IN THE FAMILY HEALTH SERVICES APPEAL AUTHORITY Case No: 10447
Dr S Ariyanayagam Professional
1. This is an appeal pursuant to section 49M(3) Health and Social Care Act 2001 against the decision of the City & Hackney Primary Care Trust (the PCT) to remove Dr Khazne from the medical list in the interests of the efficiency of the service. The appeal is by way of re-determination of the decision of the PCT to remove Dr Khazne from the list.
2. To facilitate the hearing of the case directions were made on 15 April 2003, 9 May 2003, 1 October 2003 and 14 October 2003.
3. On 10 October 2003 Dr Khazne’s solicitors requested by letter that the hearing be adjourned. This request was refused. The reasons were:
The appellant’s solicitors rely on two reasons to justify seeking an adjournment: late receipt of the respondent’s evidence which does not give them enough time to prepare the appellant’s case, and the ill health of the appellant.
The respondent’s evidence was served late – that is not according to the timetable set (and subsequently amended) by the FHSAA. The evidence is now available in accessible and comprehensive form. Bundles were made available to the appellant’s then advisers on or about 30 September 2003. Much of the evidence is known to the appellant, including the NCAA assessment. The new documentary evidence and statements amplify the details of the NCAA assessment. The panel’s view is that the appellant has had sufficient time following service of the documents to discuss those with his professional advisers and prepare his case.
The appellant also relies on a medical certificate dated 24 September 2003 (from his GP Dr Rizk) referring to him suffering from depression, anxiety and hypertension. Dr Rizk recommends the appellant refrain from work for three months. This certificate has any only limited relevance to the real issue, which is the appellant’s ability to properly participate in the hearing of his appeal.
These proceedings should be dealt with as speedily and expeditiously as possible. To delay further at this stage, without good reason, would cause all parties significant cost and inconvenience. The panel also took into account the impact that prolonging the hearing of the case may have on the appellant’s conditions as described in the medical certificate.
4. The application for an adjournment was not renewed when the hearing commenced on Friday 17 October 2003.
5. The substantive hearing of the case took place at the Kings Fund Centre on Friday 17 October 2003, Monday 20 October 2003, Tuesday 21 October 2003, Wednesday 22 October 2003 and Thursday 23 October 2003. At this hearing the parties were represented as follows: Dr Khazne by Mr Greg Chambers of counsel instructed by Geo Dowse & Co and the PCT by Mr William Edis instructed by Bevan Ashford.
6. The written material available to the Panel was collated by the PCT and was made available in several paginated loose-leaf bundles. The index to the various bundles is annexed to this decision. All the references in this decision in [ ] are to these bundles, unless otherwise stated.
7. The following witnesses gave oral evidence at the hearing:
Director of Primary Care and Community Service for the Respondent PCT
Director of Quality and Service Improvement (Nurse Director) for the Respondent PCT
GP and NCAA assessor
GP and member of PCT’s Clinical Governance Team
GP and locum medical advisor to East London and City HA
Psychologist and NCAA behavioural assessor
GP and NCAA assessor
Formerly HR Director of NHS Trust and NCAA Lay Assessor
Chief Executive of the Respondent PCT
8. At the start of the hearing on Friday 17 October 2003 a preliminary application was made on behalf of Dr Khazne that the hearing take place in private. This application was on the basis that as Dr Khazne was under stress, and the case against him was prejudicial to his reputation. In refusing the application the panel took into account Rule 39(1) Family Health Services Appeal Authority (Procedure) Rules 2001 which states that ‘all hearings by a panel shall be in public except where a practitioner..has asked for the hearing to be in private and the panel considers it is reasonable in all the circumstances for that hearing to be held in private.’ The panel concluded that the public interest in having an open hearing outweighed the reasons given by Dr Khazne for wanting the hearing to be in private.
9. Dr Khazne is aged 53. (His date of birth is 28 October 1950.) Dr Khazne qualified in medicine at Zaragoza in Spain in 1992. Prior to that he had worked as a qualified nurse. Following medical qualification in Spain he worked there for a year as a Senior House Officer. He then travelled to the United Kingdom where he worked as a locum in various hospitals for about a year. He then returned to Spain. On return to the United Kingdom in 1997 he joined Dr Rizk’s general practice. He worked with Dr Rizk for a year. He then joined Dr Satar for some sessional work and at the same time started sessional work with the Dr Lloyd’s practice. When Dr Lloyd retired in April 2000 Dr Khazne took over Dr Lloyd’s practice.
