescribed
the medication.
As far as he was concerned he was simply helping them to prepare a list of
repeat medication for their forthcoming trip, since the husband could not write
owing to his arthritic wrist and the wife was illiterate. He had not realised
his actions were in breach of his suspension.
8.6 When questioned about this incident at the hearing Dr Reddy reiterated that he
had simply wanted to help; he had not written on the prescriptions, only on the
tear off request forms so that the patients could show the locum and he could
decide if they should have the medication.
8.7 We were extremely concerned by this clear breach of the terms of Dr Reddy’s
suspension. Even if, as he claimed, he did not wilfully breach the terms of his suspension, the fact that he did not realise he was doing anything wrong indicated his total lack of insight into this incident. However, we noted Dr Reddy had not written on the prescriptions but on the tear off request forms and given this appeared to be the only clear breach of the terms of his suspension, we considered the incident should be considered in the context of efficiency rather than unsuitability.
Efficiency
9.1 We then turned to consider whether these issues, together with all of the other
issues raised and allegations made by the PCT, demonstrated Dr Reddy’s
continued inclusion in the Performers List would be prejudicial to the efficiency
of services.
9.2 In its opening skeleton the PCT made generalised submissions on the ground of efficiency. We considered these encompassed:
3.3 clinical issues
3.4 organisational/managerial issues
3.5 professional issues
and considered we should look at the totality of the evidence and the whole range
of the PCT’s concerns when we came to consider whether Dr Reddy’s continued
inclusion in the Performers List would be prejudicial to the efficiency of
services.
Clinical issues
10.1 We have already considered the evidence concerning the allegations relating to
inadequate care by reason of the lack of proper systems of chronic disease
management and instances of poor actual care in Audit 3 and 4 in paragraph 6
above.
10.2 The PCT submitted there were further clinical issues surrounding the care and
treatment of patients 1 and 2, the findings of an Independent Review Panel
(IRP) and complicity in breach of Dr Desai’s terms of suspension.
Patients 1 and 2
10.3 Dr Webster considered
the treatment of patients 1 and 2 (WS ppR126-127). She
submitted there was no evidence of any
planned terminal care or follow up by Dr
Reddy for patient 1 and
although he was asked to visit this patient on 13th August
2003 there was no
evidence he saw her at all.
10.4 Dr Webster submitted there was likewise no evidence of any plan
for terminal
care or any proactive
care at all for patient 2 and Dr Reddy only visited twice
between March 2003 and
the beginning of September 2003, on 4th July and 15th
August. The District
Nurse’s records showed she had requested visits on 8th and
13th August
but there was nothing in the medical records explaining the delay in
visiting. Dr Webster
also questioned the logic of the medication Dr Reddy
prescribed when he
visited on 15th August and the paucity and lack of clarity in
the medical notes
concerning the dose of morphine.
10.5 Dr Healy submitted there was no record of a request for a
home visit for patient 1
on 13th
August either in the medical records or the Practice registers (WS pA77).
10.6 With regard to patient 2 he contended Dr
Reddy had decided to delay the visit
on 15th
August because he was satisfied at the
time that it was clinically safe
to do so. He also
submitted that when a GP knows District Nurses are visiting
a terminally ill
patient it is common to rely on the daily entries in their notes as
the record of the
patient’s clinical condition, although he acknowledged
comments should be
made in the GP notes as well (WS pA83)
The findings of the Independent
Review Panel
10.7 The findings of the IRP (MB Vol 3 pp709-19) compounded the PCT’s concerns
around Dr Reddy’s prescribing practice. This arose from a complaint in
October 2002 where Dr Reddy refused to prescribe a dosage previously given
to a child with cystic fibrosis. The child’s father became very frustrated and
upset, the police were called and Dr Reddy removed the whole family from
his list claiming aggression towards him. The IRP preferred the father’s
version of events and found in his favour and recommended that Dr Reddy
undergo mentoring or someone to sit in his surgery .
10.8 Counsel for Dr Reddy submitted that the PCT had been wrong to place
reliance on the IRP’s findings, or it had placed excessive reliance on them.
She submitted they related to a single complaint, upon which no conclusions
could be drawn.
10.9 When questioned about this incident at the hearing Dr Reddy submitted he had
been unable to contact the child’s paediatrician and the dosage on the
computer was unclear. (This conflicted with the evidence Dr Reddy gave to
the IRP that he did not check the practice’s computer). He had thought if he
prescribed 30 capsules they would last three days whilst he checked the
correct dosage but the father had subjected him to verbal abuse and his head
was hammering so he called the police. He did not accept the IRP’s findings;
he was not at the meeting where the IRP report was signed and questioned the
justice of this.
Complicity in breach of Dr
Desai’s terms of suspension
10.10 Another source of concern to the PCT was Dr Reddy’s complicity in the
breach by Dr Desai of his terms of suspension. In March 2003 Dr Desai went
to the surgery whilst suspended and administered a vaccination to a patient, a
child. At a subsequent meeting with Carol Hogg, Dr Reddy confirmed Dr
Desai had left him a note to enter on the records that the vaccine had been
given, which he had done (WS pA78).
10.11 Dr Reddy’s evidence at the hearing was that as Dr Desai had breached the
terms of his suspension it was important that the vaccination was noted in the
child’s records. He had not reported Dr Desai to the PCT because when he had
previously written to Thirza Sawtell on another occasion the PCT did not take
any action.
10.12 The issues of record-keeping, filing and prescribing were allied to the PCT’s
allegations relating to the clinical care of individual patients.
Record-keeping, filing and
prescribing
10.13 Thirza Sawtell gave evidence (WS pR23) relating to the PCT’s concerns
regarding Dr Reddy’s scanty and illegible record-keeping, inappropriate
entries and/or alteration of notes by Dr Reddy and the lack of a system for
review of medication and repeat prescribing.
10.14 Helen Hughes gave evidence (WS pR37) the four clinical audits contained many
examples of deficiencies in Dr Reddy’s note-taking. Moreover, while the
practice had been managed under temporary arrangements, locum GPs, GPs
employed through Chilvers McCrea and the PCT’s directly employed GPs had
raised concerns with the PCT regarding historic record keeping and filing.
Subsequently the PCT has had to undertake a large amount of work to sort and
summarise the records so that GPs working at the practice could do so safely.
10.15 When the PCT went into the practice after Dr Desai’s suspension it found the
patients’ records were not filed in alphabetical order or in a systematic way but by ethnicity and age and were kept in separate boxes under the reception desk. Dr Reddy and the staff told the PCT that they often could not find records in the old system. With Dr Reddy’s agreement the PCT helped to re-organise the system into alphabetical order, which required the PCT to send a small team of staff to the practice for approximately three weeks.
10.16 Jenny Gosling gave evidence (WS pR106) that locum GPs had identified various problems with Dr Reddy’s notes; they had reported they were extremely untidy, it was difficult to locate the last entry and establish any chronology of
treatment and on occasion the medication prescribed had not been recorded.
She submitted it was difficult for receptionists to keep the notes in
chronological order as everything was stapled together. She had suggested that
treasury tags could be used but the lack of petty cash meant that these could
not be purchased.
10.17 Dr Grenville gave evidence (WS ppR112-117) in relation to Audit 3 that whilst it demonstrated some of Dr Reddy’s prescribing was appropriate, there were frequent examples of poor quality notes, misfiled notes, no record of blood tests having been carried out for a number of years for patients with chronic diseases and a lack of appropriate clinical reviews and follow up, which she submitted presented real risks to patient safety.
10.18 Dr Healy’s evidence (WS pA6) was that some criticism of Dr Reddy’s note keeping was justified. He stated that Dr Reddy would endeavour to record entries in future in a structured and consistent format and that he accepted the need to file all letters, test results and reports with the patient’s records as soon as they were received.
10.19 However, he did not agree that Dr Reddy’s prescribing and therapeutic
management was grossly immature, illogical, non cost effective and at times
dangerous to the lives and well being of patients. He submitted all of Dr
Reddy’s prescriptions were pertinent to the conditions he was treating, in
nearly every case he used the generic formulations and he saw no evidence of
excessive quantities being prescribed. As far as he could see, no patient had
come to any harm from any of his
prescriptions (WS ppA85-86).
10.20
Dr Reddy’s evidence (WS ppA112-113) was that he recognised that owing to the
volume of work the quality of his note taking may have suffered in terms
of
both content and legibility. He submitted that should he be allowed to
return to
practice he would seek to make improvements, using a specific format for
consultations. Moreover, he would seek to ensure the records were kept
in an
orderly fashion and all correspondence and test results were filed as
appropriate by the reception staff.
10.21
Dr Reddy submitted he would almost always have the patient’s records
available when they consulted him, but if they were not available he
would
write his clinical notes on a new Lloyd George card noting at the top “No notes
available” and the new card
would be added to the records once they were
available.
10.22
He claimed that the filing system was set up by Dr Desai a long time ago
but
the staff were familiar with it. He did not accept it was chaotic (WS pAA5). None
of the locums had ever complained to him about the state of the medical
records (WS pAA8).
10.23 At the hearing he acknowledged unfiled medical correspondence, test results
etc had been found upstairs at the Belmont Road surgery but he said these were
of no interest to him so why would he look. He thought it was just rubbish up
there and asked why he would have to touch dirty and nasty things..
10.24 He also told us he only recorded the main points based on past history, with minimum writing, but they were the salient points in the time available. He submitted his notes were of average quality.
Organisational /managerial issues
11.1 The PCT criticised Dr Reddy’s organisation and management of the surgery
premises and equipment, the staff and the IT system
11.2 Thirza Sawtell, Helen Hughes and Carol Hogg all submitted detailed evidence
in relation to the organisation and management of the practice.
Practice premises and equipment
11.3 Helen
Hughes gave evidence (WS ppR39-48) relating to the failings in the
administration systems
at the practice and the condition of the premises. She
submitted that she had
been aware the premises had been neglected for many
years, but when,
following Dr Desai’s suspension, she visited them with Jenny
Gosling in October
2002, she was shocked and not prepared for the state of the
neglect. She
instructed Jenny Gosling and the existing practice receptionist, Mrs
Devgun, to identify
all concerns and make improvements. As well as the
clinical problems
identified above, they identified general concerns regarding
the condition of the
practice environment, equipment and vaccines and the lack
of any payroll systems
to pay staff.
11.4 The PCT initiated an Infection Control Audit
and identified the following concerns:
·
rooms had old,
rusty and broken clinical and non-clinical equipment
·
out of date
medication was stored in clinical and treatment rooms
·
the patients’
toilet had no soap, towels or waste bin, the floor was wet and exposed live
electrical wires were found
·
vaccines were
in a fridge whose temperature was recorded as 28C
·
old inadequate
steriliser not complying with current legislation
·
dirty
consulting rooms with no evidence of soap or paper towels
·
clinical
equipment such as speculum and forceps were stored in an open tray
·
much of the
equipment was out of date
·
vaccines and
food were stored together in a domestic fridge
·
there was a
large quantity of out of date vaccines in the fridge
·
there was
evidence of rodent infestation
11.5 Helen Hughes submitted that despite Carol Hogg and Jenny Gosling
supporting Dr Reddy by addressing a number of issues, they informed Helen Hughes they felt Dr Reddy would block any progress being made, specifically in relation to engaging a cleaner for the practice. Of special concern to her was an interview with Dr Reddy in February 2003; at that point, Dr Desai had been suspended for five months but Dr Reddy failed to take any responsibility for the practice environment and equipment, specifically vaccine storage and the state of the fridge, or for lack of procedure for checking that vaccines were in date. He continued to blame others.
11.6 She submitted that once Dr Reddy became the sole responsible practitioner
following Dr Desai’s retirement in April 2003, he still did not make any
improvements to the internal condition of the practice, failing to replace or
maintain existing equipment such as the fax machine and photocopier, despite
being in receipt of the full practice income. At meetings he always devolved
funding responsibilities to the PCT and throughout this time he did not
acknowledge any responsibilities for the health and safety of staff and patients,
deferring responsibilities to Dr Desai.
11.7 When, following security concerns, the PCT had to relocate the Belmont Road
surgery, the relocation costs included Ł150,000
conversion costs, Ł65,000 per
annum to rent alternative premises for the team previously in those premises and Ł20,000 for furnishing and equipping the practice, because the furniture and equipment at Belmont Road was too outdated and in really poor condition and was the property of either Dr Desai or Dr Reddy..
11.8 Carol Hogg also gave evidence (WS ppR90-94) relating to the state of the
premises. She submitted that not only were they in need of repair, they were
also dirty and very smelly. On her first day Jenny Gosling had to remove old
dirty stained cotton sheets from the examination couches and replace them with
paper couch rolls and replace all the linen towels with paper hand towels.
11.9 Moreover, she gave evidence that Dr Reddy had unused vaccinations sitting on
the windowsill in the consulting room in the sun when he saw patients
11.10 She also confirmed mice were an ongoing problem at both premises. The staff
were very frightened and Dr Reddy was requested on a number of occasions to
sort this matter out. However, he never made any attempt to do so and in the
end Jenny Gosling had to call out Rentokil.several times.
11.11 She submitted that there was an ongoing problem with vandalism at the
Belmont Road surgery and that Dr Reddy was requested on a number of
occasions to secure the windows by boarding them up or replacing them but
despite his receiving the full income of the practice he made no improvements
to the premises and nor did he address any of the health and safety issues. He
always maintained that Dr Desai was the landlord and it was his responsibility.
11.12 Carol Hogg also submitted that although told the practice did have a cleaner
who was on leave, no one appeared to have a number for her. After a few
weeks when she still had not made contact with the surgery, she and Jenny
Gosling discussed with Dr Reddy the need to employ a cleaner for both
surgeries. Dr Reddy said he would find another cleaner, but despite repeated
requests he never advertised for one and in the end it was left to Jenny Gosling
to organise. She submitted it was typical of Dr Reddy to agree something one
minute and then deny he knew anything about it.
11.13 Carol Hogg also gave evidence concerning the lack of equipment or poor state
of equipment at both surgeries, for example the practice was running out of
disposable speculums, latex gloves, couch rolls etc. Despite several requests to
Dr Reddy to authorise the ordering of these items, he never did and Jenny
Gosling had to borrow these along with other items from practices in Newham
which Primary Solutions was also managing. She felt that although Dr Reddy
received the full income of the practice following Dr Desai’s suspension, he
was reluctant to use any of the money to provide basic items required to run a
general practice.
11.14 Dr Reddy also failed to replace the broken photocopier at Belmont Road
which meant staff or patients had to pay to copy documents at a local shop,
which.was a serious breach of confidentiality. Dr Reddy did purchase a copier,
but he kept it at home so staff had to give him documents to copy there which
quite often came back incomplete.
11.15 There was no fax machine at Shelley Avenue. Although Dr Reddy was asked
to purchase one he never did, which resulted in Carol Hogg having to instruct
Jenny Gosling to purchase one and deduct the cost from the practice income.
11.16 Dr Reddy did not provide the practice with petty cash. Jenny Gosling would
have to ask him for money for stamps and after several requests he would
provide 4 or 5 stamps.
