CASE NO. 10689



Mr. D Pratt - Chair

Dr. D. Kwan - Professional Member

Mrs. V. Barducci  - Member






(GMC Reg. No. 0769174)









1.      This is an appeal against the refusal of Camden Primary Care Trust (“Camden PCT”) to include the Appellant (“Dr. Tuckman”) in their Supplementary List of medical practitioners, under Regulation 6 (1) (a) and (e) of the National Health Service (General Medical Services Supplementary List) Regulations 2001 (“the Regulations”).


2.      The decision of the Panel is that this appeal is dismissed.


Preliminary matters

3.      Dr. Tuckman appeared in person and gave oral evidence before us. He called no other witnesses. Camden PCT was represented by Mr. S. Janisch, solicitor, of Radcliffes LeBrasseur. We heard oral evidence on its behalf from Dr. Kathy Hoffmann, who is Co-Medical Director of Camden PCT, and also practises as a General Practitioner.

4.      The documents considered by us in the course of this hearing were:

a.       Dr. Tuckman’s Notice of Appeal dated 28 July 2003 and the documents lodged by him in support, under Rule 6 of the Family Health Services Appeal Authority (Procedure) Rules 2001 (“the Rules”), together in a bundle paginated 1-59 with

b.      Camden PCT’s written response dated 21 August 2003 and documents lodged with that letter under Rule 12 (3) of the Rules.

c.       Dr. Tuckman subsequently submitted letters from Dr. Stephen Rogers, Associate Medical Director of Islington PCT,dated 12 September 2003, and from Ms Allison Porter, Deputy Contracts Manager FHS Contracts Team, who dealt with administration of applications to the Supplementary List on behalf of Camden. We treated the contents of these letters as evidence before us at the hearing.

d.      A further bundle of documents consisting of some 118 pages, which was submitted at the hearing by Camden, with the agreement of Dr. Tuckman. It duplicated all those documents in the appeal bundle but included other pieces of correspondence and copy emails passing between the parties and between Camden PCT and various other bodies in connection with attempts to find a suitable period of supervised practice for Dr. Tuckman. We agreed to consider this evidence, though not submitted in conformity with Rule 12(3), as it was apparently relevant and in particular, threw light on “behind the scenes” activity on the part of Camden PCT, at time when it might otherwise appear that there had been inactivity, of which Dr. Tuckman had previously been critical.

e.       A witness statement which was put in at the hearing by Dr. Hoffmann, and which formed the bulk of her evidence in chief.

5.      Dr. Tuckman sought pre-hearing directions that the evidence to be given by Camden PCT must be confined to matters within the Supplementary List Regulations and in particular should not refer to his 2002 application to NHS Professionals [for admission on its Flexible Careers Scheme within the GP Returners Scheme]. His written grounds put this on the basis that such evidence was irrelevant and that it had been illicitly obtained, by which he meant that it was obtained allegedly in breach of the provisions of the Data Protection Act. By a decision set out in a letter of 3 October 2003 we refused to make that direction before the hearing but indicated we were willing for the application to be renewed before us at the commencement of the hearing, when both parties could address us on relevance and any other matters of law. In the event, although we gave permission to amend his Notice of Appeal to include the point set out at paragraph 24(b) below, Dr. Tuckman indicated at the hearing that he did not wish to pursue the application to exclude evidence.


Relevant Regulations

6.      By Regulation 4 (2) (i) of the Regulations, the information which a doctor must provide with an application to join the Supplementary Medical List includes:

“ … two referees who are willing to provide clinical references relating to two recent posts… as a doctor which lasted at least 3 months without a significant break, and where this is not possible, a full explanation and alternative referees.”

And by Regulation 4 (2) (m) he must further provide:

“any other information that the [PCT] may reasonably require to determine the doctor’s application”.

7.      By Regulation 6 (1) the grounds on which a PCT may refuse to include a doctor in its supplementary list include:

“(a) that [the PCT] having considered the declaration required by regulation 4(4) and (5) and any other information in their possession in relation to this application, consider he is unsuitable to be included in the list;

(e) that there are any grounds for considering that admitting the practitioner to the list would be prejudicial to the efficiency of the service which he would undertake.”



