Professor M Mildred            -            Chairman

Dr P Leigh            -                       Professional Member

Mrs VEM Barducci              -            Member


















  1. The appeal

Dr Azhir Manzur Sarfraz (“the appellant”) appeals against the decision of the Billericay, Brentwood and Wickford Primary Care Trust (“the PCT”) of 10 February 2004 refusing his application for inclusion in its Supplementary Medical List under section 43D(8) of the National Health Service Act 1977 (as amended by section 25 of the Health and Social Care Act 2001) (“the Act”) and Regulation 6(1) of the National Health Service (General Medical Services Supplementary List) Regulations 2001, S.I. 2001 No. 3740.  The decision complained of and the appeal against it were made before the revocation of those Regulations and their replacement by the National Health Service (Performers Lists) Regulations 2004, S.I. 2004 No. 585 which came into force on 1 April 2004.


  1. Background

The decision to refuse the appellant’s application was made after a complex procedural history the important elements of which it is necessary to summarise.


  1. The appellant, who was born in 1968, was admitted to the Medical Register on 3 February 1995.  In November 2000 he began working as a GP Principal with his father, Dr Mansur Sarfraz, at South Green Surgery, Grange Road, Billericay, Essex.  At about the same time he began working for an out-of hours agency then called Healthcall Services Limited and now known as Prime Care. 


  1. On 18 July 2001 at about 1am on a Healthcall home visit an incident occurred which resulted on 30 July 2001 in a reference to the General Medical Council (“GMC”) by the then Merton, Sutton & Wandsworth Health Authority in whose area the incident had occurred.


  1. On 13 October 2001 (rather than 12 October, according to evidence given to the PCC) about 3-4 am on another Healthcall home visit a further incident occurred.


  1. On 21 December 2001 the appellant appeared before the Interim Orders Committee of the GMC (“IOC”).  The Committee imposed for 18 months conditions on his registration, in summary: except in life-threatening circumstances intimate examinations of female patients to take place in the presence of a female doctor, nurse, midwife or health visitor; a register be kept of all such examinations; not to undertake out of hours work; notify employers and potential employers of these conditions; notify GMC before undertaking any position for which registration is required.


  1. On 29 May 2002 the PCT on a monitoring visit discovered that the appellant had failed to register three intimate examinations.


  1. On 9 August 2002 after a two-day hearing the Professional Conduct Committee (“PCC”) of the GMC found the appellant guilty of Serious Professional Misconduct and suspended his registration.  The PCC found it proved that on 18 July 2001:

(i)                  the Appellant attended Miss A at her home on an out of hours visit (admitted);

(ii)                Miss A’s mother complained to the Appellant of pains in Miss A’s legs and of her having difficulty in walking;

(iii)               the Appellant carried out a full physical examination of Miss A in the presence of her mother (admitted);

(iv)              after her mother had left the room the Appellant carried out an examination of Miss A during which he touched her vagina (denied); and

(v)                the Appellant’s actions in this regard were inappropriate, indecent and an abuse of his professional position.


PCC further found it proved that on 13 October 2001:

(i)                  the Appellant attended the home of Miss B in order to carry out a consultation with her daughter (admitted);

(ii)                after examining Miss B’s daughter the Appellant discussed slimming medication with Miss B (admitted);

(iii)               during the course of the conversation the Appellant touched Miss B’s breast and thigh; and the Appellant’s actions in this regard were inappropriate, indecent and an abuse of his professional position (denied).


  1. On 21 August 2003 the matter came back before the PCC.  The appellant 

      drafted and submitted to the PCC a written document referred in the PCC

      proceedings as D1A.  The document comprising nine paragraphs was

      unsigned and undated and entitled “Submissions”. The document assumed

      such key importance in this appeal that it is necessary to reproduce it in full:


1.       It is with a very real sense of shame that I face this Committee Hearing today.  The Committee is well aware of the allegations that led to me being here – allegations which for the most part have been accepted by the Committee as fair and accurate.

2.       The allegations have been extremely serious – and have gone to the heart of the doctor/patient relationship – namely that of trust. The allegations have been in respect of two young females – one female being only 14 years of age. And it was found proven that I had abused the trust placed in me as a doctor in their own homes – places where one normally expects to feel safe and not threatened by any danger.

3.       I look back at what has happened and as I say I am filled with sorrow for the very obvious emotional upset that I have undoubtedly caused those 2 ladies and their families. I must also say, that I am full of shame for the disgrace I have brought upon my own family and the status and standing of medical practitioners generally.