11.17 Jenny Gosling submitted (WS ppR102-105) that when she became aware in
December 2002 that there was no stock control at the practice she decided to check stock in the fridge, where she found several vaccinations that were out of date by several years. She also submitted the cold chain was broken when vaccines were transferred from Belmont Road to Shelley Avenue.
11.18 Dr Reddy’s evidence (WS ppA94-96) was that the two surgeries were in poor
condition because Dr Desai did not fulfil his repairing and maintenance
obligations as landlord. He was responsible for maintaining both the structure
and the internal condition of the properties. When the Belmont Road surgery
was vandalised in September 2003 he wrote to Thirza Sawtell expressing his
concerns. She recommended he contact Dr Desai regarding the necessary
urgent works but if Dr Desai would not carry out the work she told Dr Reddy
that as senior partner he was responsible for the maintenance and security of
the practice and as employer, his staff, and that he should undertake the works
himself and address the costs he incurred as tenant with Dr Desai. She told him
the PCT would support him in addressing these issues far as reasonably
possible but Dr Reddy knew Dr Desai would be reluctant to authorise any
expenditure and he was concerned that if he incurred expense without Dr
Desai’s authority there was a real risk he would not be reimbursed.
11.19 However, Dr Reddy submitted (WS ppA105) that there was a degree of
improvement once Dr Desai retired and that he did purchase some equipment between April and October 2003, namely disposable instruments such as mono use speculums, two or three blood pressure monitors, an opthalmoscope, an otoscope, a photocopier and two sets of baby scales, plus all the materials and equipment to maintain the surgeries on a day to day basis, which included all cleaning materials and toiletries He did concede the equipment and facilities in the practice remained at a fairly poor level because of Dr Desai’s lack of co-operation, the breakdown of trust with Jenny Gosling, his being overworked, there being no practice nurse or permanent practice manager, and because he did not want to invest a lot of time and money in the premises when he was planning to relocate.
11.20 In his supplementary witness statement (WS ppAA1-16) Dr Reddy submitted that
he had kept the photocopier at home because he was concerned about it being
used for private purposes.
11.21 As regarded surgery equipment he would expect a practice manager to prepare
a list of such items and submit this to the GP for approval and then arrange
purchase. Whenever Jenny Gosling had done this he had always authorised
purchase.
11.22 He had attempted to control the mouse problem using sticky mouse traps,
which were effective. He would have expected Jenny Gosling, as the practice
manager, to have contacted Rentokil at the outset as this was not a problem
which required a doctor’s input.
11.23 He recalled agreeing that there should be a vaccine register attached to the
fridge, which contained a day to day record.
11.24 He submitted that he was willing to take responsibility for the practice
environment and equipment but his workload was such that it was difficult for
him to address all the outstanding matters. He would have expected Jenny
Gosling to address and deal with them on his behalf so that he could
concentrate on his clinical responsibilities.
11.25 At the hearing he complained that even after Dr Desai had retired he was not
allowed to run the practice; the PCT ran it. He had bought some equipment and
he asked patients who volunteered to help him to buy sundry items such as milk
and toilet paper as Jenny Gosling did not give him receipts when he gave her
petty cash.
Shelley Avenue surgery
11.26 Allied to the problem of the condition of the premises were the future plans for
the two surgeries following Dr Desai’s retirement. In a letter dated 31st March
2003 (MB Vol 1 pp241-242) Thirza Sawtell wrote to inform Dr Reddy that the
PCT’s Workforce Development Subcommitte (the WDS) had determined that
following Dr Desai’s retirement, responsibility for patients registered at the
Shelley Avenue branch surgery should be passed to Newham PCT.
11.27 Thirza Sawtell’s evidence (WS pR9) was that she followed this letter up with a
meeting with Dr Reddy on 15th April 2003 at which it was agreed he would
write to the WDS appealing its decision by the end of April, but all he did was
write to her stating the patients from the Shelley Avenue practice would be
moving to new premises in Newham from 16th May 2003, which was in direct
contravention of the WDS’ decision. She replied to him on 6th May 2003
emphasising he should not proceed with his plans. At a further meeting with Dr
Reddy, his BMA representative and Dr Ranjan on 2nd July 2003, she reiterated
her concerns that Dr Reddy had again written to her to say he would continue
practising from Shelley Avenue and that Dr Desai would be investing in the
premises. His letters failed to acknowledge the PCT’s intentions or the action
he had agreed but failed to undertake to appeal against the WDS’ decision.
11.28 Dr Reddy’s witness statement (WS pA99) did not dispute this sequence of events
but at the hearing he submitted that the first time he was told the Shelley
Avenue surgery was being closed was at the meeting on 15th April 2003. When
reminded about the earlier letter to him from the PCT he claimed he had been
confused by the PCT’s request for a business plan for both premises. When
challenged that he had ignored this decision and simply gone ahead with his
own plans, Dr Reddy replied that he should have been in charge but the PCT
treated him like a puppet.
Belmont Road surgery
11.29 Thirza Sawtell’s evidence (WS ppR10-12) was that at the meeting with Dr Reddy
on 15th April 2003 she confirmed to him that the current condition of the
Belmont Road premises was unacceptable although she acknowledged he
would need to remain there as a short-term interim arrangement. She told him
that as the responsible practitioner in receipt of the practice income he would
now be responsible for paying rent to Dr Desai as the landlord, although Dr
Desai consistently informed the PCT that he did not receive any rent from Dr
Reddy. In relation to future arrangements for the practice it was agreed that Dr
Reddy would consider his options, which were to convert his house to a surgery
or to move to modular accommodation being established within the local PCT
owned John Telford Health Centre and then to be included in the plans for
redevelopment of the centre into a One Stop Centre. Dr Reddy agreed to inform
Thirza Sawtell of his decision by the end of April but he did not do so.
11.30 On 6th June 2003 she met with Dr Reddy, his BMA representative and Dr
Desai, who stated he wanted to ultimately sell the premises. It was agreed that
the PCT would support Dr Reddy’s need to enter into short-term lease arrangements with Dr Desai. She also told Dr Reddy that he would need to make a decision by the end of June about the Health Centre so that the practice requirements could be incorporated into the tender specification, but he did not do so.
11.31 Dr Reddy then wrote to Thirza Sawtell on 20th June 2003 to inform her he was
pursuing conversion of his home. She told him at a meeting on 2nd July 2003
that this meant the Health Centre was no longer an option. On 22nd September 2003 Dr Reddy wrote to inform her planning permission for the conversion of his house had been refused but following his suspension in October 2003 he appeared not to be willing to meet with the PCT, so any further discussions
about new premises had to take place through correspondence. Although she wrote to Dr Reddy in November and December 2003 confirming he should take no further action nor incur any costs with regard to the conversion of his house until the PCT had had an opportunity to discuss his intentions with him, the local authority wrote to the PCT in January 2004 regarding a second submission for planning permission from Dr Reddy. She wrote to him again in February 2004 reiterating the position but received no response. She also wrote at the same time to the local authority explaining why the PCT was not in a position to provide a view on the planning application.
11.32 Helen Hughes’ evidence (WS ppR10-12) added that in September 2003 Dr
Reddy reported acts of vandalism on the surgery. Although Thirza Sawtell had advised him to pay for urgent works and to reclaim the cost from Dr Desai he did not take any action. In the end Dr Desai did organise for the broken windows to be boarded up. She submitted that neither Dr Reddy nor Dr Desai demonstrated any regard for the condition of the practice which the staff and patients were being subjected to, it was impossible to engage with Dr Reddy in relation to his responsibilities for the practice environment or with Dr Desai in terms of the building itself; they were locked into a personal dispute around payment of rent and it was the patients and staff who were suffering but neither doctor seemed to care about that.
11.33 In February 2004 the PCT received a letter from the Friends of Pakistan group
stating that they considered the premises were a fire and health hazard. The
PCT wrote to inform Dr Reddy and to explain it might need to take immediate
action to make the premises safe or to relocate the surgery and it arranged
independent fire and environmental.inspections.
11.34 Between 18th and 20th April 2004 an intruder broke into the premises to sleep
rough there. The PCT was left with no alternative but to relocate the practice
overnight to the John Telford Centre, which was now almost completed.
11.35 Dr Reddy told us at the hearing that when he first saw the practice he did not
think the surgery premises were any worse than others at which he had been a
locum and they were acceptable. His evidence (WS ppA96-97) was that he
recognised there were existing and continuing problems with the premises and
his intention was to relocate as soon as possible. Accordingly, he did not wish
to spend significant amounts of money on the existing premises. By the time
planning permission was granted for conversion of his home in January 2004
he had already been suspended and the PCT moved the practice to the John
Telford Clinic in April 2004.
11.36 Once he was suspended he was not permitted access to the premises which
made it very difficult for him to deal with any problems there. In effect, the PCT now controlled the practice and they decided to relocate with little or no consultation with him. He would have been willing to relocate to the John Telford Clinic but it was not ready until after his suspension. Once he was suspended the PCT was responsible for managing and maintaining the premises
and yet serious security breaches occurred (WS ppAA11-16)
The staff
11.37 Helen Hughes gave evidence (WS ppR30-34) that historically, Dr Reddy had
advised the PCT he was completely powerless within the practice because Dr
Desai had taken full control. He had never taken any responsibility for such
issues as staff management or practice income.
11.38 The PCT were aware that the suspension of Dr Desai would be very stressful
for Dr Reddy and sought advice from the SHA’s Medical Director with regard
to engaging clinical support for Dr Reddy over and above supporting him in
the running of the practice. The PCT engaged Primary Solutions to provide a
full time practice manager, Jenny Gosling at a cost of Ł1250 per week.
11.39 The PCT were aware that the existing practice manager, Mrs Devgun, had
responsibilities as a Health Advocate and was running clinics and seeing patients. The PCT asked her to stop doing this as it was inappropriate for a non-clinician.
11.40 The PCT reassured Mrs Devgun that Jenny Gosling was there to help and
support her in developing her practice management skills and experience and
set up an organised practice and her remit was either to train Mrs Devgun in
house or identify outside training which would help her.
11.41 It also asked Primary Solutions to engage a minimum of one whole time
equivalent (WTE) GP locum to support Dr Reddy, which cost the PCT Ł1200
per week from October 2002 until Dr Reddy’s suspension in October 2003. The GP support was increased to between 1.5 and 2 WTE GPs depending on the availability of practice nurses. Despite this support being in place, Dr Reddy stated at formal meetings he was practising alone with no help.
11.42 Helen Hughes also submitted that Carol Hogg, the PCT’s Primary Care
Manager, invested a high proportion of her time into the practice. Although her
role was to support 16 practices in the locality, from October 2002 she invested at least 50% of her time in this practice alone. From October 2003, when Dr Reddy was suspended, that time increased to 80%, and from March 1994 to 90%. When the PCT could no longer afford the consultancy costs and so decided to temporarily manage the practice using its own management resources.
11.43 Following the compulsory retirement of Dr Desai, Dr Reddy became the sole
responsible partner. Helen Hughes saw this as the real turning point for the
practice’s future. Although she anticipated problems with Dr Desai as landlord she felt Dr Reddy now had the opportunity to break free from the constraints of the past and improve care to patients. He would now receive the full income of the practice, which would enable him to invest in improving it. She and Thirza Sawtell met with Dr Reddy on 15th April 2003 and they discussed the fact that Dr Reddy would now be able to make the crucial permanent appointments the practice needed.. They prepared a job description for a practice manager which she circulated with a person specification for Dr Reddy’s approval. They also confirmed Dr Reddy needed to appoint a permanent GP partner and nurse, with sufficient experience to help him to move the practice forward.
11.44 At the meeting it was agreed that the existing temporary support would stay in
place until the permanent appointments were made. Dr Reddy expected the
PCT to pay for this support, even though he was now in receipt of the full
practice income.
11.45 From October 2002 to October 2003 the cost of the temporary staff was in the
region of Ł160,000. That sum did not include the costs of Carol Hogg
supporting Dr Reddy or the involvement of Thirza Sawtell It meant resources
were being taken away from other practices to support this situation.
11.46 Following Dr Reddy’s suspension in October 2003, although there were still
concerns about management systems, the PCT decided the focus of support needed to change to specialist clinical support as patients with chronic diseases were not being appropriately managed. The PCT engaged a company called Chilvers McCrea because they specialised in providing highly skilled support as opposed to GP locums and could also provide day to day management, GP locum and nursing support. They were instructed to establish disease registers, identify patients who had not been reviewed, undertake clinical and medication reviews and put in place systems in the practice to ensure ongoing management of patients’ conditions. This was in addition to the GPs and practice manager running the practice on a day to day basis.
11.47 This support, from October 2003 to March 2004, cost the PCT on average
Ł18,000 per month. Although the PCT held the practice income of approximately Ł192.000 per annum, less the salary paid to Dr Reddy, this was not sufficient and it entered into an overspend situation for 2003/4.
11.48 The PCT gave notice to Chilvers McCrea in April 2004. This was partly
because they had completed the set tasks, but also because the PCT could no longer afford to pay them.
11.49 To try and reduce costs the PCT engaged long term locums, who joined its
directly employed scheme and it has had to manage the practice through Carol
Hogg and the PCT’s access facilitator, who is an experienced practice manager.
11.50 Helen Hughes also gave evidence (WS ppR45-49) that at the meeting on 15th
April 2003, as Dr Reddy had no experience in appointing staff, the PCT offered
to support him in the advertising and interview process. It agreed to supply him
with sample job descriptions for differing grades of nurses to assist him in
producing a job description to be submitted to the PCT, so that the PCT could
agree the salary and level of reimbursement by the PCT and it offered the
PCT’s Assistant Director of Nursing to be on the interview panel.
11.51 From March 2003 the PCT had outlined to Dr Reddy a very clear process for
the appointment of a partner, which he continually failed to follow. It had approved his request for a partnership vacancy to be declared, but because of the issues with the practice standards, the approval was subject to PCT involvement in the selection, recruitment and interview process and in the terms of the partnership agreement.
11.52 She submitted that Dr Reddy consistently failed to adhere to the agreed
processes or to take the actions he had agreed. By the end of August 2003 he
had failed to submit selection criteria or a draft partnership agreement and he
only submitted the nurse job description in September 2003.
11.53 At the hearing she told us that by April 2003 the PCT was aware Dr Reddy
would need a highly skilled and competent practice nurse and that it would
need to pay for a higher level of nurse than in other practices.
11.54 Carol Hogg gave evidence (WS ppR84A-90) that Jenny Gosling raised concerns
about Mrs Devgun’s role and that neither she nor Dr Reddy were able to
provide evidence of any training to enable her to carry out this role.
11.55 She also submitted that following Dr Desai’s suspension arrangements needed
to be made to pay the practice staff but Dr Reddy had no knowledge of how the
staff had previously been paid and what system was in place. As Dr Desai had
never responded to the PCT’s request to purchase a payroll system, the PCT
asked Dr Reddy to purchase one, which he never agreed to do. As a last
resort and to ensure the staff got paid the PCT purchased the system on behalf
of the practice and deducted the cost from the practice income. The monthly
payroll was undertaken by Primary Solutions and the PCT without any input
from Dr Reddy.
