REF:  10525



                                                                                    GMC  No of Dr Roy:  1721289




DR  JAGDISH  KUMAR  ROY                            APPELLANT













The application before the panel is an appeal by Dr Roy against a decision made by the Warrington Primary Care Trust (WPCT) to remove him from the medical list. That decision was made by the General Practitioner Performance and Support Committee of WPCT after an oral hearing held on 27 February 2003. At that hearing Dr Roy was represented by Dr Gilberthorpe of the Medical Defence Union. The decision of the Committee was sent in written form to Dr Roy on 3 March 2003. By letter dated 28 March 2003 Dr Roy’s legal representatives gave notice that he intended to appeal that decision pursuant to S49M of the NHS Act 1977.  By S49M(3) of the 1977 Act the appeal is by way of redetermination.





1)                  WPCT did not respond expeditiously to the Appeal and indeed only filed their response on 19 June 2003. It is to be hoped that in the future the administration within the WPCT will respond within the time limits imposed by the Family Health Services Appeal Authority (Procedure) Rules 2001.

2)                  In their response dated the 19 June 2003 the WPCT indicated that they relied on three separate grounds of removal, namely:-

a)      Pursuant to Regulation 7(3) of the Regulations on the basis that Dr Roy had not, prior to 17.10.01, personally provided general medical services for a continuous period of 6 months, namely since 17.4.01 when he commenced a period of sickness absence.

b)     Pursuant to S49 F(2) of the NHS Act 1977 and regulation 7B(5) of the Amendment Regulations on the grounds that the continued presence of Dr Roy on the Medical List would be prejudicial to the efficiency of the general medical services provided by Dr Roy to his patients (the efficiency ground).

c)      Pursuant to S49F(4) of the NHS Act 1977 and Regulation 7B(1) of the Amendment Regulations on the grounds that Dr Roy is unsuitable to remain on the Medical List (the unsuitability ground).

3)                  At the oral hearing of the appeal the WPCT were represented by Counsel, Mr Holl-Allen . Mr Holl-Allen indicated at the outset that he relied solely upon the efficiency ground on behalf of WPCT, this was a wholly appropriate and sensible stance.

4)                  Furthermore, in the course of his submissions to us Mr Holl- Allen made clear that his primary position was that the circumstances of the case merited the removal of Dr Roy from the medical list. His secondary position was that Dr Roy should be contingently removed. He wholly opposed the reinstatement of Dr Roy to the list.


1)                             Dr Roy was represented by Counsel, Ms Neenan. On the morning of the hearing she placed before us written submissions. In summary, Dr Roy’s position was as follows:-

a)      It would be wholly disproportionate to remove Dr Roy’s name from the list in all the circumstances of the case.

b)     If the FHSAA considered that the appeal should not be allowed in full then the panel should give careful consideration to the imposition of conditions upon Dr Roy’s continued inclusion on the medical list.


1)                  As the matter proceeds by way of redetermination, Mr Holl- Allen opened the case and made submissions taking the panel through the documentary evidence that supported his case. In response to questions from the panel Mrs Deborah Maynard, Assistant Director of WPCT, was called to give oral evidence of the current situation at Dr Roy’s practice and as to some of the past procedures, however, she had little direct knowledge of the detail of the past history prior to Dr Roy’s illness.

2)                  Having read all the documentation and heard all Mr Holl-Allen’s opening submissions the panel were of the preliminary view that this was not a case for immediate removal from the list. The panel invited the parties to consider the question of contingent removal.

3)                  During subsequent discussions held between the parties and before the panel Mr Jonathan Smith, Chief Executive Officer of WPCT was present.

4)                  In principle neither party opposed contingent removal as a solution to the case and further submissions were heard as to the conditions which should be placed upon Dr Roy.


1)      As a result of the stance taken by WPCT at the hearing we considered the case solely on the issue of the efficiency of Dr Roy bearing firmly in mind the wording of S49F(2) of NHS Act 1977 as amended ie :- whether the continued inclusion of Dr Roy in the list would be prejudicial to the efficiency of the services which those included in the list undertake to provide.