4.       As the Committee may well be aware, my father is a General Practitioner and indeed I joined his practice once I  had qualified.  As I was growing up, I was well aware of the trust and respect that the public have for doctors and of the vital importance  behaving in such a way to deserve that trust and respect.  My father set me an exemplary standard and I recognise and accept that I have fallen short of those standards.  I fully appreciate and am grateful for the fact that the Committee kindly exercised its discretion in my favour and did not strike me from the register.

5.       Again, as the Committee is aware, this is the first time that I have appeared before it to answer allegations of misconduct.  Although the past 12 months have been very difficult for my wife, my parents and the staff of my practice, we have been encouraged by the expressions of support from patients, staff and professional colleagues.

6.       I took very careful note of the comments of the Committee at the previous hearing.  In the past 12 months, I have tried to maintain my medical knowledge and to this end I completed a Diploma in Dermatology, sat the written component of Part II MRCP and attended lectures for GPs organised by my local postgraduate centre.  In addition, I sought advice from Dr Hibble, the Director of Postgraduate Education for the Eastern Deanery, about learning more of medical ethics.  He suggested that I write an essay on medical ethics – but I felt that I would greatly benefit from a more formal approach and accordingly took a course in Ethics and Philosophy of Healthcare at the Society of Apothecaries in London.  That course emphasised to me the very serious breaches of good practice and protocol that I had committed.

7.       As the Committee will appreciate, I have had ample time to consider that previous hearing. The great regret that I have is that I did not demonstrate sufficient understanding of the effects of my actions upon these 2 young ladies and their families at the time – instead concentrating upon my personal circumstances. Not only was this a fundamental misunderstanding of the true values of a doctor/patient relationship – but just as importantly I now recognise that the 2 ladies and their families may have thought that I cared little for their own difficulties. I will freely and humbly offer my unreserved apologies to them now.” However, I would respectfully ask this Committee to bear in mind my own circumstances at the time of the hearing.  I was a doctor of 8 years qualification.  It was the first time that I had appeared in front of the Committee.  I was married with 2 very young children, with my wife expecting a third.  I was the sole breadwinner in the house and I faced the prospect of losing my career and my livelihood.  All that paled into insignificance when I considered the shame that I had brought upon my family and my practice and I honestly wondered how I could face the world again. Please be aware that I do not say these things to excuse my actions – but simply to inform the Committee of my thought processes at the time and the very great effect these proceeding have had upon me, how I view my work and how I approach my patients.

8.       Obviously, the Committee will be concerned to ensure that I am fully aware of the seriousness of my previous actions and will not repeat them again.

9.       As I have already indicated, I have considered very very carefully what I did. I believe that I am now much more sensitive and aware of the obligations that I have to patients in particular and the society as a whole.  The Committee may well recall that both of the complaints about me occurred at a time when I was working at an “Out of Hours Agency” which did not provide for chaperones.  The Committee had heard evidence from the last hearing that I would invariably ask for a chaperone when I examined female patients at my surgery. I would ask this Committee to accept that I would never again treat female patients in the way that this Committee has previously heard, but if the Committee has any doubts about that I am happy to confirm that I would willingly accept any restrictions upon my registration so long as I am able to practice again.  I accept that the welfare and autonomy of the patient is paramount and that a doctor must always act out of a sense of duty.


  1. The PCC imposed conditions on the appellant’s practice of medicine for 12 months, in summary: undertake six months supervised practice in a practice approved by Dr Shires of the Eastern Deanery; no unsupervised home visits in surgery hours; give Dr Shires and supervising doctor transcripts of charges and findings of PCC; undergo training in patient consultation skills and inter-personal relations, particularly with female patients; after six months satisfactory supervised practice report monthly to a mentor nominated by Dr Shires to discuss cases selected by mentor; carry out intimate examinations of female patients only in presence of chaperone; not to work for on-call agency or make out of hours visits.