8.      We find the following facts.

9.      Dr. Tuckman applied to Camden PCT on 30 January 2003 for inclusion in its Supplementary Medical List. The application revealed that he was born on 9 May 1921, and was therefore then aged 81. He had retired from full-time practice as a principal in a GP partnership in south east London, and from the Medical List (as he was obliged to do on reaching the age of 70) in 1991. Until 1993 he had performed some locums but in 1994 cared full-time for his wife in her last illness. Since 1995 he has been a co-ordinator on medical topics at the University of the Third Age in London. In evidence, he told us that in that role he explored a topic from each week’s British Medical Journal. He told us that he had done no clinical practice at all in the last 9 years, but had kept in touch with medical colleagues and recently sat in on the GP surgery of a friend to satisfy himself he could cope, in particular with the stamina required for a 3 hour surgery. We find as a fact that he had not otherwise practised medicine or attended courses designed to keep knowledge and skills up-to-date.

10.  Applications to Camden and also to Islington PCT were processed by a Family Health Services Contracts Team. There was some correspondence with the Contracts Team about providing referees. By a letter dated 5 March 2003 Dr. Tuckman informed them he was unable to provide referees of the type requested and asked that his application proceed on the basis of references he had already provided. These referees did not and could not relate to two recent posts lasting at least 3 months, so as to satisfy the first part of Regulation 4 (2)(i). Ms. Alison Porter, who was an administrator dealing with applications at the FHS Contracts Team, wrote to Dr. Tuckman on 20 March to inform him that she had been in touch with the London Deanery, regarding GP returners and the problem regarding references. The Deanery is part of the University of London, and among other things it operates postgraduate retraining schemes for GP’s who wish to return to practice after a break; it is called the GP Returners’ Scheme.

11.  Dr. Tuckman had meanwhile sought the support of the British Medical Association to make representations about the length of time it was taking to determine his application, and on 25 March emailed a suggestion of his own to Ms. Porter, namely that he should be granted conditional inclusion in the Supplementary List. The FHS Contracts Team was then in communication with various parties including the Department of Health, and Dr. Steve Rogers (Medical Director of Islington PCT) for guidance and practical solutions. Dr. Rogers in turn consulted by email with other parties including individuals at the London Deanery, with the result that by 30 April he felt he had identified a possible returners scheme in discussion with the Deanery, and Ms. Porter was asked to take action along these lines. Although we were shown this correspondence (mostly by email), it was not disclosed to Dr. Tuckman at the time.

12.  Dr. Tuckman wrote to Ms. Susan Manion, Director of Primary Care at Camden PCT, on 25 April 2003, asking her to give the matter her attention and to arrange for a determination of his application without delay. She replied on 20 May, informing him that issues were being explored with Dr. Steve Rogers relating to the length of time since Dr. Tuckman’s references were completed. Dr. Tuckman was not satisfied with the apparent lack of progress and wrote to the Chief Executive of the Strategic Health Authority and the Chairman of Camden PCT by letters dated 29 May 2003. At this stage Dr. Hoffmann, the Medical Director of Camden PCT, was brought into personal involvement with the processing of the application.

13.  Having heard the evidence we are satisfied that Camden PCT was faced with a dilemma, because this was a novel situation. On the one hand was Dr. Tuckman’s lengthy period out of practising medicine; moreover, that was a period marked by significant change and advance. On the other hand here was a willing, energetic and formerly well-respected General Practitioner in apparent good health, who demonstrated in his contacts with the PCT, as he did before us, an alert and capable mind. We accept that the PCT did not wish to turn down such a candidate without making serious efforts to find an acceptable way of re-introducing him to medical practice in a fashion which demonstrated current clinical competency, or brought him up to date within an approved scheme, or both. In our view it was open to it to take this approach, although its implementation required care.

14.  Dr. Hoffmann shared this willingness of her colleagues to find a practical solution. What she did in fact was to write to Dr. Tuckman in a letter dated 5 June 2003, which, in its revised form, offered him a choice of two alternative vetting processes:

Option  1

The PCT would be happy to include you onto its Supplementary List providing that you satisfy the following:

·        A review of your clinical educational activity and a self test of your clinical educational ability

·        An occupational health assessment

·        Following the points above, an assessment by the London Deanery

·        Demonstrative competency in computer skills

If you do not wish to proceed with option 1 above, then the PCT would like you to consider option 2 below:

Option  2

·        Consider joining the GP Returner Scheme. The aim of this scheme is to attract back qualified GPs who may not currently be working in general practice and it provides a mechanism to training etc that will satisfy PCT in considering applications for inclusion onto their supplementary list. Attached are some further details and relevant contact details.”

