DR S N PRASAD
and
REPRESENTATION
For the Appellant - Mr N Sheldon of Counsel
For the Respondent - Mr C Johnston of Counsel
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DECISION AND
REASONS
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THE APPEAL
This is an Appeal by Dr Prasad against the decision of the Respondents dated 8th June 2006 to remove the Appellant from the Medical Performance List under Regulation 10 of the National Health Service (Performers’ List) Regulations 2004.
BACKGROUND
1. The Appellant is a General Practitioner who has practiced in a particularly deprived area of Leeds for over 25 years. Most of his patients are from ethnic minorities and the overwhelming majority come from low income households. On 26th April 2005 the PMS Contract Review was concluded by Emma Wilson. The Practice achieved the lowest Q.O.F. points within the PCT which was said to be disappointing for a Practice that had received additional investment through the PMS.
2. On 6th May 2005 Dr Damien Riley produced a report which recommended that Dr Prasad’s case should be discussed at a Performance Group of the PCT with multi-disciplinary input. Dr Riley suggested the following:
i) That the Appellant was referred to the Deanery for a fuller knowledge and skills assessment.
ii) That a Deanery appointed mentor worked with the Appellant to identify areas of weakness and focus learning activities on these areas, in particular consultation skills; record keeping; communication; acute disease management; audit programmes; evidence based guidelines and appropriate prescribing.
iii) A fuller assessment of the notes was to be conducted with the Appellant’s help leading to a development of a robust summarising policy.
iv) That the Practice was prioritised for a new I.T. system.
v) That the Appellant sat with other G.P. colleagues to see how they consult.
vi) That the Appellant should meet with colleagues in a protected environment in order to develop a more reflective practice, particularly with regard to handling complaints and significant event reviews.
3. On 14th September 2005 the Appellant was suspended from the Respondent’s Performance List. This suspension was extended by the FHSAA on 21st April 2006..
4. On the 16th May 2006 the Respondent conducted a Hearing in respect of the Appellant’s removal. That Hearing was attended by the Appellant and his legal representative Mr Neil Sheldon.
5. On 8th June 2006 the Respondent removed the Appellant from the Performers’ List. The reasons given in a letter of the same date can be summarised as follows:
i) That the Appellant had prescribed inappropriately;
ii) That the Appellant’s record keeping and management of patients was poor;
iii) That the Appellant had provided inappropriate clinical care and clinical management of his patients;
iv) That the Appellant had failed to follow the protocol of acknowledging within 48 hours and replying in detail to any complaints within the stipulated time framework of 21 days and further the Appellant was not able to consider effective learning;
v) That the Appellant had a poor practice with significant system failures;
vi) That the Appellant was not able to take appropriate notice of NICE guidelines, the need to conduct in-house audits within the Practice and construct a proper personal and professional development plan as per the requirement by the annual appraisal.
6. On the 4th July 2006 the Appellant appealed to the FHSAA. Appeals to the FHSAA are by way of re-determination.
THE LAW
7. The law can be found in the 1977 Health Services Act as amended together with associated regulations. The National Health Service (Performers’ List) Regulations 2004 provides as follows:
i) Regulation
10 (3) and (4)
The Primary Care Trust may remove a performer from the Performers’ List where any of the conditions set out in paragraph (4) is satisfied.
The conditions mentioned in paragraph (3) are that:
(a) his continued inclusion in its Performers’ List would be prejudicial to the efficiency of the services which those included in the relevant Performers’ List perform (“an efficiency case”);
ii)
Regulation 11
provides:
Where a Primary Care Trust is considering whether to remove the performer from its Performers’ List under Regulation 10 (3)(4)(a) (“an efficiency case”), it shall take into consideration:
(a) the nature of any incident which was prejudicial to the efficiency of the services, which the performer performs;
(b) the length of time since the last incident occurred and since the investigation into it was concluded;
(c) any action taken by any licensing, regulatory or other body, the Police or Court as a result of any such incident;
(d) the nature of the incident and whether there is a likely risk to patients;
(e) whether the performer has ever failed to comply with the request to undertake an assessment by the NCAA on or before 31st March 2005 or thereafter by the NPSA;
(f) whether he has previously failed to supply information, make a declaration or comply with an undertaking required on inclusion in the List;
(g) whether he has been refused admittance to, conditionally included in, removed or contingently removed or is currently suspended from any List or equivalent List, and if so the facts relating to the matter which led to such action and the reasons given by the Primary Care Trust or the equivalent body for such action.
iii)
Under Regulation
12:
In an efficiency case or fraud case the PCT may, instead of deciding to remove a performer from its Performers’ List, decide to remove him contingently.