10. The case against Dr Khazne did not arise from complaints from any of his patients. Rather it arose out of mounting concerns following successive clinical governance visits by the PCT to Dr Khazne’s practice. The clinical governance visits took place on the following dates: 13 March 2001, 28 June 2001, 20 September 2001 and 1 February 2002.
11. The PCT decided at the conclusion of the last visit to suspend Dr Khazne from practice, pending further assessments of his performance. On 12 March 2002 a further assessment of Dr Khazne’s practice was undertaken by Dr Kheraj. Dr Kheraj recommended to the PCT that Dr Khazne be referred to the NCAA for more detailed assessment. 
12. The NCAA is a special health authority established in April 2001. The function of the NCAA is to help NHS organisations, such as PCTs, to handle concerns about the performance of doctors.  This function was met in Dr Khazne’s case by assessing him. ‘The purpose of an NCAA assessment is to clarify any areas of concern and to make recommendations for how those may be addressed.’  Components of the NCAA assessment included: an occupational health assessment, a behavioural assessment and assessment of clinical performance.
13. When the NCAA submitted their final report to the PCT in October 2002 they recommended that the PCT consider the measures necessary to protect patient safety. As Dr Khazne was by this time suspended, the recommendation was to consider ‘the options of continuing the suspension from the referring body’s list of practitioners and referral to the GMC.’ 
14. The PCT provided written evidence covering all the clinical governance visits and the NCAA assessment. This was the core of the PCT’s case. The witnesses who gave evidence included two of the clinical governance assessors, Dr Kheraj and Dr Patel. The PCT relied heavily on the NCAA assessment in arriving at its decision to suspend Dr Khazne from the list. Three witnesses who were involved in this assessment gave evidence. These witnesses were: Dr Mower, Dr Bowden and Molly Anderson.
15. There were a number of areas were there were irreconcilable factual disputes between Dr Khazne and the various witnesses called by the PCT. In relation to every significant area of dispute the panel preferred the evidence of the PCT’s witnesses. They found the witnesses credible, balanced and free of bias. They communicated clearly and qualified their views as appropriate; they also appeared to be determined to be fair to Dr Khazne. The panel’s impression of Dr Khazne was different and is set down in more detail below. In general terms the panel did not always find Dr Khazne a credible witness. This was only in part due to deficiencies in his communication skills, but also for other reasons. He appeared at times to be deliberately evasive. The rigidity of his thinking was reflected in his answers to many questions. Where there was conflict he tended to rely on dogmatic response rather than reflective reasoning. This was unfortunate as it made it more difficult for the panel to take into account the sometimes valid points he, and his representative, were making.
16. Dr Bowden regarded the notes as acceptable. ‘I was not overly concerned with regard to Dr Khazne’s practice following my review of these medical records.’ 
17. Dr Kheraj conducted a review of forty one (41) sets of notes supplied by Dr Khazne. His overall conclusion was that the quality of the notes was good ‘both in terms of their physical structure and also in their clinical content’ 
18. The panel were provided with eight (8) sets of anonymised notes which were analysed. The panel were aware of Dr Khazne’s list size. (1844 as at 1 January 2002 ) The panel also took into account the shortcomings in the patient care demonstrated in three (3) sets of these notes against the summary analysis of Dr Kheraj and Dr Bowden referred to above. The panel did not regard the content of the other five (5) sets of notes as demonstrating particular areas of concern.
19. Patient A was a hypertensive patient on co-tenidone. Although his condition needed monitoring there were no blood results in the last two years. Dr Khazne asserted that this was because the patient was needle phobic, and as evidence in support of this assertion referred to the patient refusing an influenza vaccination. There was no record in the notes to indicate that the patient was in fact needle phobic. Refusal of vaccination is not synonymous with being needle phobic and Dr Khazne appeared to be unable to comprehend this difference when questioned, nor did he display the area of knowledge requisite of a practitioner in the management of hypertension.
20. Patient C was a diabetic patient. There was no evidence that Dr Khazne conducted the appropriate blood monitoring to identify the level of HbA1C (Glycosylated Haemoglobin) in the patient’s blood. The notes indicated she was regularly attending Moorfields Eye Hospital. Dr Khazne's told the panel that he assumed that Moorfields Eye Hospital screened blood as routine and would only alert the practitioner if the screening detected some abnormality. The panel considered that this demonstrated a deficiency in Dr Khazne’s practice in that he had not checked the practice at Moorfields Eye Hospital, and accepted no responsibility for making contact with the hospital and chasing results.