2)      There was a long and complicated factual and procedural history to the case. Dr Roy, who was born on 16.9.1940 and is thus 62 years of age, was first admitted to the list of North Cheshire Area Health Authority in 1976. Problems arose in January 2000 when there was a complaint by Mr A, the husband of one of Dr Roy’s patients who died in December 1999. That complaint ultimately led to a referral to an Independent Review Panel which reported on 30 June 2000.

3)      The Independent Review Panel made recommendations in relation to Dr Roy’s practice which in summary were:-

a)      Dr Roy was to be reminded of the General Medical Council’s (GMC) guidance to good medical practice as to taking prompt and suitable action when necessary, recognising the limits of his professional competence and not refusing or delaying treatment because he believed the patients had contributed to their condition

b)     Dr Roy should put in place a comprehensive and safe system of prescribing repeat medication

c)      Dr Roy should put in place a comprehensive system for compiling patients’ records.

4)      In view of the findings, conclusions and recommendations in the report the Independent Review Panel recommended that the Health Authority should consider placing the matter before the General Medical Council.

5)      On 21.7.00 the Acting Chief Executive of the Health Authority put the Independent Review Panel’s report before the GMC.

6)      Prior to that matter being considered by the GMC further concerns arose. In March – April 2001 the Lorac consultancy undertook some work with the practice around repeat prescribing procedures as a result of the Independent Review Panel’s conclusions. The Lorac adviser expressed concerns with regard to Dr Roy’s understanding of diabetic patients’ clinical care and that there was little or no effective record keeping.

7)      On 21 March 2001 the practice was visited by Dr Gareth Morgan (LMC secretary) and Dr C O’Hanlon (Medical Adviser to the Health Authority) and they expressed concerns over the vaccination and immunisation procedures within the practice and found that Dr Roy could give no answer about scheduling, drawing up, administering or recording vaccines. It was clear that Mrs B, who acted as practice manager, was heavily involved in the administration of vaccines and immunisations.

8)      On 31 March 2001 Dr Roy was most unfortunately involved in a road traffic accident in which he sustained a head injury and subsequently was off work as a result of that injury from 17 April 2001.

9)      However, prior to going off sick an incident occurred in the surgery which was reported by the district nurse who was present. This incident involved Dr Roy’s intention to use a used needle to inject a ganglion on a patient’s hand. Fortunately, he was prevented from doing so by the nurse.

10)   A further matter that had been raised against Dr Roy was the issue of failed or delayed home visits when requested by patients.

11)  During the time that Dr Roy was off sick his practice was covered by a series of locums. Four of those doctors wrote a letter dated 10.8.2002 setting out their concerns about the poor clinical performance, inappropriate delegation and serious managerial deficiencies they had found at the practice. The areas of major concern included:-

a)      Organisation was poor especially at the Orford clinic

b)     Patient notes were frequently unavailable

c)      Repeat prescriptions were routinely signed without any patient check-up

d)     No oral contraceptive pill checks appeared to have been done in many cases

e)      The practice does not use a stamp to record when reports and hospital letters are received or what action is to be taken, even in a case of urgent lab reports requiring immediate action

These matters all reflect the problems that had already been identified during the course of 2000 and 2001.

12)  On the same date, i.e. 10.8.01, the North Cheshire Health Authority wrote again to the GMC asking that the GMC make a decision in relation to all the issues raised in Dr Roy’s case.

13)   On the 6 September 2001 the GMC advised the Health Authority that Dr   Roy had been invited to undergo an assessment of his professional performance. Dr Roy agreed to undertake such an assessment.

14)   The summary of findings and recommendations made to the GMC by the assessors of Dr Roy’s professional performance were in the PCT’s bundle prepared for the panel and made available on 19 June 2003. On the morning of the hearing Dr Roy’s representatives made the whole report available to the panel and WPCT.

15)  In summary the assessors looked at fifteen areas of Dr Roy’s performance as a general practitioner. Of these he achieved an “acceptable” rating in only three areas, “cause for concern” in seven areas and “unacceptable” in five areas.  In phase 2 of the assessment his score was above the minimum in the knowledge test but he failed to achieve the minimum standard in simulated surgery and OSCEs. The result of that assessment was set out in a report dated 29 November 2002.