11.56 She supported Helen Hughes’ account of events relating to the appointment of
a partner and practice nurse. She also gave evidence that despite the PCT
discussing with him the importance of employing an experienced, full-time
Practice Manager, Dr Reddy told her he wanted to appoint his wife to the post
and gave her a copy of his wife’s CV, from which it was clear she did not have
any relevant experience.
11.57 She also gave evidence that she discussed with Dr Reddy on many occasions
the importance of getting a practice nurse and provided him with several copies
of the same sample job description. She even drew up an action plan to help
guide him through the process, which he managed to lose. He asked her to
write the job description although she emphasised he needed to write it based
on his needs and that of the practice population. After ten months there was
still no job description and yet Dr Reddy wrote to the PCT in August 2003
accusing her of holding up the recruitment process. He eventually submitted
the job description in September 2003, after almost a year
11.58 Jenny Gosling submitted (WS ppRR1-2) that Mrs Devgun was not qualified to
carry out clinical tasks and that she did not appear to have the knowledge to
work as a practice manager and was essentially only able to do the work of a
senior receptionist.
11.59 She also submitted that Mrs Jan was not dismissed as she was not formally
employed at the practice and she was not suitably qualified to be employed as
the practice nurse.
11.60 Dr Reddy’s evidence was (WS ppA98-104) that when he joined the practice in
September 2001 Mrs Devgun was the practice manager for both premises and
there was a part-time nurse, Mrs Jan, who did two sessions a week. There were
also a number of receptionists.
11.61 He complained that Jenny Gosling was a law unto herself and sidelined Mrs
Devgun and himself. He complained she engaged locum GPs without
consulting him and felt she was a highly disruptive influence and ruled the
practice in a highly authoritarian fashion. He wrote to the PCT in September
2003 requesting that her role be terminated but his request was ignored.
11.62 He claimed that before Jenny Gosling joined the practice Mrs Devgun had had
a fairly responsible position and had carried out some clinical duties but always
under the supervision of Dr Desai or himself. Jenny Gosling had stripped her of
these responsibilities and her responsibilities for the reception staff as soon as
Dr Desai was suspended. Although she was trained as a practice manager, the
PCT wanted her to re-train as a healthcare assistant and so she reluctantly
attended a course at Whipps Cross Hospital which she felt unable to complete.
She feared losing her job and had family problems and she committed suicide
in March 2003.
11.63 He also submitted Mrs Jan was dismissed when Primary Solutions took over
and she was not replaced with a qualified practice nurse, which made his job
very difficult.
11.64 Once Dr Desai had retired, Dr Reddy wanted to appoint a full time permanent
GP partner, a GP assistant to cover seven sessions per week, a full-time practice
manager and a full-time practice nurse. He also wanted to have better qualified
and computer literate reception staff. He submitted that as a self-employed GP
he would normally have had a free hand in making all the necessary
appointments but the PCT sought to exercise complete control over the
recruitment of both medical and non-medical staff.
11.65 He accepted the PCT’s conditions for the appointment of a partner (see para 11.51 above) and then confirmed the appointment of Dr Bhatnagar as a part-time GP principal in August 2003 but Thirza Sawtell telephoned him to say he should not have done so and he made no further efforts to appoint a GP principal prior to his suspension because the PCT had not accepted any of his proposals.
11.66 He sought to appoint Mrs Sibley as a practice nurse as he considered she was
well qualified for the post and asked for the PCT’s support. He could not
understand why the PCT were not willing to approve her. Carol Hogg wrote to him in August 2003 blaming him for the delay in appointing a practice nurse owing to his failure to comply with the appointment protocol but he had hoped, given the urgency of the situation that Mrs Sibley could be appointed simply on the basis of her CV rather than have to go through a lengthy bureaucratic process.
11.67 At the meeting on 15th April 2003 the PCT advised Dr Reddy that a highly
experienced practice manager should be appointed. He proposed his wife as a
suitable candidate but Thirza Sawtell said that as she only had two weeks
experience of working in a practice the PCT was not satisfied she had the
relevant experience to implement the large change agenda required within the
practice. He was disappointed as he had discussed appointing his wife with
Carol Hogg in 2002 and she had been quite encouraging about her starting
work without any formal qualifications and studying for a management
diploma whilst working.
11.68 To summarise, whilst he recognised the PCT felt obliged to pursue certain
recruitment protocols, at the time Dr Reddy felt swamped and blocked by
bureaucracy and that his patients’ interests would have been best served by the
early appointment of Dr Bhatnagar, Mrs Sibley and his wife, whom he felt, with
training would make a very competent practice manager. He had candidates
ready, willing and able to take up the posts, but notwithstanding the urgency of
the situation the PCT were adamant the recruitment protocols should be
adhered to.
11.69 At the hearing Dr Reddy told us that when Primary Solutions and Jenny
Gosling came into the practice he felt they were taking over and isolating him.
He compared it to a cancer destroying his body and said he lost trust in the
PCT. He submitted Jenny Gosling acted like Hitler and there was no way
anyone could work in harmony as a team.
11.70 He had asked the PCT for details about all the staff; there was no way he could
know about there qualifications. Dr Desai had appointed them and he trusted
they were qualified and fit to do their jobs. He did not carry out any checks on
them himself.
11.71 When asked if he accepted he did not go through the necessary recruitment
protocols, Dr Reddy questioned why the PCT had allowed him to practice as a
GP principal only to fail to respect his rights.
The IT system
11.72 Dr Reddy gave evidence (WS ppA106-107) that as he was planning to relocate
the premises there was no point in investing in a new computer system. He
submitted (WS ppA117-118) that Dr Desai put the Seetec medical computer
system in place but he was not able to update it because Dr Desai owed Seetec
Ł9,800. In October 2002 he managed to obtain a printer from the PCT and
from that time onwards he was able to issue prescriptions by computer.
Although the computer did not have any kind of recall system he could review
patient medication on the computer, assuming it was working but it used to fail
on average a few times a month. In the absence of a computer review /recall
system he simply had to rely upon reviews during routine consultations
(WS ppA118).
11.73 At the hearing Dr Reddy conceded that the computer system was not
satisfactory. When reminded that the practice was at that time responsible for
IT and asked what steps he had taken, he said he had told the PCT about the
problems and that Seetec was sending invoices. He submitted he could manage
by also looking at patients’ notes, although review was only opportunistic. If
the computer was not working he would, if necessary, ask patients to bring
their tear of slips so he could write their repeat prescriptions. If they did not
bring the tear off slips he would look at their notes. As there was no computer
recall system he would tell patients when they should come back for review.
Professional issues
12.1 The PCT also alleged Dr Reddy’s lack of insight lead to mistakes and failures
and affected his professional judgment and that history demonstrated Dr Reddy
would not change and did not have the essential qualities and capabilities to
perform to the requisite standard.. In this regard we considered the evidence
relating to previous investigations of Dr Reddy’s performance, and his reaction
to the outcome of those investigations and also the evidence relating to the
PCT’s actions and involvement from the time of Dr Desai’s suspension in
October 2002 to his own suspension in October 2003.
Previous investigations
12.2 In late 1999 or early 2000, following Dr Reddy’s acrimonious departure from a partnership in Forest Gate, the East London & City Health Authority brought Dr
Reddy before the National Health Service Tribunal. The Tribunal found in
April 2001 (MB Vol 4 pp1119-1124) that he presented as a warm and caring doctor
with an obvious anxiety to support his patients and that he demonstrated an
obvious willingness to learn and improve upon his clinical skills. It concluded
that by reason of the allegations and its findings upon them which were in large
measure related to prescribing issues, Dr Reddy would have been removed from
the list and been made the subject of a national disqualification, but for the
evidence of Dr Hiew, who had taken Dr Reddy under his wing and who
considered that he could practice safely in a properly supported setting, and no
such order was made.
12.3 The Tribunal did, however, state that had it had the power to do so, it would
have imposed conditions upon Dr Reddy working as a single-handed GP, but
there was no statutory basis for it to do so. Dr Hiew had expressed the view that
Dr Reddy was clinically safe to practise as a locum in his own practice or as a
deputy in a stable situation.
12.4 Dr Reddy was also subject to a GMC Performance Assessment in October 2001.
The assessors concluded (MB Vol 3 p545 and 691) that Dr Reddy was guilty of real
deficiencies but not of seriously deficient performance. He struck the assessors
as intelligent, hardworking, caring and keen to learn. Whilst his record keeping
was criticised and he was said to be unaware of UK General Practice
requirements and that he found difficulties in identifying his deficiencies, the
assessors considered there was good evidence of significant progress having
been made. They considered that Dr Reddy would benefit from continued
supervision and mentorship from colleagues.
12.5 The PCT submitted that this was perhaps an overly rosy view that was borne out
by events
12.6 Dr Reddy was subject to a further GMC assessment instigated by the PCT on
the recommendation of the National Clinical Assessment Authority. The
assessors found that Dr Reddy was pleasant and sympathetic to his patients and
they formed the view that Primary Solutions and the PCT prevented him from
functioning as a GP principal. They concluded in October
2005 (GMC
Report
p105 ) that Dr Reddy’s professional performance was not deficient and that he
had good medical knowledge to practise as a GP. However, they did consider
he lacked knowledge in practice management and it would be in his interest to
approach the PCT and his local post-graduate tutor to seek the appointment of a
mentor, acceptable to him, for a period of twelve months to enable him to
improve his practice management and IT skills. They also considered Dr Reddy
should demonstrate he was keeping his knowledge up to date by producing a
Personal Development Plan in consultation with his mentor to enable him to
demonstrate continuous improvement in his medical knowledge.
12.7 In its closing submissions the PCT roundly refuted the assessors’ conclusion,
which it contended was far too favourable to Dr Reddy. It submitted he had been
encouraged to take a full and proper part in the steps to run and improve the
practice but he failed to take advantage of the very real opportunity offered to
him and that he unreasonably refused to work with the PCT from the beginning
and that he did not want their help in the way in which it was provided, which
the PCT contended was generous in both monetary and labour terms, and
consequently disengaged consciously or unconsciously, acting not like a GP
principal but as no more than a salaried GP removed from all decision making.
The PCT submitted the appeal panel should not be constrained in any way by
the views of the GMC assessors.
12.8 However, in Dr Reddy’s closing submissions, it was contended that although
The assessors’ conclusions did not eclipse the function of the appeal panel
which exercises an independent jurisdiction, nonetheless the conclusions of the
assessors ought to be highly influential in the outcome of this appeal.
Dr Reddy’s actions
12.9 The PCT submitted that less than six months after the original GMC
Performance Assessment in October 2001and having worked as a locum in
three practices for no more than a few weeks at a time, Dr Reddy joined Dr
Desai’s practice as a GP principal. The PCT contended this was an example of
Dr Reddy’s poor judgment and lack of insight and a clear signal that he had in
truth learnt little or nothing from the proceedings.
12.10 The PCT pointed out that Dr Spiteri had submitted (WS pR108) that anyone
who agrees to go into partnership and remains in partnership once problems with the standard of practice have been identified shows either a lack of insight or must accept responsibility for assisting in and endorsing the systems in place. The PCT submitted that Dr Reddy had chosen to stay but sought to blame others for all of the failings which had been demonstrated, but that as a professional man, he could not evade his own responsibilities in this manner.
12.11 At the hearing Dr Reddy was asked whether he had sought any independent
advice when he was offered the partnership. Dr Reddy submitted that he had
discussed the offer with a barrister friend; they had seen one quarterly return
or the practice and the income on that looked reasonable but despite asking
many times, Dr Desai never showed the practice accounts to him. When asked
why he had not queried there being no reimbursement of staff on the quarterly
return, Dr Reddy claimed that he had noticed this but somehow he had failed
to ask about it.
12.12 The PCT also submitted that the evidence on both sides indicated tensions
between Dr Reddy on the one hand and the PCT’s staff and Jenny Gosling on
the other. It contended that the difficulties which arose in 2002/2003 were the
result of the obstinate refusal of Dr Reddy to take part in the process of turning
this practice round in a proper manner. He delayed dealing with the issues (such as the preparation of job descriptions) and purported not to realise that he was responsible, for example, for staff, the equipment, the preparation of the chronic disease registers, etc.
12.13 The PCT acknowledged that up to the time of Dr Desai’s retirement in April
2003, Dr Desai’s ability to act autonomously was constrained, but that this
should not excuse his total inactivity in the period up to October 2002 or
thereafter.
12.14 It was submitted on behalf of Dr Reddy that the PCT had acknowledged the
particular difficulties which Dr Reddy encountered as Dr Desai’s partner and that it was not disputed that whilst Dr Desai was in practice he “held the purse strings” and that he guarded control over all practice issues and would not allow Dr Reddy any opportunity for improving the premises or improving systems at the practice. Those difficulties continued following Dr Desai’s suspension in October 2002 until his retirement in April 2003, and it was only thereafter that Dr Reddy had the opportunity to break free from the constraints of the past and improve care to patients.
12.15 This meant that the PCT only afforded Dr Reddy a brief period of five or six
months in which to demonstrate his resolve and his skills.
12.16 Furthermore, throughout the period when the PCT was ostensibly supporting
Dr Reddy – both personally and professionally – he was also the subject of
investigation. It was submitted on behalf of Dr Reddy that this raised the
question of how reasonable it was for Dr Reddy to recognize the existence of
such support given the fact of the congruent investigation.
12.17 Thirza Sawtell’s evidence was (WS ppR4-6) that she had confirmed to Dr Reddy
both verbally and in writing in October 2002 that following Dr Desai’s
suspension it would be necessary to investigate the practice and both partners.
Despite this, at frequent meetings during the investigation Dr Reddy would
state he had not been so informed and that he was not aware the investigation
related to him. This was clarified to him on each occasion.
12.18 The PCT recognised that Dr Reddy had been working in stressful
circumstances and that Dr Desai’s suspension and the investigation into the
practice would add to his stress. It was also aware of his limited experience of
general practice and the NHS tribunal recommendation that he should not
work as a single handed practitioner. The Strategic Health Authority
recommended a GP who was an experienced mentor and the PCT offered to
fund this support for Dr Reddy, but although he made initial contact with the
mentor, Dr Reddy failed to follow this up. However, he did subsequently bring
Dr Ranjan along to support him at meetings with the PCT, but the PCT had no
involvement in this arrangement.
12.19 Given that Dr Desai would not agree to contribute to the additional GP support
required during his suspension, the PCT also agreed to bear this cost (as
described in paragraphs 11.38-11.48 above). It also agreed to fund additional
practice management support, over and above the practice management and
administration arrangements funded through staff reimbursements, because it was aware of the inappropriate clinical role undertaken by Mrs Devgun.
12.20 At the hearing she submitted that when she met with Dr Reddy he was very
clear that he was a GP principal and that at that stage neither he nor his
representatives raised any concerns about the level of PCT support.