  1. On 11 September 2003 the appellant’s father wrote to inform the PCT that it was the appellant’s intention to return to practise at his South Green Surgery in Billericay “as soon as GMC ruling allows and providing a successful application is made to the PCT for him to work in BBW”.
  2. On 26 September 2003 Peter Greenwood, the Secretary to the Essex Performance Advisory Group (PAG) which had been appointed by the PCT to consider the appellant’s position, wrote to the appellant, asking for transcripts of PCC proceedings in 2002 and 2003.
  3. On 30 September 2003 the appellant telephoned Peter Greenwood regarding the request for PCC transcripts. In course of conversation the appellant said that “the women are liars” and “I did not do what they said”.
  4. On 3 November 2003 the appellant began working for GP Direct in Harrow prior to inclusion on any Medical List.  This was a group of GP practices including at least one training practice.
  5. On 8 November 2003 the appellant applied for inclusion in the PCT’s Supplementary Medical List. On 21 November 2003 David Gibbins, Director of Modernisation and Commissioning of the PCT, wrote to the appellant inviting the appellant’s comments on the remarks made to Peter Greenwood on 30 September 2003 in the light of the GMC’s concerns about insight.
  6. On 3 December 2003 the appellant replied, enclosing transcripts. The appellant said he fully acknowledged “the immense seriousness of the alleged offences and always have done” and continued: “I did make the statements referred to by Peter Greenwood in his statement. I have always denied the allegations made against me and always will…I did not do what the two women alleged I did. This is the truth and even though my family and I have had to accept the GMC’s decision and live by the consequences, I refuse to ever accept the allegations as being true.
  7. On 4 January 2004 the appellant stopped working for GP Direct in Harrow after his tutor, Dr I Gulamali, was advised by PAG that he could not work when he was not on the Supplementary Medical List. 
  8. On 10 February 2004 the PCT notified appellant of the refusal of his application for inclusion in the Supplementary Medical List.  The grounds for the refusal were as follows:

(a)                the appellant is unsuitable for inclusion in the list; and

(b)               the inclusion of the appellant’s name would be prejudicial to the efficiency of the services that he would undertake.

          The PCT stated that the facts and reasons relied on were those set out in the

          PAG report of 2 February 2004 which it accepted.  The PAG report

          recommended that the appellant was unsuitable for inclusion on four grounds;

(a)   the contrast between his apparent contrition to the GMC and his attitude to

(b)   the charges at the end of 2003; (c) the inappropriate, indecent conduct found proved by the GMC constituting an abuse of his professional position in the case of both complainants; (d) the conditions imposed by the GMC prohibiting out of hours

          visits, work for an on call service and unchaperoned intimate examinations of

          female patients.  The PAG further recommended that including the appellant in

          the List would be prejudicial to the efficiency of the service because of the

          above grounds and the restrictions imposed by the GMC “which would make it

          impossible for him to provide the full range of activity provided by general

          medical practitioners”.


  1. On 9 March 2004 the appellant appealed against the PCT’s decision on the

      grounds that it was “unfair and unreasonable” as he has served the sanction  

      imposed by the GMC and the findings of the GMC are not sufficient reason

      for exclusion from the Supplementary List.


In relation to the PCT’s fourth summarised reason (the question of insight), the appellant said: “The fourth reason given by the PCT is clearly an area of dispute as the appellant has never admitted to the allegations made against him. However he did accept without appeal the decision by the GMC to suspend his registration. The appellant therefore submits that there is no requirement by the GMC for the appellant to apologise for the allegations made against him and this was not a condition imposed upon him by the GMC. Accordingly he considers it unreasonable for the PCT to impose such a condition.


The appellant further argued that the conditions imposed upon him would not make him inefficient as a GP.



  1. The hearing of the appeal

The appeal was heard at the Care Standards Tribunal, London on 10 June 2004.   The appellant was represented by Mr Ian Rimmer of the BMA and the PCT by Mr Richard Booth of Counsel.


  1. At the appeal there was produced a substantial bundle of papers.  The length of the evidence given was substantially reduced by the helpful attitude of the appellant who admitted that the transcripts of the BMA hearings were accurate; the authenticity of his written submission to the GMC 2003 hearing; the statement of facts prepared by the PCT and the truth of paragraphs 1 to 48 of the PAG report.  The appellant’s position was summarised in the last paragraph of the letter of 8 April 2004 from the BMA to the solicitors for the PCT as follows:  “ As the GMC decision was not appealed by Dr Sarfraz we cannot dispute the facts or findings of the GMC.  However Dr Sarfraz has never admitted to the allegations made against him.  Dr Sarfraz considers that the conditions imposed upon him by the GMC do not make him inefficient or unsuitable”.


  1. As the hearing of the appeal is a redetermination the PCT bore the burden of establishing either or both of the “inefficiency” and “unsuitability” grounds for refusal to include the appellant in its List.