15.  Dr. Tuckman immediately replied, choosing Option 1. In fact, in January 2003 he had already applied to join the Returner Scheme for GPs operated by the London Deanery, and that application had foundered on the twin grounds that he would not be able to obtain a substantive post on completing refresher training, and that the Deanery had been unable to find a placement for returner training. This information is derived from a form originally sent by the London Deanery to NHS Professionals and subsequently supplied to Camden PCT at their request. In an email dated 8 April 2003, Dr. Tuckman was informed by the Director of Postgraduate GP Education at the London Deanery (a Dr. Hastie) that the returner has to be able to demonstrate that they will be able to return to a substantive GP post (not locums) for a reasonable length of time after their refresher training, and that in his case she had been unable to find any practice willing to take a returner who was over 70 years of age. As Dr. Tuckman put it in his evidence, the Returners Scheme was in practice not available to those in his position who wanted to do only locum work.

16.  Dr. Tuckman told us in evidence that he had mentioned to Dr. Hoffmann in a telephone conversation in March 2003 that he had applied for a retraining scheme and had abandoned it since he was not suitable for it. Dr. Hoffmann has no recollection of being told this. We do not think it necessary to make a finding of what was said; we are satisfied that if she was told this Dr. Hoffmann had clearly forgotten by the time she wrote her letter of 5 June, and Dr. Tuckman told us that he admits he was not very helpful in failing to point out, when he accepted Option 1, that he had already applied for the Deanery’s Returner’s Scheme without success. We find Dr. Tuckman was pleased to find he could opt for something which he thought was different from the Returners Scheme, since he knew he could not satisfy its requirements, and therefore chose not to draw attention to his unsuccessful application.

17.  In fact, Option 1 was not described very fully or well in Dr. Hoffmann’s letter of 5 June 2003, as she accepted in evidence to us. When she referred to “an assessment by the London Deanery” she meant supervised assessment, and such assessment was (on enquiry) only available through the Returners Scheme. She explained that Camden PCT had neither the manpower resources, nor the funds, to conduct assessments itself, and so it was bound to rely on finding other providers.

18.  Moreover, when she set out the options in her letter of 5 June 2003, Dr. Hoffmann had not explored with the London Deanery whether it could provide some other form of supervised assessment outside the Returners’ Scheme itself. She had not appreciated that in fact this was the only process within which returners could be assessed. As she accepted when asked by us, the two options would in fact amount to the same thing.

19.  In the result there was an unfortunate difference of understanding between Camden PCT and Dr. Tuckman as to what was required before he could be admitted to the List.

20.  Dr. Hoffmann made further enquiries of the Deanery which established that the only method of giving effect to a proposal for supervised assessment was as part of the GP Returner Scheme described above. By 26 June Dr. Tuckman was complaining in writing that the protracted failure to determine his application amounted to a refusal of it. However on the same date the personal assistant to Dr. Hastie at the Deanery wrote to Dr. Hoffmann enclosing a copy of the report form sent to NHS Professionals refusing Dr. Tuckman’s application for the GP Returner Scheme, and indeed a copy of Dr. Hastie’s email to Dr. Tuckman of 8 April.

21.  In light of the information now in her possession Dr. Hoffmann therefore considered, and we accept, that there was no viable scheme available, by which supervised assessment of Dr. Tuckman could be put in place.

22.  We asked Dr. Tuckman if he could put forward GP practices which had indicated they could provide the sort of supervised assessment which would provide reassurance about his current clinical skills. He mentioned one named individual, but we were told that Camden PCT had spoken to this practice and established that the doctor in question is an appraiser now retired from the practice and the current senior partner will not consider taking on a returning GP in Dr. Tuckman’s position.

23.  By a letter dated 2 July 2003, Dr. Hoffmann, writing on behalf of Camden PCT, refused the application “given the considerable period of time which has elapsed since you last worked”.  Dr. Tuckman raised further points on the decision making process to which Dr. Hoffmann responded on 23 July 2003, confirming the refusal on the basis that “Camden PCT requires that all GPs placed on its supplementary list are able to demonstrate current clinical competency evidenced by recent references. The only exceptions to this would be GPs who have satisfied the Deanery’s requirement for the Returners Scheme”.