If it so decides, it must impose such conditions as it may decide on his including in its Performers’ List with a view to:
a) removing any prejudice to the efficiency of the service in question;
PRELIMINARY MATTERS
8. At the outset of the Hearing which took place on the 5th and 6th October 2006 and reconvened in the absence of the Parties on 11th October 2006, the Appellant confirmed through his legal advisors that he did not intend to give evidence. Both the Appellant and Respondent had provided outline submissions.
DOCUMENTS & EVIDENCE CONSIDERED
9 Both parties had submitted originating documentation which was compiled in a bundle.
10 In addition to the main bundle a witness statement bundle and core bundle of medical records were provided.
11 Two further bundles of medical records were indexed and available to the parties.
ORAL EVIDENCE ON BEHALF OF THE APPELLANT
12 The Appellant did not provide oral evidence. The Appellant’s Counsel opened the case on the basis that the Appellant was not seeking to persuade anyone that his Practice was in perfect order. The Appellant’s case was that he would benefit from an assessment. If an assessment proved that the Appellant was not fit he would bow out gracefully however he would like the chance to complete an assessment and this was his position and had been throughout these proceedings.
13 In May 2005 the report from Dr Riley confirmed that it would be premature to remove the Appellant at that stage. Correspondence was entered into between Dr Riley and the Deanery and in particular with David Ede.
14 David Ede, who is an NCAS Advisor, wrote to Dr Riley on 5th September 2005 and thereafter on 14th September 2005. In the later letter it was suggested that whilst it remained open to the PCT to consider and apply for an NCAS assessment, given the range of concerns identified and the fact that the Appellant was now doing only locum work, he might find it difficult realistically to implement and demonstrate progress with a post NCAS assessment action plan. The letter does not state that NCAS would not do an assessment or in fact would turn down an assessment. The option was still there and an application form would be forwarded.
15 Dr Riley reported to the Panel that NCAS could not do an assessment or they would turn down an assessment and further that the Appellant would require an advanced training practice in order to undertake such training as they required.
16 During the course of the communications between the parties, at some stage the PCT abandoned their plan for the Appellant to be formally assessed with no good explanation being given to the Appellant.
17 Dealing with the specific issues, it was submitted as follows:
a. In respect of prescribing, it would be dangerous to rely on statistical data. There was a three-month snapshot from October to December 2004. The Appellant was not out of sync on all matters and the prescribing data had to be approached with caution. Was this so serious as to justify the actions to remove the Appellant?
b. It was accepted on behalf of the Appellant that his handwriting was not good. This could be remedied as most GP Practices are now computerised.
c. In respect of patient histories, the Appellant was overstretched and did not have time to complete history taking. There was insufficient evidence of other complaints within the documents provided.
THE Q.O.F. REPORT
18 Whilst accepting that it was the lowest in the PCT there had been no analysis as to why this was important and no evidence as to the data of other Practices, either locally or nationally.
19 Concerning the issues in respect of complaints, it was submitted that Dr Riley knew about complaints in May 2005 when he recommended the assessment. There was no criticism made of Dr Prasad in the letter of complaint, there was a delay in responding but the substance of the response was not criticised. Overall there was a mixed and inconclusive picture such that it would be unfair and inequitable to remove the Appellant.
ORAL EVIDENCE ON BEHALF OF THE RESPONDENT
20 The majority of the evidence on behalf of the Respondent was provided by Dr Riley. Dr Riley confirmed that the Appellant was the highest prescriber of new drugs, the highest prescriber of NSAID, the highest prescriber of drugs of limited value from October ’01 to September ’05, and the highest prescriber of antibiotics from October ’01 to ’05. There was concern raised in respect of Cox II anti-inflammatory drugs; evidence had come in in 2003 and 2004 suggesting that these were not a safe alternative and they were certainly hazardous in certain groups of patients. This was addressed by NICE in 2004. The Appellant continued to be the highest prescriber of Cox II anti-inflammatory until towards the end of 2005. He was the lowest prescriber of generic drugs and there was evidence of inappropriate prescribing of Statins, not following NICE guidelines again. Dr Riley summed up to say that it was unusual for a G.P. to give concern over so many areas.