12.21 She felt that when the PCT met with Dr Reddy he would clearly articulate his
displeasure but he did not take the necessary steps to enable it to dispense with Primary Solutions. The actions he did take were outside of the required processes. For example, Dr Reddy would submit CVs for people he thought.
would be suitable partners and it was not the case that the PCT disagreed with who should be recruited but that he did not follow the national protocols for recruitment. After April 2003 Dr Reddy was receiving the full practice income and he was being provided with locum and administrative support, but he failed to take any steps to improve the immediate physical environment or the staff and infrastructure required and continued to place the responsibility on Primary Solutions and the PCT. The ability to move forward was entirely within Dr Reddy’s hands.
12.22 The PCT had felt it was necessary to be involved in the recruitment and
selection of staff over and above what was normally required; it saw this as a supportive measure as Dr Reddy had no experience of working in general practice as a sole practitioner. It subsequently became concerned at Dr
Reddy’s lack of insight over whom he thought appropriate for the vacant posts, for example, his wife as Practice Manager.
12.23 The PCT had never had to invest so many resources or so much time and
money in any of the other GP practices in the area. This had a significant
impact both on the PCT’s ability to improve and drive forward improvements
within this practice and on the overall efficiency of services within this PCT on a number of levels. On a financial level the funding of this practice came at the cost of other developments within the PCT and on a resources level Carol Hogg and Helen Hughes had to spend a disproportionate amount of time in this practice.
12.24 She also submitted that it was disconcerting that Dr Reddy would agree to
certain actions at meetings but this would be totally contradicted by his
subsequent correspondence and actions. It had been submitted on behalf of Dr Reddy that he demonstrated enthusiasm for change, but she felt his enthusiasm was for things he had not been asked for, such as alternative premises for the Shelley Avenue surgery. He would also criticise the PCT for becoming too involved, only to complain that it did not take the actions he required.
12.25 Helen Hughes’ evidence (WS ppR30-34) confirmed that of Thirza Sawtell. She
also submitted that at the meeting on 15 April 2003 it was agreed the existing temporary support would stay in place until the permanent appointments were made, but it was acknowledged by all that Dr Reddy was now in a position to take responsibility for the practice and move forward. However, she did by then have concerns about Dr Reddy’s ability to recognise his responsibilities and actually implement what was required, because in the preceding months between October 2002 and April 2003, Dr Reddy had demonstrated behaviour that had actively worked against the support put in place for him.
12.26 Dr Webster, the PCT’s Medical Director met with Dr Reddy to offer
personal
and professional
support. She had told Helen Hughes of her concerns that Dr Reddy was having difficulty in
understanding his responsibilities as a GP and specifically
in securing out of hours cover.
12.27 Apart from staffing
issues, Helen Hughes and Thirza Sawtell had tried to address issues around the
premises. In April 2004, following a series of break-ins at the Belmont Road
surgery, the PCT was left with no alternative but to relocate the practice to
safe premises for the protection of patients and staff.
The relocation costs of conversion, furnishing and equipping the new premises
and renting additional space for the team moved from these premises to make
way for the surgery (as set out in paragraph
11.7 above) was considerable.
12.28 At the hearing she submitted that she did not feel her dual role, and that of Carol Hughes and Jenny Gosling, in both supporting Dr Reddy and investigating the practice was inappropriate, but it could be difficult; it was not ideal but it was the only resource the PCT had available and she considered she was sufficiently professional and experienced that if there were any problems she would report to the PCT.
12.29 The PCT did not give up on Dr Reddy; it persisted in encouraging him to take matters forward whilst continuing to support him but by July – August 2003 he became disengaged from this support and the PCT felt it had got tot the stage where Dr Reddy must take responsibility and take the agreed actions. It was also at this point that the PCT made arrangements to refer Dr Reddy to the NCAA as it wanted an outside view on whether it needed to do anything else. It was not a case of letting Dr Reddy get on with it and seeing the mess he made; the PCT’s prime responsibility was to its patients and letting any doctor fail to that extent and then turning its back on him would be neither responsible nor acceptable.
12.30 Carol Hogg’s evidence supported that of Thirza Sawtell and Helen Hughes.
She submitted (WS ppR98-99) that Dr Reddy failed to acknowledge his responsibility to provide a clean, safe environment for his staff and patients, failed to show any interest in the management of the practice and made no attempt to produce or work to policies of good practice. Dr Reddy continually failed to follow through actions he had agreed and always blamed other people. He had no insight into the basic equipment required to run a practice; although he received the full income of the practice following Dr Desai’s suspension, he continually allowed items to run out and did not replace them, which resulted in Jenny Gosling having to borrow items from other practices in Newham and Tower Hamlets and then the PCT would have to replace them or deduct the cost from the practice income. She spent approximately 80% of her time with this practice, which meant she had very little time for the other fifteen practices in her locality. She was now jointly managing the practice with a colleague and had put in additional resources to try to get the practice up to a reasonable standard as they were starting from a very low level.
12.31 At the hearing she submitted she had held three-way meetings with Dr Reddy
and Jenny Gosling because he had told her he did not feel he was being involved, although she did not think this complaint was justified. She acknowledged the problems in the relationship between Dr Reddy and Jenny Gosling but she felt the responsibility for those difficulties lay mainly with Dr Reddy; she did not experience any problems working with Jenny Gosling or with her personal style.
12.32 Jenny Gosling would raise some issues with Dr Reddy and come direct to her on some of the others. She felt Jenny Gosling became very frustrated because she needed Dr Reddy’s assistance to put policies and procedures in place, but that assistance was not forthcoming.
12.33 Jenny Gosling’s evidence (WS ppR100-107) was that she had various concerns
about Dr Reddy’s clinical practice and his management of the practice. She
found that he failed to take responsibility for the management of the practice and often said that various issues were down to Dr Desai. His time-keeping was a problem and he was late for surgeries on a very regular basis. He often failed to look at the post in a timely manner. It was difficult to get documents back from him for filing, which meant that patients’ records were often out of date.
12.34 She considered he did not know how to deal with staff appropriately; it was difficult for staff to raise issues with him and he hated to be challenged.
12.35 She and Carol Hogg tried to set up weekly meetings with Dr Reddy but this eventually collapsed because he often failed to turn up or cancelled the meeting or wanted to meet only with Carol Hogg. In any event, any actions agreed by him at a meeting were not followed up by him. She found him uncooperative and unwilling to take advantage of her support.
12.36 In summary, she did not consider Dr Reddy’s clinical practice or his management of the practice improved during the time she worked with him; if anything it became worse and she considered he had no insight into his problems.
12.37 At the hearing she submitted that there was no antagonism at the beginning; she had appreciated the situation required diplomacy and tact and that she needed to support Mrs Devgun and she considered she had tried to be diplomatic and tactful.
12.38 She did not know why Dr Reddy would perceive her role not as one of support but as a spy and part of the investigation into the practice; the PCT had asked her to report on things relating to Dr Desai’s stewardship of the practice, not Dr Reddy. The PCT wanted to know what was wrong with the practice and what needed to be put right, but as time went on she did have concerns about and some issues with Dr Reddy and the PCT had made it clear she should go through them rather than talk to Dr Reddy direct.
12.39 The PCT left it entirely up to her what she did and she felt she was an extremely competent practice manager and she knew what the role entailed.
12.40 The situation had deteriorated after Dr Desai retired because Dr Reddy then felt it was his practice and Primary Solutions should have no further role there. The PCT was supportive at the beginning of this period bur its support dwindled towards the end because it felt it had offered considerable support and a lot of resources but Dr Reddy was not fulfilling his side of things. This exacerbated her position of being caught in the middle because at that stage she did not have a working relationship with Dr Reddy and her relationship with the PCT was difficult because of the stance it was taking.
12.41 Dr Reddy’s evidence (WS pA93) was that it was only when Dr Desai retired in April 2003 that he was able to open a practice account in his own name and take responsibility for the practice finances. However, Dr Desai remained his landlord and Dr Reddy submitted that Dr Desai consistently failed in his repairing and maintenance obligations.
12.42 He also submitted (WS pA123) that a lot of the problems were down to his workload. When he took over the practice following Dr Desai’s suspension his workload increased substantially with a patient list of 5,600 for which the practice required three doctors. Although locums were appointed they were not prepared to work outside their contracted sessions or undertake visits and he was therefore responsible for all visits and the out of hours cover between 7.00am and the opening of the surgeries and all the paperwork. His clinical workload was compounded by all the other problems in the practice and he was working under very considerable pressure.
12.43 He disputed (WS pAA1-16) that he was ever late for surgeries and he dealt with the post as quickly as possible bearing in mind the other pressures on his time and the fact he had no assistance from the locums.
12.44 Dr Reddy welcomed the presence of Carol Hogg at the practice meetings because he did not feel he could trust Jenny Gosling. He found it very difficult working with her; she was very authoritarian and he felt that she undermined his position and she was a destabilising influence in the practice generally. He submitted the staff were frightened of her, in particular Mrs Devgun. Although she was highly critical of his clinical practice and management, he questioned whether she did, in fact, do anything to improve matters in the practice. Whatever the reality of the situation, she made him feel that she was collaborating with the PCT and assisting them in their investigations and he felt he had no say on staff, surgery times and the running of the premises.
12.45 Dr Reddy conceded that he had some difficulty in accepting that he was under investigation, given that there had, as far as he was aware, been no complaints from his patients and he had only been at the practice a short while. He submitted he was not told by the PCT, in detailed terms, what the problems were.
12.46 It was always his intention to follow up matters agreed upon in meetings; if this did not happen it was simply because he did not have the time. This was compounded by the fact he did not have his own staff and partner.
12.47 He did not accept that he sought to work against the PCT or failed to face up to his responsibilities as an employer. However, he did accept that he was overwhelmed by the situation he found himself in following Dr Desai’s suspension and by the pressure and volume of work. As a consequence, he simply did not find it possible, in the time available, to address certain matters as fully as he would have liked. His priority was always the treatment of patients and that being so, non-urgent clinical and administrative matters had to take second place. He would have expected Jenny Gosling, in her capacity
as practice manager, to deal with administrative matters on his behalf so that he could concentrate on his clinical responsibilities.
12.48 Whatever the reality of the situation, he got the clear impression that the PCT’s objective was to get rid of him and gain control of the practice. He submitted that rather than provide him with support they, in effect, undermined his position such that he felt totally redundant.
12.49 With regard to mentoring, he was provided with the name of Dr Dave Smith, an independent GP consultant, whom he telephoned on one occasion. Dr Smith had not received any formal instructions from the PCT and never followed up Dr Reddy’s call.
12.50 Dr Reddy also talked to the LMC’s Secretary about mentoring but he had not
felt there was anything lacking in Dr Reddy’s clinical capabilities and thought it was more important Dr Reddy should have a GP partner, together with his
own practice nurse and manager.
12 .51 Although he had met with Dr Webster, the PCT’s Medical Director, she had never advised him in any detail about the type of support she would be able to provide. The offer was on a very casual basis and did not evolve into anything.
12.52 At the hearing Dr Reddy submitted that he had not known Dr Desai was going
to be suspended or that the PCT was bringing in Primary Solutions and Jenny Gosling until they walked into the practice. They did not explain properly why they were being brought in. He was now supposed to be the GP principal but it made him feel they were coming to take away his practice and he was being stabbed in the back whilst he was working so hard.
12.53 He submitted that Jenny Gosling would be very nice when Carol Hogg came
to the practice but when she left she became like Hitler. The first day she came she had gone out to lunch with the locum which made Dr Reddy feel he was being undermined. He claimed she tried to isolate him from the staff and increased their number of hours and rate of pay without consulting him. She started reporting against him and would write to Carol Hogg without first talking to him. There was no way they could work in harmony as a team.
12.54 He never knew how long locum GPs were coming for or saw their CVs so it
was very difficult for him to run the practice. As things got worse between them he concentrated on the patients.
12.55 At the meeting on 15th April 2003 a number of issues such as the future of the
practice, premises, staff etc were discussed. He felt relieved Dr Desai had retired but he felt Jenny Gosling was still spying on him. He wanted to work as a self-employed GP principal but although he was now receiving the practice income he felt there was still a dark cloud over him.
12.56 He contended that although it was alleged he did nothing to help himself between April and October 200,3 he had in fact submitted business plans for
both surgery premises in October 2002 and again in April 2003. He found premises to replace the Shelley Avenue surgery and proposed people as a permanent new GP partner, Practice Nurse and Manager. The PCT had offered to relocate him to the John Telford clinic but because it had not as yet been built he applied for planning permission to convert his house.
12.57 Despite the closure of the Shelley Avenue surgery being confirmed to him at
the meeting on 15th April 2003, Dr Reddy claimed because he had been working so hard and he had been asked to produce a second business plan for both surgeries at the end of March, it was not clear to him that this surgery was to close and he had not wanted to close the branch surgery.
12.58 He had not started special clinics, for example for asthma and diabetes, when
he joined the practice as Thirza Sawtell had told him he should not change the way the practice was run. Moreover, he never had a properly qualified Practice Nurse. He had proposed special clinics but the PCT never approved them.
12.59 Notwithstanding the recommendations from the NHS Tribunal and the GMC Assessment in 2001, Dr Hiew had said Dr Reddy’s clinical skills were like that of an average GP and his understanding was that he was gaining experience by doing different locum posts. He had not believed Dr Desai when he confirmed to him that he would retire one year after Dr Reddy joined
him because Dr Desai would always say that; he knew the truth from other colleagues that it would be at least two years before Dr Desai retired. Dr Desai had also told him he would definitely take other partners.
12.60 Dr Reddy had superficially seen both surgeries before he joined the practice. He felt they were on a par with other practices he had worked in, maybe a
little better. He had joined the practice with good intentions; he had not known what was going on there. Before joining he had not asked about the dispute between Dr Desai and the PCT regarding the pay roll and staff. He had felt he had to sacrifice hoping he would ultimately be able to flourish and he had to wait patiently for Dr Desai to retire. When he got the freedom to run the practice he was confident he would be able to learn how to run it in a short time but he had to start at the bottom. He submitted the partnership agreement stated Dr Desai would act as senior partner until he retired and when informed it stated he would be a full partner Dr Reddy claimed he only found that out afterwards.
12.61 Following the GMC Assessment in 2001 he was aware he needed a mentor. He would contact Dr Hiew and Dr Ranjan about any problems and he was always in touch with them.
12.62 If Dr Ranjan had said in Autumn 2001 that Dr Reddy was unaware of UK
general practice requirements, that was the fault of the UK system which accepted him as a GP principal without training. He had performed very well in his hospital posts so he had been confident he could do any job.
12.63 Dr Reddy felt that if he had agreed common ground with the PCT and it had
given him two or three months’ breathing space with the staff he wanted, he would have been able to take over the practice without the input from the PCT, Jenny Gosling and the locum GPs.
12.64 He submitted the full-time locum GP, Dr Abudu, did some clinics but he did
not share equally on-call, letters, medical reports and emergency calls. He denied Dr Abudu did home visits and administrative duties at Shelley Avenue, at least for the first six to eight months, although he was not sure after that.
12.65 He felt the PCT had a hidden agenda from October 2002; it had wasted money
on locums and temporary staff. Meetings with the PCT were a waste of time and he was frustrated.