21. The Panel took the view that as diabetes is a multi-system disorder, it is incumbent on the practitioner to be aware of the extent of the patient’s control of his/her condition. From Dr Khazne’s evidence it appeared to be the case that he was reliant on finger prick testing alone as a means of monitoring for diabetes. Furthermore at no stage during the hearing did Dr Khazne acknowledge that good practice entailed the recording of HbA1C readings in the patient’s notes.
22. Patient D was apparently misdiagnosed as suffering from diabetes. ‘At diabetic clinic was told to stop all his medication.’ [Medical records bundle 65] This was the information Dr Khazne recorded on 13 October 2000. Dr Khazne took the patient’s word for this former misdiagnosis and did not check the information with the hospital.
23. The panel regarded this as an example of Dr Khazne’s inability to reflect upon, and deal with information. He asserted that his management of patient D was reasonable, as patient D would not go to hospital. In support of this contention Dr Khazne relied on a letter from the hospital dated 6 August 2001 [Medical records bundle 73d] referring to patient D’s failure to attend for an outpatient appointment. Dr Khazne failed to understand the point repeatedly made by the panel that the October 2000 meeting he referred to in his notes followed a visit the patient apparently made to the hospital prior to 13 October 2000. The patient’s condition could therefore have been investigated in 2000 - either by telephoning or writing to the hospital. The particular area of concern identified by the panel in relation to this case is as follows: if a patient asserts that they have been misdiagnosed, this assertion needs to be carefully checked in the interests of the patient’s safety.
24. A detailed analysis of Dr Khazne’s clinical skills was afforded by the use of simulated surgeries during the NCAA assessment. Dr Khazne was dismissive of the exercises criticising their superficiality. Simulated surgeries were the chosen format, as Dr Khazne was of course supended from practice at this stage. The panel heard evidence from Dr Bowden that the use of simulated surgery is generally regarded as an effective way to test practitioner’s clinical skills, and there is no body of published evidence to criticise the efficacy of the system.
25. The panel attached considerable weight to the reports of the simulated surgeries. They are an accepted and effective way of determining the quality of a practitioner’s consultation skills, covering not only clinical knowledge but also communication skills. The conditions presented by the simulated patients were as follows :
Case 1. Bereavement and depression presenting as insomnia
Case 2. New pregnancy presenting for antenatal care
Case 3. Request for antibiotics for recurrent cough
Case 4. Poorly controlled maturity onset diabetes
Case 5. Back pain probably due to lumbar disc
Case 6. Phone call from the mother of a feverish child with purpuric spots
Case 7. Chest pain which could be new angina or myocardial infarct
Case 8. Mother asks for her 18 year old daughter’s cervical smear result
26. In Case 7 the topic in the simulated surgery was to evaluate the practitioner’s skill in diagnosing, and managing, resting chest pain which may be angina or myocardial infarct. The evaluation from both assessors was that on the basis of the professional actor’s clinical presentation the management plan put forward by Dr Khazne was unsafe. Dr Mower did not consider that Dr Khazne was alert to the significance of resting chest pain and in particular he did not advise the patient to go straightaway to hospital. Although Dr Khazne maintained he did advise the patient to go to hospital he did not give any indication of appreciating the urgency of the situation as presented to him – for example by arranging for an ambulance to take the patient to hospital. Dr Mower also considered that Dr Khazne over-reassured the ‘patient’ and demonstrated poor technique in taking this patient’s blood pressure.
27. The panel noted that Dr Khazne’s record for this case  which was completed at the time of the simulated surgery contained no reference to possible resting chest pain although ample information was provide by the actor. In addition important information provided by the actor ‘Father died at the age of 52 from a heart attack whilst sitting in a chair- he died within minutes’  was not recorded by Dr Khazne. Dr Khazne totally denied that his approach, and his practice, in this case was in anyway defective. The panel preferred the evidence of Dr Mower. The panel concluded that Dr Khazne had retrospectively appreciated the failure of his approach to this simulated case study and modified his evidence accordingly.