21 The record keeping was illegible. This was less of an issue now because of computerisation. However G.Ps do have to write occasionally. It was essential to input information if the Practice was relying on the computer. It is important to use the correct READ CODES to compile various disease registers e.g. Diabetes, Coronary Heart Disease etc. The Practice failed to reach the expected standards in updating the disease registers. The history taking was briefer than Dr Riley would have taken; on the whole the referral letters were O.K., however some information had not been disclosed on the referral letters.
22 Patient JK: This was a patient who was prescribed 15mg capsules of Reductil. This is an appetite suppressant drug. Prescriber is bound by strict protocols of weight measurement and calculating B.M.I prior to commencing the therapy. Furthermore, blood pressure must be measured before prescribing the drug and should be monitored every two weeks. Therapy can only continue if the blood pressure is maintained within a normal range.
On 19th January 2005, no blood pressure was recorded at the time of a visit. The next time blood pressure was taken was not until June 2005. In addition, in October 2004 correspondence was forwarded to the Appellant suggesting that the patient should be started on Insulin; 10 units of Insulatard. The Pioglitazone should be stopped. There was no notice on the record to stop the drug nor was there any indication that Insulin had been commenced.
23. Patient GY: On 22nd March 2005 a high vaginal swab and endocervical swab was taken. On 30th March 2005 the report was returned stating bacterial vaginosis. On the 18th April 2005 the patient presented again. No action had been taken on the abnormal swab results. No prescription had been prescribed for the patient.
24. Patient MZ: This patient presented with problems on his hip on 13th July 2004. He was diagnosed as having an irritable hip. This was an incorrect diagnosis. Amoxicillin was prescribed. Dr Riley queried why. The patient consulted 5 – 6 times for hip pain, back pain and loss of appetite. An Xray was conducted on 14th April 2005. This showed malignant primary bone pathology. No Xray had been sorted out at the time of the initial symptoms being presented. This is the most basic investigation which was not carried out on the first consultation.
25 Patient NB: On 16th March 2003 the patient gave a history of blood stained discharge from the nipple. This complaint automatically triggers an urgent referral and a two-week wait protocol of suspected cancer diagnosis. Opportunities of making an urgent referral were missed repeatedly. The referral pre-printed pro forma ought to have been faxed on the very first consultation. The fact that the diagnosis turned out to be of non-malignant breast disease does not reduce the charge of gross inadequacy of clinical care of a potentially very serious medical condition.
26 Patient AI: The patient attended on 13th February 2004 with a complaint of bed-wetting. A prescription was given of Desmotab. Dr Riley suggested that there should have been a urine test before commencing treatment.
27. Patient M: On 15th July 2002 the patient was given a Sickness Certificate for 13 weeks suggesting Diabetes and Hypertension. He was prescribed Nifedifine, Inderal and Gliclazide. This patient was a high risk of a heart attack and/or stroke. The suggested practice is that there should be a 3 – 6 month blood pressure check, blood sugar levels and cholesterol levels. From 9th September until 22nd March 2005 the patient attended the surgery on numerous occasions. The patient was given repeat prescriptions and no checks were carried out. 16 dates were given in this period. On 22nd March 2005 the patient was under the care of another G.P. The checks were carried out. HbA1c which should have been below 7.5 was 13.8; blood pressure which should have been in the region of 140/80 was 203/101. The G.P. commented that the patient had not been prescribed statins. Dr Riley said that this was inadequate care.
28. Patient SRK: Had a referral letter sent to her home address instead of to the Hospital.
29. In respect of the complaints, there was a failure of the Appellant to respond to serious complaints. Complaint AC was dated 2nd February. The complaint was not received until 2nd March. A further letter was sent on 7th April and a cursory response was sent to that letter.
30. Patient GG: Filed a complaint on 10th January 2005. No response was received until 15th April 2005.
31. Patient FC: Filed a complaint on 12th April 2005. There had been no response by the end of April 2005. A response was eventually received on 2nd July 2005.
32. Patient GH: Had complained on 22nd April 2005. This was replied to on 25th May 2005.
33. Patient KL: Had complained on 28th April 2005. No response had been received.
34. Dr Riley suggested that appropriate practice would provide a comprehensive report within 21 days which would be a reasonable timeframe. The delays in the complaints were all out of time.