12.66 When he joined the practice he had expected the staff to be qualified and fit
for the jobs they were doing.
12.67 When asked why he did not go through the necessary procedures to appoint
staff, Dr Reddy countered by asking why the PCT had allowed him to practice as a GP principal and submitted it should have stopped him when it saw the Partnership Agreement. When it appointed Primary Solutions he claimed this was like a cancer destroying his body and he lost trust in the PCT.
12.68 Dr Reddy submitted he had accepted the findings of the 2001 NHS Tribunal
when he was advised to approach the Deanery. He had been advised to, and did, pass a prescribing examination with 97%. He was aware of the Tribunal’s
recommendation that he should not practice as a single-handed GP but felt that was their observation, although he had joined a partnership so Dr Desai would be there. In any event, since the Tribunal he had made a lot of effort to improve; he did not repeat the same mistakes such as prescribing too many antibiotics and he now prescribed in words and figures. There had been no allegations of wrongdoing from patients. His aim was to improve the quality of care of the patients in a safe environment.
12.69 He worked for the locum service at weekends and on public holidays in his free time
12.70 For Continuing Professional Development (CPD) after 2001 Dr Reddy attended several courses and meetings and he was in touch with senior colleagues and he did locums to see how other practices were run. He also read books, journals and magazines and incorporated what he learnt into his practice. Since he had been suspended he had used the time to attend meetings, attend sessions at other surgeries and clinics at Newham General and King George hospitals, attend GP meetings and practiced smears in Italy.
12.71 He had not instigated any proper, objective audits and there were no risk management systems or system for reviewing complaints in place either before or after April 2003. Dr Reddy submitted that if there were any complaints they would be resolved in an amicable way. They would be discussed but there were no significant complaints when he was there.
12.72 He had contacted the GP tutor at St George’s Hospital to talk about his future and he was trying to find a good GP tutor as his mentor but he had not managed to fix up any meetings. He had not approached the London Deanery.
12.73 When asked what support he thought he would have benefited from that was not provided by the PCT Dr Reddy submitted that he should have been left alone to run his own practice and employ his own staff and choose his own premises but he had not been given any freedoms. He wanted permanent staff, not patchy help; he was a self-employed GP but the PCT did not respect his rights. With the benefit of hindsight he would not have got involved with Dr Desai if he had known he was a bad doctor but he was never given the opportunity to show what he could do. He would have expected the PCT to be honest with him and expose the problems with Dr Desai because then he would known what he was taking on. If Primary Solutions had not been there he would have been fully responsible for the practice and it would have proved far better.
12.74 Dr Reddy had been a GP principal at the Upton Road practice for two and a half years up to 2001. When asked what management skills he had learnt
there, he submitted he had attended monthly practice meetings. but there were
never any audits. If there were any complaints they would sit together to
discuss how to rectify them. As far as he was aware there were no disease
registers at that practice. There was an EMIS computer system for repeat
prescriptions, recall and review and special nurse clinics. He had participated
in the recruitment of a Practice Nurse and a new GP but the Practice Manager
had dealt with recruitment and training of new staff.
Closing submissions
13.1 In closing submissions on behalf of the PCT it was submitted that a clear
example of Dr Reddy’s poor judgment and lack of insight and a clear signal
that he had in truth learnt little or nothing from those proceedings was that less
than six months after the conclusion of the NHS Tribunal proceedings in 2001
he considered Dr Desai’s practice was a suitable one for him to join. Dr Reddy
told the Panel in cross examination he did not believe Dr Desai when he said
he was going to retire in September 2002 but he knew he would reach the
statutory retiring age in 2003. On any reckoning, this was an extremely poor
career choice by Dr Reddy. By this time he was 54 years old and it was
contended he ought to have had the maturity of decision-making to know this
was not an appropriate route for him to follow.
13.2 Having joined the practice, it was contended that Dr Reddy ought to have
appreciated within a very short time what a poorly functioning practice it was.
Instead, he allowed Dr Desai to maintain complete control taking little, if any,
interest himself in staff, premises, equipment or any other aspect of practice
management. He was heavily engaged in clinical work but that was not an
answer. How he envisaged he would be in a proper position to take over
administration and control of the practice when Dr Desai did retire in 2002/3
was a complete mystery as he appeared to have no experience of such tasks
and was doing nothing to equip himself for that task. It was not disputed that
Dr Desai was a strong, if not domineering, personality but it was within Dr
Reddy’s power to leave the practice if he was unable to act as a principal.
13.3 It was further submitted that it was readily apparent that the practice was in
poor shape both as to premises and its lack of systems and the PCT did not
accept that Dr Desai could have somehow masked all the problems.
13.4 The decision to suspend Dr Desai had been a necessary step which Dr Reddy
had not actively questioned. Whilst the decision to bring in Primary Solutions
staff to act as practice manager and to provide locums was not discussed with
Dr Reddy before its implementation, Thirza Sawtell and Helen Hughes had explained that, upon Dr Desai’s suspension, there would be an immediate and urgent lacuna both clinically and administratively due to the vice like grip Dr Desai had exerted over all matters and if there were any gap in covering those matters, the patients would be likely to suffer and immediate assistance was required.
13.5 As Dr Desai was entitled to matters being dealt with confidentially, Dr Reddy could not be told in advance of the PCT’s intention to suspend his partner and so the only possible course open was the one which the PCT adopted. The PCT conceded that in a perfect world, Dr Reddy might have been introduced to Jenny Gosling before she took up her post but time constraints prevented that happening and the PCT questioned whether it really mattered save for a possible short-term affect on Dr Reddy’s sensibilities. It was submitted that if, as alleged, Dr Reddy allowed this to materially and irrevocably affect his ability to work with Jenny Gosling, then he should not have allowed it to do so. He should have acted as any professional man should in such circumstances by registering, if he wished, his displeasure at the manner of appointment adopted by the PCT and then getting on with the job of working with her. Instead, Jenny Gosling’s evidence was that Dr Reddy effectively refused to work with her and relations between them became increasingly strained. The PCT submitted the Panel should conclude that this situation was the result of Dr Reddy’s refusal to engage with Jenny Gosling or the PCT in any meaningful way and to continue to function for almost all intents and purposes as a GP assistant rather than as the sole principal of a troubled practice.
13.6 The PCT submitted it was a recurring theme of Dr Reddy’s case that he
claimed to be unaware of the PCT’s concerns about him. The PCT pointed out he had been told orally and in writing of the PCT’s concerns and this was another sign of his poor insight and understanding of what was required of him.
13.7 The PCT also contended that Dr Desai’s retirement in April 2003 should have
been a defining moment for Dr Reddy as he now had the opportunity to grab
the reins and move forward, but that did not happen and the PCT staff
considered that in the period between April and October 2003 before Dr Reddy was suspended, he did little or nothing to put right the very many faults of the Belmont Road practice and allowed himself to become preoccupied with the PCT’s decision not to grant him succession to the Shelley Avenue practice. It submitted that extremely belatedly and in a highly unsatisfactory manner which necessitated the adjournment of this appeal, Dr Reddy produced documents which he claimed to be chronic disease registers, but this was too little, too late and at no time did he exhibit the necessary skills, abilities or even real intent to turn the practice round in an ordered manner, or to assume proper responsibility for what plainly needed to be done.
13.8 The PCT submitted it was Dr Reddy’s responsibility to appoint a practice
nurse, practice manager and a partner but despite being assisted by the PCT
with sample job descriptions etc he simply failed to do so, instead putting
forward the names of individuals who were unsuitable, such as Dr Appa,
or who did not have appropriate qualifications, such as Mrs Sibley and his
wife.
13.9 The PCT contended that this was part of a recurring and depressing theme that
an intelligent man who has, as the GMC has concluded, reasonable clinical
skills in many regards, could be so lacking in the skills necessary to be a GP in
the modern NHS. Despite the huge input in terms of money and time by the
PCT over the period of a year, with support in the year prior to that as well, Dr Reddy was no more equipped to run this practice in October 2003 when he was suspended than he was in September 2001 when he joined the practice.
13.10 The PCT pointed out that Drs Webster, Grenville and Spiteri had criticised Dr
Reddy’s clinical capabilities whilst Dr Healy considered he had the potential
to be a good GP, although he had reservations about Dr Reddy’s care in some
instances and was critical of his note taking. The PCT submitted this was a sad
indictment of a doctor in his mid 50s who ought to have learnt over the twenty
years he had been medically qualified how to make good and adequate notes
and should have realised that potential long before 2002/2003 when the cases
upon which Dr Healy was commentating occurred.
13.11 The PCT also pointed out that Dr Reddy in cross examination continued to
refute that the criticisms levelled at him by the Independent Review Panel
relating to his care of a child with cystic fibrosis were correct.
13.12 The PCT also made submissions on the effect of the 2005 GMC assessment
Report. It pointed out that Dr Reddy was previously assessed in 2001 and the conclusions of that earlier assessment were not a ringing endorsement as they indicated he was guilty of “real deficiencies” but not of seriously deficient performance. His record-keeping was criticised, his mentor said he was unaware of UK General Practice requirements and that he found difficulty in identifying his deficiencies. Although it was considered that he had made significant progress and improvement had been achieved, the PCT suggested that this was an overly rosy view that was not borne out by subsequent events.
13.13 It was clear from the Assessors’ 2005 report that they found Dr Reddy to be
pleasant and sympathetic to his patients and they formed the view that Primary
Solutions and the PCT prevented him from functioning as a GP principal. The
PCT refuted this conclusion and contended it was far too favourable to Dr
Reddy. It submitted that he was encouraged to take a full and proper part in
the steps to run and improve the practice but he failed to take advantage of the
very real opportunity offered to him and he unreasonably refused to work with
the PCT from October 2002 onwards. He did not want their help in the way in
which it was provided and consequently disengaged consciously or
unconsciously, acting not like a GP principal but as no more than a salaried
GP removed from all decision making. The PCT submitted it was for the Panel
to form its own view about the motivation of Dr Reddy from October 2002
onwards and it was in no way constrained by the views of the GMC Assessors.
13.14 In any event, the GMC Assessors had found Dr Reddy’s performance as a GP
acceptable in seven areas, cause for concern in seven areas and unacceptable
in one area, namely staff supervision. Whilst the Assessors had considered Dr
Reddy had shown himself willing and able to improve his performance, the
PCT questioned the accuracy of that assessment given that Dr Reddy had
shown his apparent willingness to improve to the NHS Tribunal and to the
GMC Assessors in 2001, but had not done so in the last five years.
13.15 The PCT asked what could right the wrongs in Dr Reddy’s skills and
submitted the position has become irremediable. It also submitted that if the
Panel considered contingent removal was a sufficient remedy then extensive
conditions would be required to ensure that Dr Reddy achieves the appropriate
skill base before he is able to resume practice as a GP.
13.16 The PCT pointed out that Dr Reddy was keen to blame others but not to accept
responsibility or blame for any of his own failings. Although he said he had
attended courses and meetings, the PCT questioned what he had learnt from
his academic experiences and submitted Dr Reddy’s lack of insight meant he
had learnt little or nothing and part and parcel of that lack of insight was his
lack of motivation to learn or to change.
13.17 The PCT submitted that even if Dr Reddy’s sensibilities had been affected by
the way the situation was dealt with, he should not have allowed that to turn a
period of development and progression into one of disaster and bitterness. He
was no further forward four years after the last NHS Tribunal and GMC
Assessment and he did not have the ability to function in a regularised NHS.
All of this indicated to the PCT that the end of the road had been reached.
13.18 In closing submissions on behalf of Dr Reddy it was submitted that the
criticisms made of Dr Reddy by the PCT were identical to those which were
the subject of scrutiny by the GMC and that the GMC Assessors had access to
similar evidence both factual and expert to that available to the Panel. In
addition, the GMC assessment involved a wide-ranging investigation into Dr
Reddy’s clinical skills. It was submitted that although the Assessors’
conclusions do not eclipse the function of the Panel, which exercises an
independent jurisdiction, nonetheless the conclusions of the Assessors ought to
be highly influential in terms of the outcome of this appeal.
13.19 It was further submitted that the criticisms levelled against Dr Reddy had to be
evaluated against the backgound of Dr Desai’s highly controlling, manipulative and exploitative force and the fact that he was unlikely to have afforded Dr Reddy any control or effective management exposure within the practice. Dr Desai had forced Dr Reddy to shoulder an unacceptable burden of out of hours work, on the basis he was not prepared to subsidise the use of an out of hours agency and/or because such agencies would be unwilling to work for Dr Desai. He only belatedly made available to Dr Reddy for this appeal certain crucial documents in return for Dr Reddy’s assistance in connection with his own forthcoming GMC conduct hearing. The Panel were accordingly asked to consider the reality of Dr Reddy’s scope for effecting improvements to the management of the practice between October 2001 and October 2002.
13.20 It was contended that the practice Dr Reddy “took over” following the
suspension of Dr Desai in October 2002 was primitive in terms of its facilities
and organisation. The facilities were poor, the equipment inadequate and the
premises dilapidated. The organisation of medical records was idiosyncratic
and only embryonic Disease Registers were in existence and, such as they
were, they were not available to Dr Reddy. The PCT had agreed that until his
retirement in April 2003, Dr Desai retained a vice-like grip upon the finances
and made it clear to Dr Reddy that he would not reimburse expenditure upon
the premises which did not meet with his approval.
13.21 It was submitted that following the suspension of Dr Desai, Dr Reddy had a
legitimate expectation that he would, subject to appropriate guidance and
support, have some freedom to manage the practice. However, the GMC
Assessors concluded that following Dr Desai’s departure, Dr Reddy’s role was
effectively that of a salaried doctor and he was never given an opportunity to
run his own practice independently. The failure of the PCT to consult with Dr
Reddy about the involvement of Primary Solutions and the employment of
Jenny Gosling, who had no terms of reference in respect of her role at the
practice, her heavy-handed manner and her failure to involve Dr Reddy in key
management decisions such as the termination of the contract with the practice
nurse, the choice of locum practitioners and the modification of Mrs Devgun’s
role as practice manager, were all cited as evidence in support of this
conclusion. Accordingly, Dr Reddy’s conclusion that Primary Solutions and
the PCT were effectively taking over his practice was neither irrational nor
extreme and it was contended that the practice was being run by proxy by the
PCT.
13.22 It was also contended that the basis of the PCT’s decision to investigate Dr
Reddy was not properly explained or examined. Thirza Sawtell had
acknowledged that the PCT’s concerns related principally to Dr Desai. In
the absence of a clear and legitimate basis for an investigation into Dr Reddy’s own practice, it was submitted that it was not unreasonable for Dr Reddy (rightly or wrongly) to consider that the PCT was antipathetic in its attitude to him even from the outset.