28. In case 6 the actor was playing the part of the mother of a 14 month old child who had been unwell. The actor spoke to Dr Khazne on the telephone and provided information. The purpose of the simulation was to analyse the practitioner’s skill in the diagnosis and management of children with who may be suffering from a serious life threatening condition - meningitis. The evaluation of both clinical assessors, that is Dr Bowden and Dr Mower, was that Dr Khazne was not aware of the significance of non-blanching rash. He falsely reassured the ‘mother’ thereby inhibiting her providing vital information. Dr Khazne in his evidence said that he told the mother to bring the baby to the surgery and he ‘offered a home visit’. The record for this case completed by Dr Khazne at the time of the simulated surgery  gives no indication that Dr Khazne was alert to the possible seriousness of the child’s condition. Furthermore there is no reference in these notes Dr Khazne offering a home visit. The panel concluded that by the time Dr Khazne gave his evidence he had realised his failings during this simulated consultation and simply embellished his evidence to give the impression that at the time he had considered it to be serious. Dr Khazne was also unaware that a meningitis injection does not protect against all causes of meningitis and as a consequence inappropriately reassured the mother in the case study.
29. In case 8 the simulated surgery was configured to test Dr Khazne’s understanding of confidentiality issues. The instruction to the actor who played the part of the patient’s mother is as follows: ‘Your daughter, Anna Brown, who is aged 18 years old, gets a letter from the surgery to attend for a test result. You inadvertently opened the envelope since you both have the same initials. Having opened the letter you are worried as to what the test is about and the result. Your daughter has not seen the letter yet as you don’t want to worry her.’ 
30. The point of the case, as described by Dr Bowden, was to identify whether the practitioner can retain patient confidentiality and at the same time not alienate the patient’s mother
31. Dr Bowden gave evidence that Dr Khazne firmly and unequivocally asserted that the patient’s mother had a ‘right to know’ confidential information about her daughter’s health and when Dr Khazne was challenged by the assessors he did not accept that there alternative ways of handling the exchange of confidential information. Molly Anderson described Dr Khazne ‘launching in’ and giving the patient’s mother confidential medical information about her daughter, including the fact that her daughter was on the pill.
32. As with other instances there was a major factual dispute between Dr Khazne’s version of what he said in this simulated surgery, and what the assessors heard and observed. The Panel preferred the evidence of the assessors. Dr Bowden, Dr Mower and Molly Anderson impressed the Panel as experienced and conscientious assessors. They demonstrated a sound grasp of the details of the assessment exercises they were undertaking and the purpose of the exercises. Dr Khazne on the other hand was inconsistent and unconvincing. Under cross-examination he stated that the NCAA assessors were accusing him and were ‘one million percent’ exaggerated in what they said.
33. The panel concluded that Dr Khazne had an entirely misconceived understanding of the basic principles of medical confidentiality. During the process of the appeal it also appeared that Dr Khazne re-formulated his own position on confidentiality. The Panel have no doubt that the position that the NCAA assessors observed Dr Khazne adopting was that the patient’s mother was fully entitled to be given confidential details of her daughter’s medical history. Dr Khazne, following a similar path observed above in relation to cases 6 and 7, retrospectively recognised the failure of his approach and when he gave evidence he took up a new extreme position that his patients were entitled to absolute confidentiality. Dr Khazne then demonstrated his inflexibility when he was not able to consider any circumstances that his patient’s right to confidentiality might have to be qualified. He was not aware of the availability of any General Medical Council (GMC) guidance on confidentiality issues.
34. The other case studies used by the NCAA assessors also displayed deficiencies in Dr Khazne’s clinical and communication skills. Case 2 was the only case where Dr Khazne acknowledged he might have dealt with a consultation differently. He made an opening remark to a newly pregnant patient presenting for antenatal care ‘Do you want to carry on with the baby or have an abortion’ . He did not deny making this remark. The panel accept that Dr Khazne may have been making what he regarded a friendly gesture. This however was an age inappropriate introduction given that the ‘patient’ was described as 32. Generally the panel regarded his opening remarks as insensitive and likely to deter a patient from communicating openly with the practitioner.
35. In case 1, the 56 tabs of amitryptilline prescribed to a patient suffering from depression demonstrated a failure in prescribing methods. Dr Khazne’s failure to seriously engage with the potential risk to the patient, and his bland explanation that he was tied to prescribing a number of pills because of the way the pills were packaged, indicated to the panel that he had not grasped the issues involved. He further chose to try and support this by stating as a fact that a pharmacist will never provide a lower number of pills than the pre-packaged amount.