35. The reflective learning was a concern. The Disease Register had been brought to Dr Riley’s attention prior to his visit in May 2005. The Appellant confirmed that he would audit thyroid patients but when asked how he intended to implement this audit the Appellant did not know. There was very little evidence of a structured training programme provided by the Appellant. Dr Riley confirmed that he had identified areas of concern being record keeping, clinical care and history taking. The training programme did not target any of these areas. After receipt of the report in May the Appellant continued to work out of hours at very high levels. This was not initially known to Dr Riley.
36 Mr Riley confirmed that a referral had been made to NCAS by telephone in Spring 2005. Both he and other members of the PCT had been in constant communication with various people up until 2006. The NCAS assessment would have covered occupational health, behavioural and clinical assessment.
Performance indicators would be looked at. Dr Riley had worked as an NCAS assessor in the past and confirmed that the assessment would clarify concerns, identify contributory factors and make recommendations. The NCAS assessment had not been taken up due to the fact that he did not believe it would come up with any other options other than those before the PCT which he had provided.
37 The Appellant had, during the course of the investigation, decided to retire from Practice and take up work as a Locum. Dr Riley said that the Appellant could not be monitored in a Locum capacity. If he was a G.P. in his own Practice he could be supported with an I.T. team, Practice Nurse and Medicine Management Team. It was difficult to target and put focused support in. It was difficult to monitor the outcome. Prescriptions could not be monitored as they were completed under the name of a registered G.P. The advice from NCAS, the Deanery and the GMC confirmed that Locums did not operate in a clinical governance scheme. They did not adopt clinical governance, it was a high risk.
38 To work successfully as a Locum G.P. you would have to be astute with consultation skills. It required the highest level of consultation skills. Dr Riley suggested that the Appellant would require 6 – 12 months of training. He would need clinical supervision. It was not workable. Despite the Appellant having been advised in November that he required a training practice, by May ’06 the Appellant had still not found the training practice. The training practices were in any event geared up for Registrars, one of the reasons being that you had to explain to the patients. They were not geared up for failing G.Ps.
Under cross-examination Dr Riley accepted that he had mis-represented the position in respect of one of the patients. It was patient MZ who had had cancer and not patient NB. Under further cross-examination Dr Riley suggested that the Appellant was not capable of change and that he showed lack of insight. In one of the patients where harm did not occur, he maintained that it was still a risk even if on that occasion harm had not occurred. The mis-diagnosis was a fortunate outcome which did not excuse the lack of the following procedure.
39 Dr Riley maintained that overall a clinically safe environment could not be established and that he maintained his submission that the Appellant should be removed.
40. Dr Berty gave evidence in respect of Patient NB. She confirmed that there had been three attendances prior to her own attendance on 16th March; 23rd March and 30th March. Dr Berty had sent the urgent 14-day referral on 28th April 2005 and faxed it through herself. She said that there were two courses of antibiotics prescribed, this was a red-flag symptom and should have been addressed earlier. Insofar as the entry on 13th April 2005 was recorded under her name, she confirmed that she had not seen the patient on that date and that somebody else had logged in on her name.
41. Julie Bolus is the Lead Director for Data. She confirmed that there had been a team in place since 2002. They had worked with the Appellant for a period of time with limited impact. It was wrong to prescribe drugs of limited clinical value.. It was an inefficient use of NHS resources. There had been excessive prescribing, however there were a range of other issues which gave cause for concern to her. The NCAS assessment had not been taken up as the PCT Panel felt that they had sufficient evidence, depth and breadth with supporting information that they did not need a referral or assessment. The Panel accepted that there were no suitable placements.
42 It was maintained that the Appellant had a lack of insight, there was no demonstrable evidence that he had built up a relationship with the Deanery at all from May 2005 to September 2006 and overall there was a lack of holistic care.
RESPONDENT’S SUBMISSIONS
43 Mr Johnston, on behalf of the Respondent, relied on written submission.
44 This was an efficiency case and Regulation 10.11.6 set out the criteria which need to be taken into account before reaching a decision.