The appeal

24.  Dr. Tuckman’s Notice of Appeal of 17 July 2003, in its amended form before us, complains that:

a.      “Dr. Hoffmann’s decision was made following her failure to implement the agreed procedure as set out in the revised version of her letter to me dated 5 June.

b.      Her decision was based on information obtained in a manner not provided for in the Supplementary List Regulations and on a misinterpretation of that information. The information is contained in a document from the files of NHS Professionals sent to Dr. Hoffmann.

c.       Further, the Regulations make no mention of “not eligible for re-training” as grounds for refusal.”

25.  By a further Notice of Appeal dated 28 July, Dr. Tuckman complained that:

a.       The PCT has not followed requirements of Regulation 4(2)(i). It failed

To request further information as provided for by 4(2) (m) and

To implement the agreements set out in its Medical Director’s letter of 5 June 2003 (revised version)

It thus prevented my being able to demonstrate “current clinical competency” if indeed that is the purpose of 4(2) (i).

b.      The PCT did not ask me to cooperate with an assessment by the NCAA (Reg 4 (3) (e)).

There follows a paragraph which essentially repeats that set out at paragraph 23 (b) above.

26.  By its response, dated 21 August 2003, Camden PCT asserts that:

“The grounds of refusal are that Dr. Tuckman is, in light of the information in the PCT’s possession in relation to his application, considered unsuitable to be included in the list and that admitting him to the list would be prejudicial to the efficiency of the service which he would undertake, as set out in regulation 6(1) (a) and (e) of the NHS (General Medical Services Supplementary List) Regulations 2001 (“the Regulations”)”.

27.  The facts and matters relied on by Camden PCT in its Response include the following:

“…Dr. Tuckman is a retired GP who has been out of the clinical arena for some 12 years. When his application to joint the supplementary listwas received it was not supported by suitable references under regulations 4(2)(i) of the Regulations. Dr. Tuckman was informed of this by those managing the list jointly on behalf of Camden and Islington PCT’s. Dr. Tuckman challenged this view, approaching Canden PCT directly to do so. As a result, the PCT then became involved in protracted discussions with other agencies to explore the possibilities for allowing Dr. Tuckman to re-enter the workforce. The discussions were complicated by the fact that, given Dr. Tuckman’s extended absence from practice, the PCT needed to confirm his fitness to practise with a period of supervised assessment to compensate for the lack of current clinical references. Supervised assessment of a clinician’s practice is not something that the PCT has experience of and for this reason support was sought from the London Deanery which has well developed links with suitable practices and practitioners able to perform such assessments…..The PCT is not in a position to fund such placement whereas the Deanery … does have dedicated funding for such a purpose. The Deanery’s Returners Scheme has been developed for doctors in Dr. Tuckman’s position seeking re-entry into the workforce after prolonged periods of absence. At the time the PCT was researching the options for Dr. Tuckman it was uunaware that he had approached the Deanery direct regarding suitability for the Returners Scheme. The Returners Scheme requirement for supervised practice reflects the importance placed on validating clinical competency directly and not relying solely on information from paper exercises. The Returners Scheme’s inability to secure a practice prepared to supervise Dr. Tuckman resulted in his rejection from the scheme. In addition this decision also rendered non viable Option 1 as per my letter to Dr. Tuckman of 5th June 03 as the Deanery Assessment quoted would have included a period of supervised practice.

We have emphasised in bold the crucial factor causing Camden PCT to reject the application (as Dr. Hoffmann confirmed to us in her evidence).

Application of the Regulations

28.  Dr. Tuckman’s grounds of appeal raise various points on the application of the Regulations. Regulation 6 (1) sets out discretionary grounds for refusing an application. In reaching a decision, the PCT is therefore required to consider (among other things) whether, in the light of all the information they have including current clinical competency, the doctor is unsuitable, within the meaning of (a), or likely to be prejudicial to the efficiency of the service if admitted to the list. The PCT is not limited to a consideration of the mandatory information provided by the doctor under Regulation 4. Nor is it, our view, obliged to require the doctor to provide information under Regulation 4 (m), which simply obliges the doctor to give the information if asked. Insofar as Dr. Tuckman appeared at one stage to be suggesting in correspondence, (see for example a letter to the PCT dated 26 June 2003) that there was a culpable failure to ask for further information, we find that in the circumstances of this case there was no obligation on the PCT to do so, and reject any contrary construction of Regulation 4(2)(m).