36. In simulated case 5, a patient presented at the surgery with back pain. According to Dr Bowden the consultation was 'noted to be of low challenge'  Dr Khazne made what was regarded by Dr Bowden and Dr Reed an inappropriate secondary referral. Dr Khazne asserted that all cases of disc prolapse should be referred to hospital and simply disagreed with the NCAA assessors that any other course of action was possible.
37. Other shortcomings in Dr Khazne’s clinical practice were identified by the NCAA assessors. The panel heard evidence that Dr Khazne would not always examine patients with vaginal discharge, but he would prescribe. Similarly he would sometimes prescribe for patients with incontinence without examination.  Although the Panel accept that it may be appropriate to prescribe without examination particularly on the first visit of the patient, Dr Khazne failed to qualify and justify when this approach could be necessary. Dr Khazne told the NCAA assessors , and repeated in his evidence, that an ultrasound scan is the diagnostic method for endometriosis. In doing so he displayed a lack of basic gynaecological knowledge which would be reasonably expected from a practitioner.
38. Dr Khazne maintained that a high vaginal swab would allow a diagnosis of genital chlamydia to be made.  The Panel regarded his knowledge in this area as inadequate. Chlamydia swabs should be taken from the cervix, not the high vagina. The consequence of using an inadequate technique is that chlamydia may be missed, potentially resulting in serious long term complications for the patient such as Pelvic Inflammatory Disease.
39. There were a number of areas concerning Dr Khazne’s practice where irreconcilable factual disputes between Dr Khazne and the various PCT witnesses occurred. In particular the panel heard evidence around Dr Khazne’s use of refrigerated storage, his conduct of gynaecological examinations and his use of the thermometer.
40. Dr Khazne confirmed that over the winter of 2001 he stored influenza vaccinations in medical fridge. He had clearly accepted by September 2001 that his existing fridge was inadequate as he had agreed to purchase a new medical fridge.  This had not been purchased by February 2002, the date of the last clinical governance visit.  The panel concluded that Dr Khazne was not sensitive to the fact that his refrigeration system was unsafe and he simply did not recognise that he had no safe storage system for medication which required storage in conditions of controlled temperature.
41. Dr Khazne described to Dr Patel an unsafe procedure for vaginal examination. Dr Khazne allegedly stated that ‘I part the lips and then look’.  When he was first challenged about this by Dr Patel and others, he claimed he was joking. When he gave evidence he denied completely making this statement at all. The panel saw no reason to doubt Dr Patel’s account.
42. It was alleged that Dr Khazne was re-using medical instruments without properly sterilising them.  It was also alleged that there was one thermometer that Dr Khazne would use in the mouth, armpit and in the rectum of children. This he would clean with a medi-swab.   The panel set Dr Khazne’s denial of only having one thermometer against the evidence of both Dr Patel and Dr Mower and concluded that Dr Khazne’s recall was inaccurate. In any event even if Dr Khazne’s recall was accurate, and he had three or four thermometers as he asserted when he gave evidence the method of sterilisation that he relied on - use of antiseptic and medi-swab - represented an inadequate and unsafe system of infection control.
43. Generally in relation to the environment in Dr Khazne’s surgery the panel relied on the evidence from the written and oral evidence of those involved in the various clinical governance visits. The panel gave little weight to the findings of the NCAA’s evaluation of the environment within the surgery. This was because Dr Khazne was being assessed about his surgery ergonomics at a time when he was not in charge of the surgery. The panel query the value of bringing a suspended doctor back to his work place at a time when he cannot be expected to be in touch with the surgery.
44. There were two other matters that the panel identified as being particularly relevant in weighing up the evidence as to the safety of the patient environment that Dr Khazne was responsible for maintaining. These were the availability of speculae and disposable paper rolls for the examining couch.
45. Dr Khazne stated that he did use speculae and although he stored the speculae in a separate room to his consulting room he always had some available before examining a patient. The panel accepted his evidence in that regard and considered that the discrepancy between the PCT clinical governance witnesses, and Dr Khazne, was due to a misunderstanding. The misunderstanding centred on the availability of the speculae - that is they were kept in a separate room not within the consulting room itself. This meant that if Dr Khazne wished to have use of speculae, he need to leave the consulting room and collect the instruments.