45 The PCT would rely on the following matters to demonstrate that the Appellant’s continued inclusion would be prejudicial;
i) That it was unusual for a Doctor to come out top in so many areas in respect of prescribing. The Appellant was an outlier in seven different areas. This indicated that his prescribing practices placed the patients at risk and they impacted on the efficient use of NHS resources. There were four years which were analysed. As such this was a pattern of prescribing over a long period of time which was a worrying approach to patient safety. It also indicated a failure of the Appellant to stay up to date in his clinical practice.
ii) His record keeping and in particular the writing was indecipherable. The Q.O.F. assessment selected 20 records, most of which were illegible. Illegible entries can prejudice future treatment of patients when salient parts of the history are not identified by subsequent Practitioners. In a Locum practice there would be the need for a G.P. to communicate with others using handwriting. With regard to computer records, there was a lack of system for chronic disease management, missing data, no verification of registers and a failure to follow diabetic clinic protocol. On an assessment of records, major diagnoses were found to be missing, there was inconsistency with the transcribing of data, inconsistent recordings of smoking status and blood pressure and no coherent system for the extraction of data or diagnoses from letters.
iii) Clinical management was likely to place patients at risk. It had an adverse
impact on patient care. The patients which have been identified; JK; GY; MZ; NB; AI; SRK; M; all showed areas of concern.
· JK was not monitored for blood pressure nor was the direction from Leeds Teaching Hospital complied with.
· GY: No action was taken by the Appellant in respect of the report.
· MZ: Diagnoses of irritable hip was made. This was incorrect. When the Xray was undertaken this showed malignant lesions of the pelvis (metastatic).
· NB: Presented with blood stained discharge from the nipple. This mandated an urgent 14-day referral. It was not done.
· AI: The child should not have been given a prescription. The starting point should have been to check whether there was any urine infection.
· SRK: The referral letter was sent to the incorrect address.
· CM: Was prescribed three drugs from July 2002 until 22nd March 2005 with no monitoring. When a further G.P. monitored the patient its blood pressure and blood sugar were both high and dangerously abnormal.
46 The Appellant had failed to respond to complaints. None of the complaints which had been raised were responded to in an adequate time.
47 There was little evidence as to appropriate guidelines for managing patient care. Despite guidance having been provided to the Appellant it had not resulted in appropriate changes to his Practice, for example the prescribing issues. The Appellant had not put in place any meaningful professional development plan nor had he taken steps himself to put in place any meaningful educational plan to address his failings. There was no evidence to demonstrate that the Appellant had adopted an appropriate approach in the past to professional development and learning and thus it should be inferred that there will be similar problems in the future.
THE APPELLANT’S SUBMISSIONS
48 Mr Sheldon, on behalf of the Appellant, had also provided closing submissions. Dr Riley’s evidence illustrated that a formal independent assessment of Dr Prasad’s abilities was necessary before a decision was taken as to his removal.
49 It was not submitted on the Appellant’s behalf that all of the concerns raised by the PCT were wholly without merit. The Appellant recognises that further training was appropriate.
50 Patient JK was not on a potentially dangerous combination of treatment for two months.
51 Patient MB did not have breast cancer.
52 The referral letter for SRK was a referral made by Dr Berty, not the Appellant.
53 The delay in referring NB to the Cancer Clinic was contributed to either by Dr Berty or the Practice Nurse or both.
54 Patient GY: There was no indication that the Appellant saw particular test results and therefore had not acted isufficiently quickly.
55 This was all anecdotal evidence; some cases had been abandoned by the PCT prior to the Hearing commencing. The better and fairer course was to proceed by way of formal and thorough assessment rather than edited extracts from the notes of a handful of the thousands of patients cared for by the Appellant during his 30 year career.
56 The complaints were responded to within a reasonable time. The case of AC, which the PCT maintained the response was wholly inappropriate, was not upheld by the Health Care Commission, who made no criticism about the reply of the Appellant and further the Appellant did respond in a reasonable time. The Appellant responded within the time frame identified by Dr Riley in his evidence.
57 There was no good explanation as to why prescribing trends, which were clear since 2001, suddenly merited removal in 2006. No attempt had been made to establish whether the side effects in respect of NSAIDs, which were stated to cause stomach ulceration or side effects, were actually present amongst the Appellant’s patients.
58 The PCT unjustifiably changed their position. Having identified that an NCAS referral or assessment was necessary, it was then submitted to the PCT by Dr Riley that they would not accept a referral and further, if the PCT were relying on the basis that they had undertaken an adequate assessment, why was it not until 24th November the PCT proposed the removal of the Appellant.