29.  We find that Dr. Tuckman could not provide clinical referees which satisfied regulation 4(2)(i), having retired from practice almost 12 years earlier and that (save to the limited extent set out at paragraph 9 above), he had not been engaged in the practice of medicine thereafter. In evidence before us he accepted that it was important that the PCT should be satisfied about his fitness to practise, and also that it should have the safety of patients at heart. If (as we understand is the case) he meant that it was right for Camden PCT to satisfy itself that his clinical competency was up-to-date and satisfactory, in the absence of references or evidence of recent periods of medical practice, then we agree.

30.  In our view, the Regulations contemplate that where there is a good reason for the absence of suitable referees, a doctor might nevertheless be admitted to the Supplementary List. In those circumstances, in our view it is both reasonable and necessary for a PCT to consider (among other matters) what evidence there is to demonstrate current clinical competency, including whether it is feasible for the returning practitioner to update his skills through one of the established Returners Schemes.

31.  The Regulations themselves are silent as to what alternative evidence of current clinical competency it might be reasonable to seek. We find that the alternatives explored by Camden PCT were reasonable, and that on the evidence before us, there were no other reasonable alternatives to provide the PCT with reassurance as to current clinical competency. It is not for the PCT to prove (as Dr. Tuckman submitted to us) that he is unfit to practise. That is not the issue. It is necessary and appropriate for the PCT to have robust evidence of current clinical competency before admitting someone to the Supplementary List who has not been in the clinical arena for 9 years. Dr. Tuckman submitted that there are other forms of assessment (which he had hoped would be followed) such as summative assessment. In our view it was reasonable to require that in these circumstances any assessment was in the practical clinical setting, under supervision.

32.  We therefore reject the grounds of appeal set out at paragraph 24, which seek to argue that obligations were placed on the PCT by Regulation 4(2).  That regulation places obligations on the applicant, not on the PCT. Nor do we find that Regulation 4(2) places any obligations on the PCT by necessary inference, other than the overriding obligation to consider the information provided, along with any other information it has.

33.  We also find that Dr. Hoffmann never abandoned Option 1, as further suggested in the Notice of Appeal, because from the outset, unfortunately and unknown to her when she made the offer, the two options were one and the same thing. In any event, the offer of a process to vet current clinical competence did not confer on Dr. Tuckman any right outside the Regulations to pursue that option come what may, if it transpired that that option was impractical, or failed to satisfy the PCT’s perfectly reasonable requirement for some robust process to demonstrate current clinical competence.

34.  It is very unfortunate that, because of the novelty of this situation, Camden PCT was to some extent devising the procedure as it went along, and particularly unfortunate that the options were expressed as two alternatives when, for the reasons set out above, they were in truth one and the same thing. This in turn caused delay which, because Dr. Tuckman was not party to the communications going on behind the scenes, caused him to believe that Camden PCT was procrastinating unjustifiably. It may be that the information being given to him could have been fuller and more helpful, but we are unwilling to be critical where the PCT was feeling its way and did not have clear answers to give him.

35.  Lastly, insofar as we are required to say whether it was appropriate to take into account the information passed to Camden PCT by Dr. Hastie of the London Deanery, including a report form she had submitted to NHS Professionals, our answer is that it was. In light of the fact that by then it had been established that the only route for supervised assessment was the GP Returners Scheme, it was plainly relevant to know that Dr. Tuckman had previously applied and had been considered unsuitable and the reasons for that. We observe that if the PCT had requested Dr. Tuckman to provide it with information about any applications he had made for “return to practice” schemes, he would have been obliged under the Regulations to disclose at least the email which he had received from Dr. Hastie dated 8 April 2003, and the outcome. Moreover Regulation 6 (1) requires the PCT to consider “any other information in their possession in relation to this application”. We do not think it was inappropriate to take this information into account, nor do we think there was any misinterpretation of it, or inappropriate weight given to it.

36.  We approach this appeal as a redetermination of the issue of whether Dr. Tuckman should be admitted to the Supplementary List. Camden PCT could have rejected the application for failure to provide references complying with Regulation 4. It did not choose to do so but instead sought other ways of satisfying itself of Dr. Tuckman’s current clinical competency. In the event, it did not feel that there was evidence which could satisfy it of that necessary degree of current competency, and nor do we. With some sympathy for both parties, and in particular for Dr. Tuckman, whose vigour and mental acuity were amply demonstrated during the hearing of this appeal, we must dismiss this appeal.

37.  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.



Dated this 12th day of November 2003






Duncan Pratt

Chair of the Panel