46. In relation to the use of disposable couch covers Dr Khazne stated that he did not have disposable couch covers, but used a sheet that was changed after every patient consultation. This evidence conflicted with the evidence of Dr Patel  and Mary Clarke  and the panel preferred their evidence in that respect.
47. Dr Khazne’s emergency equipment did not allow him to provide safe emergency care. He did not have appropriate drugs to deal with severe pain such as could be encountered in some cases of renal colic. His stated reliance on co-codamol and paracetamol as a means of pain relief for renal colic was unsatisfactory. Good practice requires that the practitioner must possess, and have immediately available, more potent analgesics even if the practitioner is dependent on hospital admission on these occasions. Dr Khazne’s justification for not carrying certain medications was not credible, nor did he see any requirement for improving in the future.
48. He did not have drugs to effectively ameliorate the effects of a severe asthma attack. Dr Khazne was unable to comprehend that his management of ‘status asthmaticus’ would vastly improve if he had access to a nebuliser, even if he did not carry one. The evidence that he gave that he would administer oxygen in an emergency case of asthma was irrelevant and inappropriate.
49. He did not have a single drug available to deal with meningococcal meningitis, a condition that would require immediate treatment with penicillin. In his evidence Dr Khazne failed to demonstrate he was aware that the possession of parenteral penicillin in the emergency bag could provide vital life saving treatment.
50. The panel were provided with a graphic illustration of Dr Khazne’s lack of grasp of basic issues in relation to confidentiality. When the subject of chronic disease registers was being discussed Dr Khazne, with no warning to his representative or the PCT, produced plastic bags containing boxes of card files which he claimed were the manually maintained chronic disease registers maintained by his predecessor, Dr Lloyd. When challenged about this Dr Khazne did not understand that these documents contained confidential patient information.
51. The panel did not attach great weight to the fact that Dr Khazne spoke to patients when he went to the surgery for the NCAA assessment.  Dr Khazne appears to be popular with his patients and it seemed unremarkable that they he would talk to them. The fact that they chose to talk to him about their medical conditions was outside Dr Khazne’s control. The criticism that has validity, however, is that Dr Khazne was not aware of the need to maintain confidentiality and chose to discuss his former patients’ conditions with them in a public place.
52. The panel took as a starting point that the maintenance of up to date chronic disease registers is essential to allow a competent practitioner to actively manage chronic disease.
53. Dr Khazne maintained on a number of occasions that due to his patient’s records being transferred from a manual to a computerised recording system he was unable to introduce disease registers as recommended by the clinical governance assessors. The panel were not able to accept that this was an adequate response. The panel considered that it was Dr Khazne’s responsibility to maintain an adequate manual system pending the introduction of computerised records. In addition Dr Khazne did not demonstrate any real understanding of the active management of chronic disease. From maintaining a position that his attempts to introduce chronic disease registers were being hampered by the process of computerisation, Dr Khazne without notice or warning, produced during the course of the hearing papers which he maintained represented adequate and up to date chronic disease registers. Apart from the concerns that this immediately raised in relation to patient confidentiality, the panel concluded that this demonstrated Dr Khazne’s complete inability to constructively engage with those professionals who had been working with him to improve his practice in this area.
54. Dr Kheraj noted that there was no clear system for repeat prescribing in existence in Dr Khazne’s practice.  Dr Bowden, in his evidence, stated that the system was hopeless from the point of view of patient safety. The system that was in existence was simple. All requests for repeat prescriptions were routed through the receptionist, who wrote down the medication requested by the patient and then passed the request to Dr Khazne for formal prescription. The panel identified that this meant there were at least two areas of weakness in the system:
a. This system was so laborious and time inefficient (Dr Khazne gave evidence that it could take him around two hours an evening) that it contained potential for human error.
b. The system was dependent on the reliability of the receptionist receiving accurate information from the patient and then communicating it accurately to the practitioner.
55. Dr Khazne asserted that his personal involvement made any mistakes impossible without any acknowledgement of the weaknesses and risks in the system. Another inherent weakness was demonstrated when Dr Khazne’s practice came to be managed by agency staff. The existing system was then  modified on safety grounds.