59 Similarly in respect of the identification of a suitable training practice, the first time the assertion was advanced that all the training practices were full was in evidence before the Panel. There was no indication that this was the case in the email from the Deanery and no indication or mention anywhere in the documentation that the training practices lacked capacity.
60 The PCT had identified what was required in this case and subsequently abandoned the course for reasons of convenience and expediency. A proper NCAS assessment and a chance to put right any deficiencies should be undertaken. The Appellant should be given the chance to be assessed before his career was ended.
ASSESSMENT OF EVIDENCE AND FINDINGS OF FACT
61 The Panel have considered the evidence in the bundles; the submissions of the representatives; oral evidence given and make the following findings:
PRESCRIPTIONS
62 The Panel find that the Appellant has not monitored prescriptions. The Appellant has taken the easier option of prescribing not in accordance with NICE guidelines. There has been a lack of medical or medication review. Good practice would involve medication review at least once per year. The Panel find that the Appellant has a lack of ability to change his working practice.
63 Dealing with specific prescribing, the Panel find that the Appellant is the highest prescriber of new drugs. The Appellant was the highest prescriber of drugs of limited value from October 2001 to June 2005. Drugs of limited value are not a risk to patients but they are an inefficient use of resources. The Appellant was also the second highest prescriber of NSAID’s where the average for the PCT stood at 0.95 and Dr Prasad at 1.78.
64 In respect of generic prescribing the Panel find that the Appellant was under the PCT average. The Panel did not find that this was very significant given that the national target is 80% and the Appellant was almost at 73%.
65 The Panel also find that the Appellant was the highest prescriber of antibiotics from October 2001 to June 2005.
66 The Panel find overall that the Appellant’s prescribing gives rise to concern due to the fact that he is an outlier in most areas of prescribing. The Panel also find that despite significant advice and support which had been offered to the Appellant over a long period of time that the Appellant has not listened to advice and acted upon that advice such that his method of prescribing has altered in accordance with GMC guidelines.
RECORD KEEPING
67 The Panel find that the Appellant’s handwriting is illegible. This is evidenced on all of the records which were viewed by the Panel. The Panel also find that history of record taking is well below that which would be expected from an average G.P. The Panel make those findings from the sample of medical records to which the Panel had access.
68 The Panel accept that the Appellant knew his patients well and would probably not revisit their medical problems on each consultation. Unfortunately this practice does not assist any other G.P. who may be dealing with the Appellant’s patients either by way of Locum or by way of transfer.
PATIENTS
69 AI The Panel accept that there was evidence of bedwetting with no investigation. The Panel find that this is evidence of not good practice but it is not a risk to the patient.
70 MZ The Panel find that this patient presented with an irritable hip on the 14th March 2005. The Panel do not accept that the irritable hip presented in July 2004 as suggested by Dr Riley. The Panel accept that the diagnosis is unorthodox as is the medication. Irritable Hip is a condition generally found in children under 10. The Panel accept that the Xray was arranged on 14th April 2005. The patient had not been referred for Xray in March 2005 and in fact problems were mentioned initially on 27th January 2005. The Panel accepts that when the results were returned on 14th April 2005 these showed a possibility of malignancy. Further tests confirmed malignancy. Having considered the steps which were taken by the Appellant, the Panel do not find that there has been gross mismanagement in this case. However there has been delay in referring which does give cause for concern. The patient could have come to harm because of the delay.
71 SRK The Panel accept that the referral letter was sent to the patient’s home address in error. There is no evidence upon which the Panel can place responsibility. The Panel find however that there is a lack of appropriate systems in the Practice.
72 NB The Panel accept that this patient presented with a left breast bleeding nipple. She was seen on 16th March; 23rd March and 27th April by the Appellant. The Appellant made a referral on 13th April 2005. The Panel accept Dr Berty’s evidence that whilst the notes state it was her referral she confirmed that she did not know anything about it. The Panel accept that those notes have been made by another person under her name. The Panel find that no urgent referral form was submitted by the Appellant. The Appellant has not followed protocol for cancer two-week wait. The Panel also find that it is concerning, given an appointment on 27th April 2005 with the Appellant, that the patient complained of no notice of an appointment; however no steps were taken at that consultation either by telephone, fax or at all by the Appellant. The urgent referral was sent by Dr Berty on 28th April 2005. The Panel find that the appropriate action for a potentially serious condition was not taken, or if it was it was not recorded. The Panel find that the patient did not have cancer as misrepresented by Dr Riley at the PCT Hearing. Dr Riley acknowledged that there was no evidence in the notes confirming the patient had cancer.