13.23 It was further submitted that the decision by the PCT to offer support whilst at
the same time undertaking an investigation was always likely to engender
conflict, especially when the same personnel were intended to undertake both
functions. Dr Reddy’s perception of Jenny Gosling as a “spy” for the PCT was
understandable as she was placed in the invidious position of offering support
whilst at the same time reporting matters of concern directly to the PCT rather
than discussing them with Dr Reddy. It was contended that if the decision to investigate Dr Reddy’s practice was reasonable, then it was incumbent upon the PCT to maintain a clear delineation between the investigation team and the support team and to deal with him with scrupulous fairness and courtesy.
13.24 The PCT witnesses had agreed that until Dr Desai’s retirement in April 2003,
Dr Reddy’s ability to manage the practice would have been profoundly
affected by Dr Desai’s ongoing control of the financial situation.
Unfortunately, his retirement coincided with Dr Reddy being advised at the
meeting on 15 April 2003 of the PCT’s decision to close the Shelley Avenue
practice. It was submitted that this was a personal and professional loss to Dr
Reddy; he had built up a relationship with the patients at that surgery and its
closure represented to him a loss of status. Dr Reddy had difficulty in
appreciating that a final and irrevocable decision had been made by the
workforce group without consulting him.
13.25 It was submitted that following the meeting on 15th April 2003, Dr Reddy
demonstrated energy and commitment in relation to future plans for the
practice as evidenced by his plans for the relocation of the practice and his
proposals for the future recruitment of partners and members of staff. The
PCT felt his energies were insufficiently focussed upon PCT requirements but
it was likely that by April 2003 his previous experience with the PCT had
affected his judgement as to the motivation of the PCT. In any event, the
decision to refer Dr Reddy for an NCAA assessment was taken only four
months after Dr Desai’s retirement, in August 2003, and the decision to
suspend him made in October 2003.
13.26 Accordingly, it was submitted it was unfair to judge Dr Reddy’s management
and organisational skills on the basis of the PCT’s experience of him either
between October 2002 and April 2003 or between April and October 2003. At no stage was he given an opportunity to make decisions or exercise independent judgements in respect of the management of the practice. He considered that the practice had been taken over by the PCT and it was submitted that this perception was accurate.
13.27 It was further submitted that Dr Reddy had tried to improve upon Dr Desai’s
handwritten disease registers by transcribing information onto the computer , which involved him attending a nearby practice in order to familiarise himself with the computer system. He had subsequently written protocols for the management and review of patients with chronic diseases.
13.28 It was contended that although in the absence of a formal system of review
Dr Reddy relied upon opportunistic review of patients with chronic diseases
and placed appropriate reliance upon hospital investigations and testing, it should be noted that the selection of notes for scrutiny by audit remained unclear and the possibility of biased sample remained, no input from Dr Reddy was sought by Dr Grenville or Dr Webster before their conclusions were formed and the GMC Assessors criticised the audit process. When Jenny Gosling was practice manager and the PCT were involved in the management of the practice, no dedicated nurse-led clinics were initiated. Moreover, Dr Reddy was questioned and underwent objective testing of his knowledge and management of chronic disease processes as part of the GMC assessment process
13.29 Dr Reddy was criticised for his lack of insight in joining Dr Desai’s
partnership but it was submitted that he did so believing Dr Desai’s retirement
was imminent and he then envisaged recruiting further partners who would be, in his judgement, both competent and sympathetic, but he was unable to carry his plan into effect before his referral to the NCAA and his subsequent suspension by the PCT.
13.30 Dr Reddy was willing to learn and improve and there could be no doubt that
he would accept support and guidance in respect of his management skills if such support was unambiguous and tactful. It was submitted there was scope for such a low-key approach as Dr Reddy’s core clinical competence, his ability to enjoy good relationships with his patients and his sympathy as a family practitioner were not disputed.
13.31 If the Panel felt the blame lay with both sides, it would seem wholly
disproportionate for Dr Reddy to be removed from the Performers List and the
Panel might feel attracted to the middle way of imposing some conditions on a
contingent removal. In that event Dr Reddy’s only caveat was that there
should initially be some time-limit imposed upon those conditions and it was
submitted on his behalf that this was not an unreasonable request.
Submissions relating to
contingent removal
14.1 At the Panel’s request, prior to the end of the appeal the parties were invited to
consider conditions which would be acceptable to them and workable in
practice should the Panel ultimately consider contingent removal to be the
appropriate remedy. The PCT suggested that if the Panel did not accept Dr
Reddy had reached the end of the road the following conditions should be
imposed on him for patient protection and the efficient running of the
Performers List:
(1) To practise only as a salaried GP within a practice with a minimum of three partners
(2) Not to engage in single-handed practice
(3) To work under the supervision of a senior GP colleague agreeable to the PCT who holds MRCGP or equivalent or who is a recognised trainer, for a period of at least twelve months after returning to practice
(4) Not to undertake any work as a locum or with a deputising service except as part of any re-education or training programme undertaken
(5) To satisfactorily complete and pass the “Fresh Start” Course by 30 April 2006
(6) Any re-education or training programme undertaken to remedy the deficiencies in practice identified by the PCT to take place outside the area of Redbridge PCT at an advanced NHS training practice. No work to be undertaken involving the management and treatment of patients other than as part of such re-education or training activities until these have been completed to the satisfaction of the Regional Director of Postgraduate General Practice Education.
(7) To co-operate with the PCT in providing it with information concerning any re-education or re-training programme undertaken, or any other relevant information reasonably required by the PCT
(8) To co-operate with the PCT, to any extent necessary, to find a permanent provider to take over responsibility for the care of those patients for whom Dr Reddy was previously responsible
14.2 Dr Reddy did not suggest any conditions. He was asked by the Panel to
comment on the PCT’s suggested conditions. He submitted that it was a very
difficult thing to answer. He would like a mentor of his choice. He had learned one computer system and he needed to practice the Phoenix system. He
submitted he was the victim and he had been deprived of his freedom. He
asked why he had been given a list of patients and asked to submit business
plans . It was easy for others to comment but he was proactive. Taking away
his freedom did not mean he was lacking in insight. He asked why Drs
Webster, Grenville and Spiteri had discriminated against him and why they
had not discussed issues with him. Although he had had meetings with the
PCT they said one thing and the words looked very attractive but inside the
PCT had very different motives.
14.3 At this point Dr Reddy was given a short adjournment to consider the PCT’s
suggested conditions with his representatives. Counsel for Dr Reddy subsequently submitted that her impression was that Dr Reddy wished to continue in his job as a GP principal with full freedom for one year, but if contingent removal was imposed upon him he was reluctant to accept conditions without an end point and he would want a time-limit to be imposed on any attached conditions.
14.4 Dr Reddy confirmed at this point that he would agree to a mentor of his choice
but he did not need supervision and it would be totally unacceptable to him.
14.5 The PCT submitted that even in his responses to its draft conditions and even
allowing for his reluctance to submit to them, the overwhelming picture was
of a man who felt he had been greatly wronged and who should be left to
practice as a GP principal without any supervision. His caveats to the proposed conditions did not instil much confidence in the PCT but if the Panel were to decide to contingently remove him the PCT would attempt to work with him.
D. Consideration of the Evidence
Unsuitability
15.1 The PCT had requested we should determine that all of its allegations with
regard to practice issues or clinical management went to both issues of
efficiency and suitability and the overlap could not and should not be
overlooked.
15.2 We accepted the overlap between the grounds of efficiency and unsuitability and
agreed the allegations could go to both issues. However, we thought it was
equitable to consider them separately and as if distinct where possible as
otherwise one would add little or nothing to the other. Accordingly, we first
considered the evidence relating to the grounds given by the PCT which it
claimed went to unsuitability in sections 5 to 8 above.
15.3 H aving therein concluded that the PCT’s concerns relating to Dr Reddy should
more properly be considered under the ground of efficiency, we turned to
consider whether any or all of the evidence relating to those issues and/or to the
issues referred to in sections 9 to 12 above, together with the parties’ closing
submissions in section 13 above, demonstrated Dr Reddy’s continued inclusion
in the Performers List would be prejudicial to the efficiency of services.
Efficiency
16.1 We first considered the evidence relating to the allegations relating to clinical issues in the context of efficiency. These included:
· inadequate care by reason of the lack of proper systems of chronic disease management and instances of poor actual care in Audit
3 and 4 (see paragraphs 6.1 to 6.22 above)
· the care and treatment of patients 1 and 2 (see paragraphs 10.3 to 10.6 above)
· the findings of the Independent Review Panel (see paragraphs 10.7 to 10.9 above)
· complicity in the breach of Dr Desai’s terms of suspension (see paragraphs 10.10 to 10.12 above)
· the issues of record-keeping, filing and prescribing were allied to the PCT’s allegations relating to the clinical care of individual patients (see paragraphs 10.13 to 10.24 above).
16.2 In considering these issues we were aware of the conclusions of the GMC
Assessors that in the right conditions Dr Reddy’s performance was clinically
acceptable (although they acknowledged he lacked knowledge in practice
management). The Assessors concluded that Dr Reddy was a polite, courteous
and sympathetic doctor who cared for his patients and had a good relationship
with them, that he communicated well with his patients and treated them with
respect, respected their confidentiality and dignity, assessed his patients
appropriately, carried out appropriate investigations prior to making a diagnosis
and made appropriate referrals. They formed the view that Primary Solutions
and the PCT prevented him from functioning as a GP principal
16.3 The PCT suggested that this was an overly rosy view that was not borne out by
subsequent events and it was far too favourable to Dr Reddy.
16.4 It was clear to us that Dr Reddy is an intelligent man with, as the GMC
concluded, reasonable clinical skills in many regards. It was also clear to us that
he had faced enormous difficulties when he joined the practice, when Dr Reddy
was suspended and when Dr Reddy retired. We were also concerned about the
sampling method for Audits 3 and 4.
16.5 However, having considered all of the evidence, we did not consider Dr Reddy
made serious or realistic attempts to improve matters during his time at the
practice. By his own admission, his chronic disease management was
opportunistic; whilst we accepted things were not going to change whilst Dr
Desai was in control, once he retired we considered Dr Reddy should have
begun to take some positive steps to improve chronic disease management. We
heard conflicting evidence from the PCT’s witnesses and Dr Reddy about who
was prepared to help whom in the setting up of disease registers but having had
the benefit of seeing and hearing Dr Reddy give evidence and answer questions
at the hearing, we regret to say that we came to very different conclusions to the
GMC Assessors as we formed the strong view that he had no real insight into
what was required and we were not convinced by his version of events. Whilst
we appreciate that he nursed a real grievance about the way the PCT parachuted
Jenny Gosling into the practice, we concurred with the PCT that he should have
acted professionally and registered his displeasure at the manner of her
appointment and then got on with the job of working with her and utilised the
support and assistance she offered to set up disease registers, instead of
attempting to compile his own very basic form of disease registers with his
wife, who was not a member of staff.
16.6 We noted Dr Reddy had submitted that if he was permitted to return to practice he would expect to make very significant improvements to his chronic disease management and he was confident these improvements would be successful in a practice with the appropriate sources in terms of staffing and IT support, but given that he had failed from April to October 2003 to take any realistic steps to improve chronic disease management, we were concerned that he was just telling us what he thought we wanted to hear rather than what he actually intended to do.
16.7 When we turned to consider the evidence relating to patients 1 and 2, the
findings of the Independent Review Panel and Dr Reddy’s complicity in the
breach of Dr Desai’s terms of suspension, we were concerned that a pattern
seemed to emerge of Dr Reddy’s inability to accept he had acted incorrectly and
his predisposition to blame others without accepting any responsibility himself. For example, in cross examination Dr Reddy continued to refute that the criticisms levelled at him by the Independent Review Panel relating to his care of a child with cystic fibrosis were correct.
16.8 We were also extremely concerned by the standard of Dr Reddy’s record
keeping. We heard evidence relating to his scanty and illegible notes and the
lack of a system for review of medication and repeat prescribing, which Dr
Grenville submitted presented real risks to patient safety. We also heard
evidence that locum GPs working at the practice under temporary
arrangements had raised concerns with the PCT regarding historic record
keeping and filing and we noted that subsequently the PCT has had to
undertake a large amount of work to sort and summarise the records so that
GPs working at the practice could do so safely.
16.9 We noted that Drs Webster, Grenville and Spiteri had criticised Dr Reddy’s
clinical capabilities whilst Dr Healy considered he had the potential to be a
good GP, although he had reservations about Dr Reddy’s care in some instances and was critical of his note taking. The PCT submitted this was a sad
indictment of a doctor in his mid 50s who ought to have learnt over the twenty
years he had been medically qualified how to make good and adequate notes
and should have realised that potential long before 2002/2003 when the cases
upon which Dr Healy was commentating occurred.
16.10 Both Dr
Healy and Dr Reddy stated that should he be allowed to return to
practice,
Dr Reddy would endeavour to make
improvements and record
entries in a structured and consistent format and that he accepted the need to file all letters, test results and reports with the patient’s records as soon as they were received. Dr Healy submitted that as far as he could see, no patient had come to any harm from any of Dr Reddy’s prescriptions.
16.11 Again, we felt that Dr Healy and Dr Reddy were telling us what they thought
we wanted to hear rather than what Dr Reddy actually intended to do. We
were not comforted by Dr Healy’s statement that no patient had come to any
harm from any of Dr Reddy’s prescriptions as we did not consider this to be a
suitable test of the standard of Dr Reddy’s record keeping. Likewise, we were
not reassured by the way Dr Reddy, whilst acknowledging unfiled medical
correspondence and test results had been found upstairs at the Belmont Road
surgery, dismissed them as being of no interest to him so why would he look
and saying that he thought it was just rubbish up there and asked why he would
have to touch dirty and nasty things. We considered this to be a grossly
immature and inappropriate attitude.
16.12 We went on to next consider the evidence relating to the allegations relating to
organisational/managerial issues in the context of efficiency. These included:
· practice premises and equipment (see paragraphs 11.1 to 11.25 above)
· the Shelley Avenue surgery (see paragraphs 11.26 to 11.28 above)
· the Belmont Road surgery (see paragraphs 11.29 to 11.36 above)
· the staff (see paragraphs 11.37 to 11.71 above)
· the IT system (see paragraphs 11.72 to 11.73 above)
16.13 The PCT had contended that Dr Reddy ought to have appreciated within a
very short time of joining the practice what a poorly functioning practice it
was. It questioned how Dr Reddy could have allowed Dr Desai to maintain
complete control taking little, if any, interest himself in staff, premises,
equipment or any other aspect of practice management. It submitted that being
heavily engaged in clinical work was not an answer and contended that how Dr
Reddy envisaged he would be in a proper position to take over administration
and control of the practice when Dr Desai did retire in 2002/3 was a complete
mystery as he appeared to have no experience of such tasks and was doing
nothing to equip himself for that task. It also submitted that it was readily
apparent that the practice was in poor shape both as to premises and its lack of
systems and the PCT did not accept that Dr Desai could have somehow masked all the problems. It contended that Dr Desai’s retirement in April 2003 should have been a defining moment for Dr Reddy as he now had the opportunity to grab the reins and move forward, but that did not happen and the PCT staff considered that in the period between April and October 2003 before Dr Reddy was suspended, he did little or nothing to put right the very many faults of the Belmont Road practice and allowed himself to become preoccupied with the PCT’s decision not to grant him succession to the Shelley Avenue practice and at no time did he exhibit the necessary skills, abilities or even real intent to turn the practice round in an ordered manner, or to assume proper responsibility for what plainly needed to be done.