56. The panel regarded much of the information contained in Dr Khazne’s practice information leaflet as seriously misleading and deliberately created an unrealistic expectation of the range of services offered by the practice. The leaflet reads [263-267]:
The surgery runs nine clinics:
· Blood pressure
· Well person
· Family Planning
· Travel/General Immunisation
· Dietary Advice
· Antenatal Care
· Baby Clinics
57. At the second clinical governance visit Dr Khazne was advised to immediately amend his practice leaflet to show a true reflection of the services he provided.  Dr Khazne when giving evidence stated that ‘I did not do general immunisations.’ Dr Khazne also stated that when he wrote the copy for the leaflet he intended to run all the specialist clinics described, and since he had got the leaflets printed he might as well use them. He later contradicted this evidence by suggesting that his individual patient consultations amounted to ‘specialist clinics.’
58. There appeared to be general consensus amongst those that gave evidence to the panel that Dr Khazne was liked by his patients. It was unfortunate that the NCAA were not able to present data from the patient questionnaires as they were not able to rely on their validity.  The NCCA should revise this component of their assessment if it is to be used in the future.
59. Dr King referred to the way Dr Khazne is affectionate about his patients and staff which was reflected in the way he talked about his practice. 
60. In relation to Dr Khazne’s approach to staff training, the panel considered that his response to suggestions that his staff should be trained in basic resuscitation methods indicated a failure to avail himself of an opportunity to improve the provision of safer systems of care for his patients. Both Dr Khazne’s response to the initiative to place de-fibrillators in surgeries and his entirely negative response to the benefits of team training were, in the panels’ view, symptomatic of his lack of flexibility, his inability to think laterally or to place patient safety at the centre of his thinking. [313 and 329]
61. The panel noted the views of Dr Khazne’s colleagues, and in particular the view of Dr Sattar  The Panel did not take into account the anonymised ‘colleague’ questionnaires which were sent out by the NCAA to assist the assessment of Dr Khazne’s clinical performance. The questionnaires were contradictory and their programme of selection was unclear. In any event, the questionnaires were not relied upon by the NCAA assessors in coming to their conclusions. The panel did not consider that this system of seeking anonymous opinions was an appropriate way of gathering information and should be revised in the light of these proceedings.
62. The panel took into consideration that Dr Khazne demonstrated low scores in the knowledge tests. These tests were undertaken by Dr Khazne and organised and facilitated by the NCAA as part of their overall assessment. He scored 57% on the Multiple Choice Questions (Peer scores average 78.48%) and 43% on the Patient Management Problems (peer scores average 71.45%) 
63. The panel read a statement [347-352] and report from Dr King [273-280] She also gave evidence. Her behavioural assessment of Dr Khazne formed part of the NCAA assessment.
64. The panel regarded it as significant that when Dr Khazne was questioned about the tabular presentation of his strengths and weaknesses contained in the NCAA report [98-101] he resolutely refused to accept that he had any significant weaknesses.
65. The panel were impressed by the evidence of Dr King. She has relevant experience in exploring the ways behaviour and personality contribute to doctor’s performance. She acknowledged that Dr Khazne could have been in an anxious and worried state when he undertook the evaluation but saw no evidence of this being apparent when he underwent the psychometric testing. [283-285] Because of concerns that Dr Khazne's cultural background could have impacted negatively on his response to the tests, Dr Field confirmed that the tests were fully validated in relation to different cultures and languages.
66. She was asked to comment on the likelihood of Dr Khazne successfully being retrained. She gave evidence that the conditions that need to be present before a practitioner embarked on retraining were self-reflection, self insight and motivation to change. The panel did not consider that Dr Khazne gave the impression of possessing any of these attributes. She gave evidence that Dr Khazne could not see the deficiencies in his practice. This was also the impression the panel gained from observing Dr Khazne giving evidence. Given that the deficiencies in his practice will put his patients at risk, this is a significant deficit.
67. The medical certificate (dated 24 September 2003) submitted by Dr Khazne’s solicitors in support of an adjournment stated that he should refrain from work for three months due to ‘depression, anxiety and hypertension.’ Whilst the panel took this into account the Panel also took into account that the psychiatric report that Dr Khazne submitted on the second day of the hearing (dated 15 October 2003) made no reference whatsoever to any of these conditions. [235d-235e]
68. He attributed his low scores on the clinical tests to be partly due to the language difficulties. When he gave evidence on particular disputed facts, therefore, the panel took care in making sure that his evidence was understood.