  1. The evidence. 

The only witness called by the PCT was Mr Peter John Greenwood the Corporate Services Manager of the Chelmsford PCT and Secretary of the PAG. The latter advises the thirteen Essex PCTs on performance in general medical practice.  He verified and relied upon a short statement dated 25 May 2004 pointing out that a career in hospital medicine was not precluded by the PCT’s decision and that the appellant sitting the RCP (rather than RCGP) examinations might suggest that the he may take this course.  He confirmed that the PCT continued to rely on both the inefficiency and unsuitability grounds.


  1. In reply to questions on behalf of the appellant he explained the workings of the PAG, confirmed that he was not a clinician, and that efficient general practice would not be rendered impossible by the conditions imposed on the appellant by the GMC.  In re-examination he confirmed that the PCT regarded the inefficiency and unsuitability grounds as somewhat overlapping.
  2. The appellant gave evidence.  He confirmed the truth of a statement dated 9 June 2004.  He said he had always accepted the decision of the PCC and had written DA1to apologise for his mistakes.  He was asked what those mistakes were. He replied here and throughout the hearing that he had been unprofessional.  He further replied that in relation to Ms A it was a mistake to remain in her room and not go downstairs with her mother and to examine her legs outside her mother’s presence when downstairs.  In relation to Ms B the mistake was to engage her (or be engaged by her) in conversation which, he believed, may have been misunderstood or misinterpreted.
  3. He said he had at no time accepted the charges and apologised because it was a doctor’s duty when a complaint was made.  He did not appeal on legal advice and because he did not want to prolong the stress on his family.  He described the insight he had gained from the course he attended into the importance of respecting the autonomy of the patient.
  4. He admitted he had made the allegations against the complainants referred to in paragraph 13 and explained them as the result of stress and accepted that they had been inappropriate.
  5. The appellant said that in his meeting with Dr Hibble on 2 November 2003 he was told of the need to apply to be on a Supplementary List. He had been ignorant of that requirement before. He began working on 3 November and applied to the PCT on 8 November.  He has also applied to Harrow PCT and awaiting the outcome, wanting to get back into general practice.
  6. The appellant explained that there was in existence a chaperone policy in his father’s practice and that out of hours work was routinely delegated to agencies so that the conditions imposed upon him would not cause any efficiency problems.  He described the effects of the case on himself and his family as devastating and said that he was becoming de-skilled, a process which would get worse.
  7. The appellant was cross-examined at length.  He accepted that he must have made the complainants feel unsafe in their homes in the early hours of the morning.  He maintained that they were liars, but also described them as mistaken and said he should have respect for their views and it was in that context that he had made his submissions to the PCC.  He denied he wrote D1A to save his career but said it was the result of his realisation from the course he attended that he should respect patients and apologise.
  8. He accepted that it had been inappropriate to describe the complainants as liars and could not explain why he had done so after gaining the insight he claimed from attending the course.  Mr Booth for the PCT took the appellant carefully through the wording of D1A.  The appellant denied creating it to deceive the PCC and further denied that he had been careful not to include an explicit denial of guilt.  He refused to accept the suggestion that the objective reader of D1A would be bound to conclude that the appellant accepted the charges and wanted to make a new start with the insights gained from the experience.
  9. The appellant maintained that before 2 November 2003 he had no idea he had to be on a List and said that the letter from his father to the PCT of 11 September 2003 had been written by the practice manager without his knowledge.  He accepted that he had begun work before even applying to go on the List but said he had been led to believe that it was not a problem and a matter of paperwork.
  10. The appellant was given an opportunity to define his view of the complainants and said that he believed they were confused.
  11. The defendant’s father Dr Mansur Sarfraz also gave evidence. He was candid in admitting that he had not read the letter of 11 September 2003 before signing it, that he had no knowledge of PCT procedures including the application procedure and said that the practice manager had dealt with the chaperone policy.  Apart from the points that a chaperone could be arranged for an out of hours visit and that staff and patients were keen to see the appellant back at work in the practice, his evidence did not assist the Panel.
  12. Written testimonials were handed up.  Most of these were from family friends and were of little assistance to the Panel in weighing the merits of the appeal.
  13. Submissions

Mr Rimmer submitted that the conditions imposed upon the appellant might be inconvenient but did not result in inefficiency.  He reminded the Panel of Mr Greenwood’s answer to this effect, saying that the inefficiency ground was “not our strongest point”.  In relation to unsuitability he urged on the Panel the need for a proportionate response to the circumstances and the disastrous consequences of the case for the appellant and his family.  He submitted that the appellant had had no intention to deceive the PCC.   