16.14 Dr Reddy contended that the two surgeries were in poor condition because Dr
Desai did not fulfil his repairing and maintenance obligations as landlord and
he was reluctant to authorise any expenditure on them. Dr Reddy was concerned that if he incurred expense without Dr Desai’s authority there was a real risk he would not be reimbursed. He also claimed that there was a degree of improvement once Dr Desai retired and that he did purchase some equipment between April and October 2003, although he conceded the equipment and facilities in the practice remained at a fairly poor level because of Dr Desai’s lack of co-operation, the breakdown of trust with Jenny Gosling, his being overworked, there being no practice nurse or permanent practice manager, and because he did not want to invest a lot of time and money in the premises when he was planning to relocate. At the hearing he complained that even after Dr Desai had retired he was not allowed to run the practice; the PCT ran it.
16.15 We heard
evidence from Helen Hughes that the PCT
had been aware the
premises had been neglected for many years, but when, following Dr
Desai’s
suspension, she visited them in October 2002, she was shocked and not
prepared for the state of the neglect and she instructed Jenny Gosling
and Mrs
Devgun, to identify all concerns and make improvements. She also told us that
despite Carol Hogg and Jenny Gosling supporting Dr Reddy by addressing a
number of issues, they informed her they felt Dr Reddy would block any
progress being made, specifically in relation to engaging a cleaner for the
practice. Of special concern to her was an interview with Dr Reddy in February
2003; at that point, Dr Desai had been suspended for five months but Dr Reddy
failed to take any responsibility for the practice environment and equipment
and he continued to blame others. Once he became the sole responsible
practitioner following Dr Desai’s retirement in April 2003, he still did not
make any improvements to the internal condition of the practice despite
being in receipt of the full practice income. She said that at meetings he always
devolved funding responsibilities to the PCT and throughout this time he did
not acknowledge any responsibilities for the health and safety of staff and
patients, deferring responsibilities to Dr Desai.
16.16 We also heard conflicting evidence relating to the future plans for the two
surgeries following Dr Desai’s retirement. We noted that the PCT had
written to Dr Reddy at the end of March 2003 to inform him that following Dr Desai’s retirement, responsibility for patients registered at the Shelley Avenue branch surgery should be passed to Newham PCT and followed this letter up with a meeting with Dr Reddy on 15th April 2003 at which it was agreed he would write to the PCT appealing its decision by the end of April. Instead, Dr Reddy wrote to the PCT stating the patients from the Shelley Avenue practice would be moving to new premises in Newham from 16th May 2003, which was in direct contravention of the PCT’s decision.
16.17 At the hearing Dr Reddy submitted that the first time he was told the Shelley
Avenue surgery was being closed was at the meeting on 15th April 2003. When
reminded about the earlier letter to him from the PCT he claimed he had been
confused by the PCT’s request for a business plan for both premises and when
challenged that he had ignored this decision and simply gone ahead with his
own plans, Dr Reddy replied that he should have been in charge but the PCT
treated him like a puppet.
16.18 We heard evidence with regard to the Belmont Road surgery that in April 2003
the PCT informed Dr Reddy that as the responsible practitioner in receipt of
the practice income he would now be responsible for paying rent to Dr Desai
as the landlord, although Dr Desai consistently informed the PCT that he did
not receive any rent from Dr Reddy. The PCT submitted that neither Dr Reddy nor Dr Desai demonstrated any regard for the condition of the practice which the staff and patients were being subjected to, it was impossible to engage with Dr Reddy in relation to his responsibilities for the practice environment or with Dr Desai in terms of the building itself as they were locked into a personal dispute around payment of rent and it was the patients and staff who were suffering but neither doctor seemed to care about that and when an intruder repeatedly broke into the premises in April 2004 to sleep rough there the PCT was left with no alternative but to relocate the practice overnight to the John Telford Centre, which was now almost completed.
16.19 We were informed the relocation costs included Ł150,000 conversion costs, Ł65,000 per annum to rent alternative premises for the team previously in those premises and Ł20,000 for furnishing and equipping the practice, because the furniture and equipment at Belmont Road was too outdated and in really poor condition and was the property of either Dr Desai or Dr Reddy.
16.20 As regards staffing issues, we noted that that historically, Dr Reddy had
advised the PCT he was completely powerless within the practice because Dr
Desai had taken full control. He had never taken any responsibility for such
issues as staff management or practice income and so when Dr Desai was suspended the PCT was concerned there would be an immediate and urgent lacuna both clinically and administratively due to the vice like grip Dr Desai had exerted over all matters and if there were any gap in covering those matters, the patients would be likely to suffer and immediate assistance was required.
16.21 The PCT therefore engaged staff support for Dr Reddy over and above
Supporting him in the running of the practice. It engaged Jenny Gosling at a cost of Ł1250 per week, and a GP locum to support Dr Reddy at a cost of Ł1200 per week from October 2002 until Dr Reddy’s suspension in October 2003. The GP support was increased to between 1.5 and 2 WTE GPs depending on the availability of practice nurses. Moreover, Carol Hogg, the PCT’s Primary Care Manager, invested a high proportion of her time into the practice. Although her role was to support 16 practices in the locality, from October 2002 she invested at least 50% of her time in this practice alone. From October 2003, when Dr Reddy was suspended, that time increased to 80%, and from March 1994 to 90% when the PCT could no longer afford the consultancy costs and so decided to temporarily manage the practice using its own management resources.
16.22 We noted that at the meeting on 15th April 2003 it was agreed that the existing
temporary support would stay in place until the permanent appointments were
made and that Dr Reddy expected the PCT to pay for this support, even
though he was now in receipt of the full practice income. The PCT’s evidence
was that from October 2002 to October 2003 the cost of the temporary staff
was in the region of Ł160,000 and that sum did not include the costs of Carol
Hogg supporting Dr Reddy or the involvement of Thirza Sawtell This meant
resources were being taken away from other practices to support this situation.
16.23 We noted the PCT incurred further expenditure following Dr Reddy’s
suspension in October 2003 when it decided the focus of support needed to change to specialist clinical support as patients with chronic diseases were not being appropriately managed. The PCT engaged a company called Chilvers McCrea to establish disease registers, identify patients who had not been reviewed, undertake clinical and medication reviews and put in place systems in the practice to ensure ongoing management of patients’ conditions. This was in addition to the GPs and practice manager running the practice on a day to day basis and from October 2003 to March 2004 cost the PCT on average Ł18,000 per month. Although the PCT held the practice income of approximately Ł192.000 per annum, less the salary paid to Dr Reddy, it submitted this was not sufficient and the PCT entered into an overspend situation for 2003/4 resulting in it having to give notice to Chilvers McCrea in April 2004, partly because they had completed the set tasks, but also because the PCT could no longer afford to pay them.
16.24 We also noted that to try and reduce costs the PCT engaged long term locums, who joined its directly employed scheme and it had to manage the practice through Carol Hogg and the PCT’s access facilitator.
16.25 Whilst we appreciated that the circumstances relating to this practice were
unique and the PCT could not initially have done anything other than engage
additional temporary support for Dr Reddy, we felt Dr Reddy failed to even
begin to set out about taking the first steps to alleviate the situation. The PCT had outlined to him clear processes for appointing a permanent partner, a practice nurse and a practice manager but he failed to follow those processes and instead attempted to pursue his own agenda for appointing staff who were unsuitable. We noted that it was not necessarily the case that the PCT disagreed with whom should be recruited but that Dr Reddy did not follow the national protocols for recruitment, let alone the additional conditions the PCT felt it was necessary to put in place to ensure suitably qualified staff were selected and recruited. Dr Reddy told us that whilst he recognised the PCT felt obliged to pursue certain recruitment protocols, at the time he felt swamped and blocked by bureaucracy and that his patients’ interests would have been best served by the early appointment of Dr Bhatnagar, Mrs Sibley and his wife, whom he felt, with training would make a very competent practice manager. He had candidates ready, willing and able to take up the posts, but notwithstanding the urgency of the situation the PCT were adamant the recruitment protocols should be adhered to. He went on to say that when Primary Solutions and Jenny Gosling came into the practice he felt they were taking over and isolating him. He compared it to a cancer destroying his body and said he lost trust in the PCT. He submitted Jenny Gosling acted like Hitler and there was no way anyone could work in harmony as a team and questioned why the PCT had allowed him to practice as a GP principal only to fail to respect his rights.
16.26 We felt this evidence demonstrated Dr Reddy’s immature and naďve attitude.
Given the dire circumstances of this practice and Dr Reddy’s lack of experience as a GP principal, we felt it was completely unrealistic of him to expect to have a free hand in making all the necessary appointments. We were aware that the GMC Assessors considered Dr Reddy had not been fairly treated by the PCT insofar as he was never treated as an independent contractor and given the opportunity to run his own practice but our unanimous impression of him as a witness was that he could not safely be left to do this as he had a profound lack of insight into the current requirements of modern medical practice.
16.27 We also noted the amounts expended by the PCT on this practice resulted in
resources being taken away from other practices to support the situation and
an overspend situation in 2003/2004. We heard evidence that the PCT had
never had to invest so many resources or so much time and money in any of
the other GP practices in the area and this had a significant impact both on the
PCT’s ability to improve and drive forward improvements within this practice
and on the overall efficiency of services within this PCT on a number of
levels. On a financial level the funding of this practice came at the cost of
other developments within the PCT and on a resources level Carol Hogg and
Helen Hughes had to spend a disproportionate amount of time in this practice.
We felt that if there had been any convincing evidence that Dr Reddy desired
to work with the PCT to ameliorate the situation, the expenditure would have
been justified on a temporary basis, but in circumstances such as these where
the evidence was that despite the huge input in terms of money and time by
the PCT over the period of a year, with support in the year prior to that as
well, Dr Reddy was no more equipped to run the practice when he was
suspended in October 2003 than he was in September 2001 when he joined the
practice and his continued inclusion in the Performers List could not be
interpreted as other than prejudicial to the efficiency of the services
16.28 Turning to consider the IT system we noted that Dr Reddy’s evidence was that
as he was planning to relocate the premises there was no point in investing in a
new computer system and he claimed he was not able to update the Seetec computer system Dr Desai had installed because Dr Desai owed Seetec
Ł9,800. He told us that in October 2002 he managed to obtain a printer from
the PCT and was than able to issue prescriptions by computer, assuming it was
working but it used to fail on average a few times a month. In the absence of a
computer review /recall system he simply had to rely upon opportunistic
review during routine consultations. At the hearing Dr Reddy conceded that
the computer system was not satisfactory but when reminded that the practice
was at that time responsible for IT and asked what steps he had taken, he said
he had told the PCT about the problems and that Seetec was sending invoices.
16.29 Yet again we considered that this was an example of what the PCT had
described as a recurring and depressing theme; when Dr Reddy took over the
practice it was incumbent upon him to ensure there was an adequate functional
computer system which is the cornerstone of modern general practice and yet,
notwithstanding the fact he was now receiving the full practice income, he
would tell the PCT and expect it to take responsibility without being prepared
to expend any of his own time or practice income on the problem.
16.30 We went on to next consider the evidence relating to the allegations relating to
professional issues in the context of efficiency. These included:
· the previous investigations into Dr Reddy’s performance and his reaction to the outcome of those investigations (see paragraphs 12.1 to 12.8 above)
· the evidence relating to the actions of Dr Reddy and the actions and involvement of the PCT from the time of Dr Desai’s suspension in October 2002 to Dr Reddy’s own suspension in October 2003 (see paragraphs 12.9 to 12.74 above)
16.31 Dr Reddy was investigated by the National Health Service Tribunal in 2001,
which concluded that it would have removed Dr Reddy from the list and nationally disqualified him but for the evidence of Dr Hiew, who had taken Dr Reddy under his wing and who considered that he could practice safely in a properly supported setting, and so no such order was made. It also commented that had it had the power to do so, it would have imposed conditions upon Dr Reddy working as a single-handed GP, but at that time there was no statutory basis for it to do so. Dr Reddy was also subject to a GMC Performance Assessment later that year, when the assessors concluded that he was guilty of real deficiencies but not of seriously deficient performance. Whilst his record
keeping was criticised and he was said to be unaware of UK General Practice
requirements and that he found difficulties in identifying his deficiencies, the
assessors considered there was good evidence of significant progress having
been mad and that Dr Reddy would benefit from continued supervision and
mentorship from colleagues. In 2005 Dr Reddy was subject to a further GMC
Assessment instigated by the PCT on the recommendation of the National
Clinical Assessment Authority, when the assessors found that Dr Reddy was
pleasant and sympathetic to his patients and they formed the view that Primary
Solutions and the PCT prevented him from functioning as a GP principal. They concluded that Dr Reddy’s professional performance was not deficient and that he had good medical knowledge to practise as a GP. However, they did consider he lacked knowledge in practice management and it would be in his interest to approach the PCT and his local post-graduate tutor to seek the
appointment of a mentor, acceptable to him, for a period of twelve months to
enable him to improve his practice management and IT skills. They also
considered Dr Reddy should demonstrate he was keeping his knowledge up to
date by producing a Personal Development Plan in consultation with his
mentor to enable him to demonstrate continuous improvement in his medical
knowledge.
16.32 Whilst Counsel for Dr Reddy acknowledged that the assessors’ conclusions
did not eclipse our function as an independent jurisdiction, she submitted their conclusions ought to be highly influential in terms of the outcome of this
appeal.
16.33 Counsel for the PCT submitted it was for the Panel to form its own view about
the motivation of Dr Reddy from October 2002 onwards and we should in no
way be constrained by the views of the GMC assessors. She questioned the
assessors’ conclusion that Dr Reddy had shown himself willing and able to
improve his performance, given that Dr Reddy had shown his apparent
willingness to improve to the NHS Tribunal and to the GMC assessors in
2001, but had not done so and he was no further forward five years after the
last NHS Tribunal and GMC Assessment.
16.34 Dr Reddy told us that he had accepted the findings of the 2001 NHS Tribunal
when he was advised to approach the Deanery and that he had been advised to,
and did, pass a prescribing examination with 97%. He said he was aware of
the Tribunal’s recommendation that he should not practice as a single-handed
GP but felt that was their observation, although he had joined a partnership so
Dr Desai would be there. He told us that since the Tribunal he had made a lot
of effort to improve; he did not repeat the same mistakes such as prescribing
too many antibiotics and he now prescribed in words and figures. There had
been no allegations of wrongdoing from patients. His aim was to improve the
quality of care of the patients in a safe environment. He also told us that
following the GMC Assessment in 2001 he was aware he needed a mentor and
that he would contact Dr Hiew and Dr Ranjan about any problems and he was
always in touch with them. With regard to the recent recommendation for mentoring he had contacted the GP tutor at St George’s Hospital to talk about his future and he was trying to find a good GP tutor as his mentor but he had not managed to fix up any meetings, although he had been provided with the name of Dr Dave Smith, an independent GP consultant, whom he telephoned on one occasion, but. Dr Smith had not received any formal instructions from the PCT and never followed up Dr Reddy’s call. He had not approached the London Deanery.