69. When Dr Khazne gave evidence he appeared at times to have problems understanding the meaning of particular words. English is not his first language. His use of English words could sometimes confuse. For instance he often stated that his approach was ‘perfect.’ When questioned by the panel what he meant by this he said he meant right/OK/good/acceptable but not the ideal.
70. The difficulties that the panel observed in relation to Dr Khazne’s communication appeared, however, not only to be related to his language skills. When Dr Khazne gave evidence he appeared to be verbose but non attentive in the way he mumbled ‘mmm’ and then respond with statements such as ‘perfect’ and ‘never’. The panel considered that this type of communication could lead to misinterpretation, particularly on the telephone. This would have an impact on his ability to properly diagnose.
71. Dr Khazne also demonstrated a tendency to ‘jump’ to responses. He interrupted counsel, and the panel members, before questions were concluded. This indicated to the panel that Dr Khazne would find reflective listening difficult. (This was also noted by Dr King in her assessment.) The ability to listen is, of course, a key skill necessary for the practice of primary care.
72. The PCT acknowledge that Dr Khazne is not a wholly bad doctor. They accept he demonstrates a commitment to patients and works long hours [Respondent’s opening observations paragraph 19.]
73. The panel also took into account a number of factors including the following: Dr Khazne had taken over a practice with a high degree of over prescription, he was working single handed and he was providing a service in a geographic area of high social deprivation.
74. The evidence justifying Dr Khazne’s removal from the medical list is comprised of a range of concerns, some more significant than others. An inescapable pattern however emerged from the totality of the evidence; that is Dr Khazne was not competent in a number of key areas of general practice. Cumulatively these concerns represent major deviation from good medical practice. The panel concluded that whilst there were some areas of Dr Khazne’s practice which were of an acceptable standard, there were substantial areas in which he failed to meet acceptable minimum standards of competence. This puts his patients at risk, and justifies his removal from the list.
75. Section 49M Health and Social Care Act 2001 allows a practitioner removed from the list of medical practitioners by a Health Authority to appeal against that decision to the FHSAA. Section 49M(4) provides that the FHSAA, on an appeal, may make any decision that the Health Authority could have made. This allows the FHSAA to remove a practitioner from the list contingently, that is by imposing such conditions on his inclusion in the list with a view to removing any prejudice to the efficiency of the service.
76. The panel therefore gave consideration as to whether to direct contingent removal with requirements that Dr Khazne undergo an extensive period of retraining.
77. The panel concluded that it was not reasonable to expect the PCT to embark upon a retraining programme for Dr Khazne because the outcome would be so uncertain. In reaching this conclusion the Panel particularly took into account Dr King’s assessment : ‘Dr Khazne displayed no willingness to look critically at his own behaviour or professional conduct, no genuine interest in learning new communication or clinical skills and no understanding of the allegations against him.’  This analysis was reflected in the panel’s assessment of Dr Khazne’s performance throughout the hearing.
78. An essential part of the process of retraining must be some acceptance on the part of the person to be retrained that the process has some value. The panel saw no evidence that Dr Khazne perceived this to be the case. It was not until Dr Khazne gave evidence that he evinced any commitment to retraining. The panel concluded that this was simply a tactical concession on Dr Khazne’s behalf.
79. The panel were made aware that the Interim Orders Committee of the GMC had imposed conditions on Dr Khazne’s registration requiring him, inter alia, to undergo a cognitive assessment. The function of such an assessment would be to identify if Dr Khazne had the capacity to be retrained. The panel were also made aware that Dr Khazne had been requested on many occasions to have this assessment and had been dilatory in his response.
80. The panel gave consideration to delaying a decision about a contingent removal until the cognitive assessment had been undertaken. The panel decided not to adopt this course for the following reasons: because of Dr Khazne’s expressed reluctance to undergo such an assessment and also the fact that the cognitive assessment is only one component in identifying whether he should be retrained. The panel noted (ante) that Dr King’s primary concerns were around Dr Khazne’s capacity for self-reflection and his motivation to change, not his cognitive capacity.
81. The panel will hear representations as soon as practicable as to whether Dr Khazne should be subject to national disqualification pursuant to section 49N Health and Social Care Act 2001. The panel will also decide whether this decision should be sent to the Spanish medical authorities.
82. Either party to these proceedings has the right to appeal this decision under and
by virtue of Section 11, Tribunals and Inquiries Act 1992.
Dated this day of 2003