  1. Mr Booth submitted that the evidence would justify a finding of inefficiency in the absence of an allegation of unsuitability.  In any event, he said, it was clear from Guidance that there was an overlap between the two grounds and from the case of Kataria v Essex Strategic Health Authority [2004] EWHC 641 (Admin) at paragraph 69 that a lack of probity might prejudice the efficiency of the service so that the evidence on unsuitability should also go to prove the ground of inefficiency.
  2. In relation to unsuitability he submitted that the appellant lacked insight into himself and others, was dishonest and prepared to tailor his story before the PCC and at this appeal to his own ends.  He referred to the appellant’s evidence about D1A and his changing answers to the question whether he still said the complainants were liars. He described the appellant as devious and calculating.  He understood why the appellant had not appealed the PCC findings but submitted that the appellant could and should have drafted D1A to make it plain that he maintained his denial whilst setting out to show the PCC how he had changed himself so as to be a trustworthy doctor.  He also reminded the Panel of context of the original offences.
  3. Conclusions

In relation to inefficiency there is no evidence of lack of clinical competence.  We do not accept that the conditions imposed upon the appellant’s practice of medicine would make him inefficient, although they would add burdens to any practice where he worked.  Whilst we accept the overlap between the grounds of efficiency and unsuitability, we think it right in the circumstances of this case to deal with them separately as far as possible. Whilst, if the PCT had chosen to proceed on the efficiency ground alone we should and would have taken evidence relating to the appellant’s probity into account, where (as here) the PCT chooses to pursue both efficiency and unsuitability it seems to us logical and fairer to the appellant to treat them as if distinct.  Otherwise one would add little or nothing to the other.  Our finding is that the PCT has not made out the efficiency ground.


40. In relation to unsuitability the appellant accepts that he cannot ask us to go behind the findings of the PCC.  Accordingly we bear in mind the context of two indecent assaults on strangers in their homes in the small hours of the morning (one a 14 year old with a hearing impairment, the other a single parent with a sick child) carried out by a doctor in his first year of general practice.  In each case the appellant had been called to provide medical advice and help so that his professional duties were fully engaged.  The second assault took place after a complaint had been made in relation to the first.


41. To this unpromising start other factors must be added.  The appellant was in breach of the condition imposed by the IOC to keep a register of intimate examinations on three occasions in less than six months and whilst awaiting his PCC hearing.


42. A main factor in our considerations was D1A.  We find it impossible, in view of the language and context of the document, for any fair-minded reader to conclude that that document should be given the highly limited interpretation for which the appellant contended so as to be consistent with a denial of guilt.  Contrary to the appellant’s evidence we find that it was written to mislead the PCC with great care taken to choose words so as to omit any express acceptance of the charges themselves whilst conveying the impression that acceptance, contrition and insight were the very basis of the document.  Whilst we understand the reasons for which he chose not to appeal the findings of the PCC, we cannot accept that he conducted himself with probity and insight thereafter.


43. We also find that the appellant’s words about the complaints in his conversation with Mr Greenwood on 30 September 2003 were highly inappropriate and inconsistent with the insight and respect he had claimed before the PCC only five weeks before.  The fact that he could not make up his mind before us whether he maintained the complainants were lying or mistaken or confused was further evidence of a lack of probity in trimming evidence to achieve a perceived advantage.


44. Further, the appellant began work on 3 November 2003 knowing he was not entitled so to do before being admitted to a List.  Even if he was led to believe this would be a formality, the responsibility was on him to secure admission and the failure to take that responsibility seriously appears to us to be evidence of unsuitability for general practice.  We have reservations about the appellant’s claimed ignorance of this requirement and about the writing of the letter of 11 September 2003 in this context. 


45. For all these reasons the Panel unanimously finds that the appellant is unsuitable to be included on what was at the time of the application the PCT’s Supplementary List and dismisses his appeal in relation to the unsuitability ground.


46. National disqualification

Under section 49N(3) we are empowered, on dismissing a practitioner’s appeal, to impose a national disqualification.  The PCT urged upon us the view that this was a suitable case for the exercise of that power.  No prior notice of this had been given to the appellant (although none is required) and in the result it was common ground that consideration of the imposition of a national disqualification would be adjourned to a further hearing of the Panel on a date to be fixed.


47. In accordance with Regulation 42 (5) of the Family Health Services Appeal Authority (Procedure) Rules 2001, we notify the appellant that he may have rights relating to appeals under Section 11 of the Tribunals and Inquiries Act 1992.




14 June 2004





Mark Mildred - Chair