The Panel find that there is gross mismanagement in this case. The Appellant’s practices in not following protocol will put patients at risk.
73 GY The Panel find that the patient presented with a non-serious condition on 30th March 2005. No prompt treatment was given. The report was not actioned. The Panel do not find that this is a matter of serious concern.
74 NK This patient was diabetic. Repeat prescriptions of three drugs were issued by the Appellant from July 2002 to March 2005. The patient was at a high risk of stroke and heart attack. The Panel accepts that these drugs require three-monthly testing and regular monitoring. The Panel find that although the patient attended the surgery on a regular basis no checks were carried out and no monitoring was done by the Appellant. The Panel also accept that the Appellant should have prescribed Statins. This was not done until March 2005 when another G.P. took over the care of the patient.
The Panel find that the clinical management of this patient falls well below acceptable standards; it is totally inadequate and a high risk to the patient’s health. When the patient’s health was monitored the HbA1c was recorded at 13.8 against a normal reading of below 7.5 and the blood pressure 203/101 against a normal reading of 140/80. The Panel find that the Appellant has not followed protocol. This patient was put at risk as would any other patients where medications such as these were not monitored.
75 JK The Panel accept that a letter was sent on 28th September 2004 advising that Pioglitazone should be stopped and Insulatard should have been prescribed. The Panel find that there were no notes made on the patient’s records in respect of that recommendation. The Panel find that the Appellant did not prescribe Insulatard after the date of the letter and that the old treatment continued contrary to Hospital advice. The Panel find that this patient came to no harm. The advice came from a Senior House Officer and not a Consultant. The Panel find that the non-recording on the patient’s notes of the correspondence is a further example of bad practice/organisation, which again could lead to a risk to the patient’s health.
76 The Panel find that the evidence of Dr Mak, which was not challenged, also gives rise to cause for concern in respect of bad clinical management, bad record keeping and poor prescribing practices.
COMPLAINTS
77 In respect of the major complaint AC, the Panel find that the Independent Commission did not criticise the response received nor does the Panel.
The Panel find however that the proper protocol for dealing with complaints has not been followed by the Appellant, which is an indication of not good practice.
PRACTICE ISSUES AND CONTRACTS
78 At the outset the Appellant confirmed that they would not deal with this issue as the Appellant’s position was that he intended to work as a Locum only, therefore these alleged complaints were to an extent irrelevant. The Panel accepts that position.
PROFESSIONAL
DEVELOPMENT/INSIGHT
79 The Panel find that no evidence has been presented to either the PCT or the Panel as to appropriate professional development. The Panel finds that the Appellant has chosen to work extensively as a Locum from May 2005 to July 2005 rather than addressing the extensive problems which were identified in the report of Dr Riley in May 2005.
80 The Panel accept that the Appellant did show some insight into the problems facing him. The Panel find that the Appellant has failed to grasp recent changes and requirements of NGMS or NPMS contract as is the case with the Appellant. The sole evidence presented to the Panel by the Appellant were articles supporting his continued antibiotic prescribing written by pharmaceutical companies. The Panel find that this shows a lack of insight by attempting to justify his position.
NCAS
81 A referral was made by Dr Riley. This referral was not actioned. There was an option to refer to NCAS and that would have been available for an assessment pursuant to the letter of David Ede dated 14th September 2005. It was suggested in that correspondence a referral form would be forwarded. The Panel do not accept the evidence of Dr Riley as presented to the PCT that NCAS stated any assessment was unlikely to be of benefit or likely not to be accepted by NCAS even if referred. At no stage did NCAS state that they would not accept a referral.
82 The Panel find however that the correspondence from NCAS did raise concern. NCAS confirmed that they would accept an assessment, however given the range of concerns identified and the fact that the Appellant was only doing Locum work, he may find it difficult to realistically implement and demonstrate progress with a post-NCAS assessment plan. Prior to that correspondence David Ede had written in September 2005 suggesting that it may be unhelpful to seek an NCAS assessment given the uncertainty about the Appellant’s future work plans. If such an assessment was to be undertaken, whether this was reasonable in respect of time and resources, would the areas of shortfall identified be resolved within a realistic timescale at this stage?