16)  By that time the IOC had decided to suspend Dr Roy from clinical practice for a period of eighteen months. The suspension coming into force on the 24 October 2001.

17)  On the 27 February 2003 the GP Performance and Support Committee of WPCT removed Dr Roy’s name from the list.

18)  On the 4 March 2003 the Committee of Professional Performance of the GMC considered Dr Roy’s case. That committee concluded that Dr Roy’s standard of performance was seriously deficient in the areas of:-

a)      providing and arranging investigations

b)     providing and arranging treatment

c)      record keeping

d)     paying due regard to efficacy and use of resources

e)      relationships with colleagues/GPs/teamwork.

The committee also found the following areas of Dr Roy’s performance to be a cause of concern:-

a)      assessment of patients condition

b)     referring patients when indicated and working within limits of competence

c)      working within laws and regulations

d)     constructive participation in audit, assessment and appraisal

e)      teaching and training doctors, students and colleagues

f)       communication with patients, listening to patients, respecting their views and providing comprehensible information

g)      arranging cover, delegation and referral.

19)  The committee directed that for a period of 12 months Dr Roy’s registration should be conditional upon certain requirements which were directed at re-training Dr Roy and ensuring that his performance reached appropriate standards.

20)  Those conditions were subsequently adopted by the IOC.

21)  The matter came before the Committee on Professional Performance again on 15 May 2003 at Dr Roy’s request because one of the conditions proved impossible to meet and was altered by the committee.





1)      It appears that Dr Roy accepted the findings of the Independent Review Panel in June 2000 in that in his written submissions for the hearing on 27 February 2003 he states that he did make a number of changes to his practice.  However, he states these were interrupted by his road traffic accident.

2)      With regard to the concerns surrounding the administration of vaccinations and immunisations it was accepted by WPCT that action had been agreed and put into place prior to Dr Roy’s absence due to sickness on 17 April 2001.

3)      In relation to the incident involving the intended use of a used needle, it does appear from Dr Roy’s written response that he accepts that he was going to use the needle in question.

4)      As to the concerns about his management of diabetic patients Dr Roy has indicated that he would have taken steps to change his procedure had other events not intervened. Again this stance indicates some acceptance that the existing procedures were inadequate.

5)      Indeed in paragraph 55 of his written submissions for the hearing on 27 February 2003 Dr Roy accepts the Assessors recommendations (in the report of November 2002) which the Professional Performance Committee were due to consider on 3 March 2003.

6)      Furthermore, Dr Roy was accepting of the conditions imposed upon him by the GMC as to his re-training and has at last put some effort into ensuring that he complies with those conditions in that he has identified tutors to assist him in his programme of personal development.

7)      When informed of the panel’s preliminary view that a conditional removal would be appropriate Dr Roy did not instruct his legal representatives to persist in seeking reinstatement on the list. This was a realistic and responsible approach.




The panel was satisfied that the condition in S49F(2) of the NHS Act 1977 (as amended) was met in that the continued conclusion of DR Roy in the list would be prejudicial to the efficiency of the services which those included in the list undertake to provide.

The findings of the Independent Review Panel in June 2000, the concerns raised by Drs Morgan and O’Hanlon on 21 March 2001, the conclusions of the Lorac consultancy in April 2001 and the report of the GMC’s assessment panel in November 2002 all identify serious deficiencies in Dr Roy’s professional performance particularly in the areas of :-

a)      providing or arranging investigations and treatment, including prescribing and chronic disease management

b)     record keeping, including history taking

c)      paying due regard to efficacy and use of resources and relationships with colleagues/Gps/teamwork

d)     assessment of patient’s conditions

e)      referring patients and working within limits of competence

f)       working with laws and regulations

g)      constructive participation in audit, assessment and appraisal

h)      teaching and training doctors, students and colleagues

i)        communication with patients

j)       arranging cover and delegation

The panel has considered these identified deficiencies and have also considered Dr Roy’s response to them.

It is our conclusion that the weight of evidence in relation to these deficiencies leave us in no doubt that the continued inclusion of Dr Roy would be prejudicial to the efficiency of the services provided to the patients.