16.35 We acknowledged that Dr Reddy had received no formal training in general
practice in the UK and yet due to European reciprocal arrangements he was
able to enter general practice here with only a little experience of Italian
general practice and this made his task of performing as a competent GP very
difficult. However, we considered that as a professional man he should have
had the insight to realise there would therefore be gaps in his knowledge of
UK general practice and if these were not immediately apparent to him, they
certainly should have been after several years in general practice and the
previous three investigations into his performance. We are sorry to say that we
were not convinced by Dr Reddy’s evidence on the steps he had taken
following the previous three investigations into his performance. It seemed to
us that Dr Reddy was complacent about the findings of these previous
investigations and that he did not appreciate the importance of the
recommendations arising from them, since he did very little about them apart
from attend a basic prescribing course. We did not think one phone call to a
possible mentor was sufficient or that the onus should be placed upon Dr
Smith to follow up Dr Reddy’s call.
16.36 We then turned to consider the evidence relating to the actions of Dr
Reddy and the actions and involvement of the PCT from the time of Dr Desai’s suspension in October 2002 to Dr Reddy’s own suspension in October 2003. Less than six months after the original GMC Assessment in 2001 and having worked as a locum in three practices for no more than a few weeks at a time, Dr Reddy joined Dr Desai’s practice as a GP principal. It was clear from his evidence at the hearing that he had not asked to see the practice accounts before joining. We heard evidence that when Dr Desai was suspended, Dr Reddy made it very clear to the PCT he was a GP principal and, as such, he received the full practice income.
16.37 We felt very strongly that if Dr Reddy wanted the benefit of the full practice
income he must also be prepared to shoulder the responsibility that came with
it. The PCT told us it had never had to invest so many resources or so much
time and money in any of the other GP practices in the area and this had a
significant impact both on the PCT’s ability to improve and drive forward
improvements within this practice and on the overall efficiency of services
within the PCT on a number of levels. On a financial level the funding of this
practice came at the cost of other developments within the PCT and on a
resources level Carol Hogg and Helen Hughes had to spend a disproportionate
amount of time in this practice.
16.38 Whilst we accepted Dr Reddy felt aggrieved by the PCT’s investigation into
the practice and both partners and it was contended on his behalf this
raised the question of how reasonable it was for him to recognize the existence
of the PCT’s support given the fact of the congruent investigation, we
considered the PCT had followed correct procedure and clearly explained to
Dr Reddy both verbally and in writing what it intended to do; we considered
Dr Reddy’s apparent failure to recognize what was going on further demonstrated his lack of insight into the necessary protocols and procedures which the PCT was bound to follow.
.
16.39 The overwhelming impression we formed was that Dr Reddy was happy to
accept, and indeed appeared to expect, the PCT’s financial support but he was
not prepared to work with the PCT and implement the necessary changes
required to upgrade the practice with a view to dispensing with the
expensive and time-consuming temporary arrangements. We heard evidence that Dr Reddy would agree to certain actions at meetings but this would be totally contradicted by his subsequent correspondence and actions. It was submitted on Dr Reddy’s behalf that he demonstrated enthusiasm for change, but this enthusiasm was for things he had not been asked for, such as alternative premises for the Shelley Avenue surgery.
16.40 We heard that by July/ August 2003 the PCT felt it had got to
the stage where
Dr Reddy must take responsibility and take the agreed actions and it was also at this point that the PCT made arrangements to refer Dr Reddy to the NCAA as it wanted an outside view on whether it needed to do anything else. We noted that the Department of Health Advice for PCTs on the management of Performers Lists strongly recommends PCTs obtain appropriate advice in possible efficiency cases, including NCAA advice, and that was precisely what the PCT had done. However, we acknowledged that the PCT had initially informed Dr Reddy that it had contacted the NCAA to undertake an assessment of his practice, and that its function was not to find fault with him as a GP but to agree an action plan with him following assessment to reflect his training and education needs which the PCT would be expected to support and implement. Accordingly, we considered that whilst the PCT could not be expected to do other than follow the NCAA’s advice for referral of Dr Reddy to the GMC without assessment, it was understandable that Dr Reddy should feel aggrieved that the promise of constructive assessment of his practice was removed. Likewise, we acknowledged that Dr Reddy must have felt aggrieved when the PCT offered him his annual appraisal, only to cancel it without explaining why.
16.41 We also noted that Dr Reddy felt a lot of the problems were down to his
workload. He submitted that when he took over the practice following Dr
Desai’s suspension his workload increased substantially with a patient list of
5,600 for which the practice required three doctors and although locums were
appointed they were not prepared to work outside their contracted sessions or
undertake visits and he was therefore responsible for all visits and the out of
hours cover between 7.00am and the opening of the surgeries and all the
paperwork. He said his clinical workload was compounded by all the other
problems in the practice and he was working under very considerable
pressure. He told us that whatever the reality of the situation, Jenny Gosling
made him feel that she was collaborating with the PCT and assisting them in
their investigations and he felt he had no say on staff, surgery times and the
running of the premises. He also said that it was always his intention to follow
up matters agreed upon in meetings; if this did not happen it was simply
because he did not have the time. His priority was always the treatment of patients and that being so, non-urgent clinical and administrative matters had
to take second place. He did not accept that he sought to work against the PCT
or failed to face up to his responsibilities as an employer. He contended that
although it was alleged he did nothing to help himself between April and
October 200,3 he had in fact submitted business plans for both surgery
premises in October 2002 and again in April 2003. He found premises to
replace the Shelley Avenue surgery and proposed people as a permanent new
GP partner, Practice Nurse and Manager.
16.42 Dr Reddy submitted that when he got the freedom to run the practice he was
confident he would be able to learn how to run it in a short time but he had to
start at the bottom. He felt that if the PCT had given him two or three months’
breathing space with the staff he wanted, he would have been able to take over
the practice without the input from the PCT, Jenny Gosling and the locum GPs.
He felt the PCT had a hidden agenda from October 2002; it had wasted money
on locums and temporary staff. Meetings with the PCT were a waste of time
and he was frustrated. When it appointed Primary Solutions he said it was like
a cancer destroying his body and he lost trust in the PCT.
16.43 We felt that as Dr Reddy had agreed to go into and remain in partnership with
Dr Desai once problems with the practice had been identified, he must accept
some responsibility for assisting in and endorsing the systems in place. The
PCT had submitted that Dr Reddy had chosen to stay but sought to blame
others for all of the failings which had been demonstrated, but that as a
professional man he could not evade his own responsibilities in this manner
and we felt this was indeed the case.
16.44 As previously mentioned, we were concerned that we came to different
conclusions to the most recent GMC Assessment, but having had the benefit of
seeing and hearing Dr Reddy give evidence, we were not convinced that he had
any real insight into what is expected of a GP principal today and the
requirements of Good Medical Practice. For example, it was clear that Dr
Reddy did not know the elements of good record keeping as demonstrated by
his own scanty, poor quality note taking which in some instances was so
illegible that Dr Healy, his own witness, was unable to decipher it. Audit 3 had
revealed that the frequent examples of poor quality notes and misfiled notes
meant there was lack of appropriate clinical reviews and follow up, which
presented real risks to patient safety. Moreover, Dr Reddy was not aware either
of the need to instigate objective audits and to put in place risk management
systems and a system for reviewing complaints. We also considered he showed
a serious lack of professionalism by claiming that the filing system by age
and ethnicity set up by Dr Desai was one with which the staff were familiar
and he did not accept it was chaotic or appear to realise that it could
compromise patient care.
16.45 There were also issues relating to prescribing; with no systematic, or indeed
any, review of repeat prescribing, which might or might not be computer
generated depending on whether the computer was working, we considered
there was a serious risk to patient safety as neither Dr Reddy nor any of the
locum GPs would have access to full information.
16.46 We also considered that Dr Reddy was woefully unaware of both the
requirements of Good Medical Practice and the seven pillars of Clinical
Governance. The seven pillars are:
1. Clinical effectiveness programmes
2. Risk management
3. Education, training, personal/professional development
4. Patient and public involvement
5. Information systems to support clinical governance and health care delivery
6. Clinical audit
7. Staffing and staff management.
For example, on being asked how he applied clinical effectiveness to his
practice it was clear that Dr Reddy had no knowledge of the National Service
Framework for diabetes despite there being a high incidence of diabetes
amongst the Asian community in which he practised. Nor did he appear to be
aware of the need for risk management systems or the requirement to carry
out clinical audit.
16.47 We also felt that Dr Reddy put his personal grievances against the PCT above
patient care and he had no insight into the working relationship that was
required with either the PCT or his colleagues and staff.
16.48 It was submitted on behalf of Dr Reddy that if he was allowed to continue in
practice he was willing to learn and improve and there could be no doubt that
he would accept support and guidance in respect of his management skills if such support was unambiguous and tactful. It was submitted there was scope for such a low-key approach as Dr Reddy’s core clinical competence, his ability to enjoy good relationships with his patients and his sympathy as a family practitioner were not disputed. We regret to say that we were not persuaded that this was the case. It was apparent to us that what Dr Reddy really wanted was to be left alone to run the practice in the way in which he saw fit, without PCT involvement or adherence to national protocols.
16.49 Although we accepted that Dr Reddy is not a wholly incompetent doctor and
that he demonstrated a commitment to his patients and worked for long hours
and that he attempted to make some improvements and plans for the future of
the practice between April and October 2003, we considered these were either
minimal or misguided in the context of the very wide ranging concerns
justifiably held in relation to the practice. Nor did we consider that the steps he
has taken to address his personal professional development since his
suspension in October 2003 demonstrated any real understanding of the
profound level of re-education and re-training he requires to safely practice
as a principal GP. Although, as mentioned above, we acknowledged Dr Reddy
must have felt aggrieved that the promise of constructive assessment of his
practice by the NCAA was removed, we noted that the PCT had followed the
correct procedures and could not proceed with the assessment if the NCAA
was unwilling to undertake it.
16.50 We concluded that the pattern which had emerged from the totality of the
evidence was that there were a number of key areas of general practice in
which Dr Reddy failed to meet acceptable minimum standards of competence,
leading to the PCT having to invest an unreasonable amount of time and
money in his practice without any realistic signs of improvement in Dr
Reddy’s performance. Given that he appeared to us to be unaware of both the
requirements of Good Medical Practice and Clinical Governance we were not
convinced the situation is remediable.
16.51 We were aware that if we dismissed Dr Reddy’s appeal in relation to the
efficiency ground the effect would be to prevent him from practicing his
chosen profession as a general practitioner for the foreseeable future with
consequent effect upon his livelihood. Accordingly, we weighed the prejudice
to Dr Reddy against the potential prejudice to the efficiency of the NHS should
he remain on the Performers List. In all the circumstances, and with very
careful regard to the findings
of the GMC Assessors in 2005, we nonetheless
came to the clear and unanimous
view that Dr.Reddy’s name should be
removed from the Performers
List maintained by the PCT.
Contingent Removal
17.1 Section 15(3) of The National Health Service (Performers List) Regulations
2004 allows the FHSAA on appeal to impose any decision which the PCT
could have made. This allows the FHSAA to remove a practitioner from the
Performers List contingently, that is by imposing conditions on his inclusion in
the Performers List with a view to removing any prejudice to the efficiency of
services.
17.2 We therefore gave vary careful consideration to the draft conditions suggested
by the PCT in paragraph 14.1 above and to the parties’ submissions in respect
of those conditions in paragraphs 14.2 to 14.5.
17.3 In our view the draft conditions demonstrated the fundamental and wide
ranging nature of the re-education and re-training required in order to remove any
prejudice to the efficiency of the relevant services. We noted that some of the
matters identified in the draft conditions had been prioritised in the previous
investigations into Dr Reddy’s performance back in 2001 but he had not addressed
them.
17.4 At the hearing it was clear to us that Dr Reddy had not considered the possibility of
contingent removal. When we allowed him some time to consider the draft
conditions suggested by the PCT he was unequivocal in his assertion that he
would agree to a mentor of his choice but he did not need supervision and it
would be totally unacceptable to him.
17.5 We considered that an essential part of the process of re- education and re-training must be some acceptance on the part of the person to be re-trained that the process has some value. However, it appeared to us that given the fundamental and wide ranging nature of the re-education and re-training which would be required to bring Dr Reddy’s practice up to acceptable standards, it would not be practicable to remove him contingently, not least because he had clearly indicated to us that he did not need supervision and it would be totally unacceptable for him.
Undertakings
given to the GMC
18.1 Subsequent to the end of the appeal Dr Reddy’s solicitors forwarded to the
panel members a copy of the GMC’s letter to Dr Reddy dated 24th February 2006 and the Schedule of Undertakings drawn up by GMC Case Examiners in the light of the findings of certain deficiencies in the standard of his professional performance as set out in the GMC Performance Assessors’ Report issued on 18th October 2005. Dr Reddy signed the Schedule of Undertakings on 1st March. The PCT’s solicitors submitted in a letter dated 6th March that these did not in any way affect the representations previously made on behalf of the PCT, including the representation that Dr Reddy should not engage in single-handed practice.
18.2 We carefully considered these undertakings but they did not persuade us to
alter our determination. As previously stated, we considered the GMC
Assessment was a separate procedure governed by separate regulations and the
test it posed, namely whether a practitioner’s performance is so seriously
deficient that his registration should be restricted or removed, is different to
the test posed by regulation 10(4) of the Performers List Regulations.
Furthermore, when Dr Reddy appeared before us he made it clear that the only
condition he was prepared to accept was a mentor of his choice.
Findings
19.1 For all the above reasons the Panel unanimously finds that Dr Reddy is
not unsuitable to be included in the PCT’s Performers List and allows his
appeal in relation to the unsuitability ground.
19.2 For all the above reasons the Panel unanimously finds that Dr Reddy’s
continued inclusion in the Performers List would be prejudicial to the
efficiency of services which those included in the PCT’s Performers List
perform and dismisses his appeal in relation to the efficiency ground.
20.1
We did not
hear submissions on national disqualification pending our
determination
on the the grounds of unsuitability and inefficiency. We are
content to
determine this issue upon the basis of written representations alone,
or, if the
parties wish, an oral hearing will be held on a date to be agreed.
20.2 The attention of both parties is hereby drawn to the provisions of Rule 33 of the
Family Health Services Appeal Authority (Procedure) Rules 2001 (the Rules).
20.3 We direct that a copy of this decision be sent to the persons and bodies referred
to in Regulation 47 of the Rules.
20.4 Finally, in accordance with Rule 42(5) of the Rules, we hereby notify the
parties that they have the right to appeal this decision under and by virtue of
section 11 of the Tribunals and Inquiries Act 1992 by lodging notice of appeal in the Royal Courts of Justice, The Strand, London WC2A 2LL within 14 days from receipt of this decision.
Dated this day of 2006
……………………………………………
Debra R Shaw
Chairman of the Appeal Panel