83 The Panel find that the Appellant’s decision to work as a Locum complicated the position with regard to the referral. The Panel accept that Dr Riley’s change of position was due to:
(a) the Appellant stating that he intended to work as a Locum only;
(b) other unchallenged evidence i.e. that of Dr Mak, which again gave rise to bad clinical judgement, together with his own knowledge of a patient, which came to light after the initial report in May 2005.
84 The Panel find that it will take the PCT 6 – 12 months to complete the assessment.
85 In respect of a training practice, the Appellant was advised that he was required to attend an advanced training practice. It is accepted by the Panel that no such place existed in the Leeds area.
86 The Panel nonetheless accept that the Appellant then produced two possible training practices, one of which withdrew the offer of training and a further was stated to be not suitable by the PCT.
87 The Panel find that there is no evidence that the Appellant contacted NCAS himself to arrange any such assessment. The Panel accept that it is not appropriate to use funds on training resources for failing G.Ps rather than G.P. Registrars. There has been no evidence presented upon which the Panel can make finding that the Appellant is capable of making a quantum leap, by way of assessment and re-training, to grasp the substantial changes which the new contract brings and which are required. The Panel find medical practices have changed substantially since the new GMS contract and Performers are expected to adapt to it rapidly.
88 The Panel do not find that this Appellant, even if such training was available and to be offered, would be able to remedy the serious defects upon which the Panel have made findings.
89 The Panel do not find, even with re-training, that the Appellant is capable of achieving the standard which is required due to the breadth of areas which give cause for concern.
90 In addition, the Panel accept that it is much more difficult to supervise a Locum. The Panel accept it is more difficult to put targets and focused support in and to monitor an outcome. The Panel also accept that evidence from NCAS, The Deanery and the GMC confirm that Locums are a higher risk and they do not operate in a clinical governable environment. The Panel also accept that if the Appellant were to work as a Locum his consultation skills would need to be significantly higher and more astute.
OTHER MATTERS
91 The Panel find that the PCT have conducted a complete assessment over a long period of time from early 2005 onwards and have spent a considerable amount of resources in supporting the Practice to little avail. There is no evidence that despite the extent of support and recommendations given by the PCT that this has been incorporated and adopted by the Appellant.
92 The Panel accept that Dr Prasad is a hard working G.P. who has worked in a deprived area of Leeds for over 25 years. The Panel also accept that there have been no complaints about Dr Prasad from his own patients.
DECISIONS AND REASONS
93 There is a significant amount of evidence. The Panel do find that the Appellant is a risk to patients as his current method of practicing can cause harm, the organisation is poor and that there has been and continues to be an inefficient use of resources. The Panel therefore direct that the Appellant be removed from the Respondent’s Performers’ List because the continued inclusion would be prejudicial to the efficiency of the service which those included in the relevant Performers’ List perform.
94 The Panel have considered contingent removal. The Panel find that this is not an appropriate case in which to direct contingent removal. The Panel find that the Appellant would not be able to be supervised or monitored satisfactorily. The conditions which would need to be imposed on the contingent removal are unworkable.
95 The Panel believe that there are too many significant concerns over too many areas. The Appellant would need to change his method of working to demonstrate that he could comply with conditions imposed. The Panel find that there has been a lack of reflective learning and lack of insight which impacts upon the Appellant’s clinical management of patients. Therefore the Panel believes that they are not in a position to impose conditions which would remove the prejudice to the efficiency of the services in question.
THE PANEL DIRECTS THAT:
96 Dr Prasad is removed from Leeds North East PCT Performers’ List on the grounds that his continued inclusion in its Performers’ List would be prejudicial to the efficiency of the services which those included in the relevant Performers’ List perform.
97 In accordance with Rule 42(5) of the Rules the Panel hereby gives notice that a party to these proceedings can appeal the decision under Section 11 of the Tribunals and Enquiries Act 1992 by lodging a Notice of Appeal in the Royal Courts of Justice, The Strand, London WC2A 2LL within 28 days of receipt of this decision.
Dated this …. day of ……………… 2006.
Judith R Crisp
Chairman of the Panel