Having reached the conclusion that Dr Roy does fall within the efficiency provisions under S49F(2) the panel then considered whether the appropriate course and proportionate response  is to wholly remove or contingently remove the doctor from the list. Under the provisions of s49G(2) of the NHS Act 1977 if the panel decides to remove a practitioner contingently the panel must impose such conditions with a view to removing any prejudice to the efficiency  of the services in question.


Although the panel bears in mind the conclusions of the GMC Professional Performance Panel we reach our conclusion on the documentary and oral evidence and the submissions made before us.


We are not satisfied on the evidence that WPCT has put before us that they have demonstrated that it is right to remove Dr Roy from the list completely. We concur with the view expressed by the GMC that the weaknesses identified in the various assessments of Dr Roy are rectifiable if Dr Roy undertakes remedial steps. Dr Roy appears to accept the need to take such steps and indeed has started to undertake them.  We are satisfied that until all the steps proposed by the GMC are undertaken or attempted by Dr Roy it is not possible to say that he will be unable to provide efficient services to his patients. Dr Roy has begun this process and it is to be hoped that with the support of WPCT, the Post Graduate Dean and his Educational Supervisor that he will successfully undertake further work to enable him to provide efficient services again.

We are aware that these matters have now been in progress for almost three years and there must be some finality for all concerned WPCT, the patients and Dr Roy.

We therefore have decided to contingently remove Dr Roy from the list. The conditions we attach to that removal are based upon those set by the GMC, in addition we have included two further requirements in order to limit the process to a period of a year, dating from the decision by the GMC to amend their conditions. It is to hoped that should Dr Roy fulfil all the conditions imposed upon him prior to the 16 June 2004 the WPCT will consider his earlier reinstatement.

We believe that such a decision is a proportionate response to the concerns raised in relation to Dr Roy’s performance.

The conditions we impose upon Dr Roy are as follows:-

1)                  You shall produce a personal development plan, in conjunction with a Postgraduate Dean or Director of Postgraduate General Practice Education, which addresses your retraining needs, with particular reference to those areas identified in the GMC Performance Assessment Panel’s report (dated November 2002) as being unacceptable or giving cause for concern. In addition history taking, prescribing, chronic disease management and appropriate referral of patients need to be addressed.

2)                  You shall seek and follow the advice from the Postgraduate Dean or Director of Postgraduate General Practice Education to implement this plan and remedy the deficiencies in your professional performance highlighted in the GMC’s Performance Assessment Panel’s report.

3)                  You should restrict your practice to posts approved by the Director of Postgraduate General Practice Education under the supervision of an appropriate Educational Supervisor, also approved by a Director of Postgraduate General Practice Education. The level of supervision determined by the Director of Postgraduate General Practice Education should be adequate in all the circumstances to ensure the protection of the public. The Educational Supervisor must be prepared to accept responsibility for your supervision, and for reporting back on your performance, as agreed with a Director of Postgraduate General Practice.

4)                  You shall provide the Postgraduate Dean and/or Director of Postgraduate General practice Education with a copy of the GMC’s Performance Assessment Panel’s report and this panel’s determination, and you shall permit them to give a copy of that report and this determination to any doctor involved in supervising your retraining.

5)                  You shall provide a written progress report to the WPCT as to your progress with particular reference to those areas identified in paragraph 1 above every 3 months, such written report to be counter-signed by your educational supervisor. The first report to be available 3 months from the date of the letter advising you of this panel’s decision.

6)                  At the conclusion of your training, you shall satisfactorily complete the four elements of the National Summative Assessment on or before 16 June 2004 irrespective of any more flexible timetable imposed by the GMC.

7)                  You shall inform the GMC and the PCT before undertaking any post for which medical registration is required.

8)                  You shall allow the PCT to obtain information about the standard of your professional performance and any further remedial action which you have taken in relation to your performance, from the relevant Postgraduate Dean or Director of Postgraduate General Practice Education and any other person involved in your retraining.


Dated  2 July 2003


Dr S Sharma – Professional

Mrs L Bromley - Lay