Anjaneyulu v. General Medical Council (GMC) [2001] UKPC 60 (19 December 2001)
Privy Council Appeal No. 49 of 2001
Dr. Kandukuri Anjaneyulu Appellant
v.
The General Medical Council Respondent
FROM
THE HEALTH COMMITTEE OF THE
GENERAL MEDICAL COUNCIL
JUDGMENT OF THE LORDS OF THE JUDICIAL
COMMITTEE OF THE PRIVY COUNCIL,
Delivered the 19th December 2001
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Present at the hearing:-
Lord Nicholls of Birkenhead
Sir Martin Nourse
Sir Kenneth Keith
[Delivered by Sir Martin Nourse]
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- Dr Anjaneyulu, a general practitioner now aged 53, appeals from a decision of the Health Committee ("the Committee") of the General Medical Council ("the GMC") given on 6th June 2001, whereby it was directed, pursuant to section 37(3)(a) of the Medical Act 1983, that the current period of the suspension of his registration in the register be extended for a further period of twelve months. The essence of the decision was expressed as follows:-
"The Committee have again judged that your fitness to practise remains seriously impaired by reason of a condition classified in the ICD-10 Classification of Disorders as F10.1 – harmful use of alcohol."
- The hearing on 6th June 2001 was the sixth occasion on which Dr Anjaneyulu's case had come before the Committee. The first hearing on 23rd June 1998 was adjourned on undertakings. On 2nd November 1998 the Committee decided that Dr Anjaneyulu's fitness to practise was seriously impaired by reason of the harmful use of alcohol and suspended his registration for a period of four months. At hearings on 2nd February and 28th October 1999 and on 8th May 2000 the Committee decided that the serious impairment continued and suspended Dr Anjaneyulu's registration for further periods of eight, seven and twelve months respectively. Dr Anjaneyulu did not appeal from any of those decisions.
- Dr Anjaneyulu was present at the hearings before the Committee on 23rd June 1998 (when he gave undertakings) and on 2nd February 1999. He was not present on 2nd November 1998, nor on 28th October 1999. He agreed to be medically examined, and was examined, by two examiners appointed by the Committee before each of the hearings on 2nd November 1998 and 2nd February and 28th October 1999. However, in a letter to the GMC dated 29th March 2000 he said:
"I will waste no further valuable time and money in continuing with the saga of the framework of the GMC health and safety procedures. I will neither attend medical examinations nor GMC Committee meetings."
- In the result, when the matter came back before the Committee on 8th May 2000 Dr Anjaneyulu was not present and no up-to-date medical reports were available. In deciding that the serious impairment continued, the Committee had regard to rule 24(3) of the GMC Health Committee (Procedure) Rules 1987 ("the Rules"), which entitles them, if they think fit, to find that the practitioner's fitness to practise is seriously impaired on the basis of the information before them and his refusal or failure to submit to medical examination. The determination continued:
"The lack of up to date medical evidence means that the Committee are unable to see evidence of any improvement in Dr Anjaneyulu's condition since the last hearing and they do not consider that it would be appropriate to allow him to return to medical practice. They have directed that his registration should be suspended for a further period of 12 months."
- It is to be observed that the further period of suspension imposed on 8th May 2000 was of a significantly longer duration than any that had preceded it. If that was intended to encourage co-operation on the part of Dr Anjaneyulu, it had the desired effect. Before the hearing on 6th June 2001 he was examined and reported upon by Dr Mohammed Abou-Saleh, Reader in Addictive Behaviour and Clinical Director (Addiction Services) in the Department of Addictive Behaviour and Psychological Medicine at St George's Hospital Medical School and by a consultant psychiatrist, Dr Jennifer Bearn, MRCP MRCPsych. There was also before the Committee a report by another consultant psychiatrist, Dr Harish M Gadhvi, MBBS DPM FRCPsych, who had acted as Dr Anjaneyulu's medical supervisor since April 1999.
- Dr Abou-Saleh examined Dr Anjaneyulu on 5th April 2001 and arranged for relevant laboratory investigations. This was the first time that he had examined him and his report dated 19th April 2001 contains a full rehearsal of Dr Anjaneyulu's account of the history of his alcohol problem and his family background. Having observed that the laboratory investigations showed raised MCV, raised TSH, raised alanine transaminase and gamma GT, Dr Abou-Saleh stated his opinion and recommendations as follows:
"It is evident that Dr Anjaneyulu is suffering from chronic alcoholism (ICD - 10 harmful use of alcohol F 10.1). By his own account he has stopped drinking since Christmas 2000. His laboratory results however indicate continuing alcohol misuse. He has throughout minimized the extent and the seriousness of his alcohol problem. He has no current psychiatric disorder other than his alcohol misuse and there is no evidence that he suffers from personality disorder. It is encouraging to note that he has decided to stop drinking and it remains to be seen if he is able to achieve and maintain abstinence from alcohol. I believe that his health is seriously impaired and that he is not fit to practice absolutely.
I recommend that he continues under the medical supervision of Dr H Gadhvi and that he is encouraged to attend the Doctors and Dentists Group for support."
- Dr Bearn had examined Dr Anjaneyulu twice previously, on 11th January and 13th September 1999, for the purpose of preparing reports for the hearings before the Committee on 2nd February and 28th October 1999 respectively. Her report dated 2nd May 2001 was based on a further clinical examination of Dr Anjaneyulu. She recorded that he had told her that he had decided to become completely abstinent from alcohol and had had his last alcoholic drink on New Year's Eve 2000. Under the heading "Biochemical Investigations" she said:-
"Dr Anjaneyulu has abnormal liver function tests, including an elevated MCV = 99.4fL and GGT = 67 IU/L (results enclosed). These results suggest that Dr Anjaneyulu may still be drinking alcohol at hazardous levels and that if he is currently abstinent, he has not maintained abstinence long enough for normalisation of these investigations to occur. I note that there is a substantial improvement in his liver function tests compared with 1998."
Dr Bearn's findings and recommendations were summarised in the last three paragraphs of her report. She said:-
"My clinical findings are most consistent with an ICD-10 diagnosis of harmful use of alcohol (FIO.1). There has been a substantial improvement in liver function tests since 1998 but they remain abnormal and I cannot rule out the possibility that Dr Anjaneyulu is under-reporting his current alcohol use, particularly as I have been denied access to information from his general practitioner. Dr Anjaneyulu has incomplete insight into his problems with alcohol. I cannot find any evidence for a formal personality disorder.
I am of the opinion that Dr Anjaneyulu's fitness to practise is seriously impaired by reason of his hazardous use of alcohol and that his insight into his illness is limited. There is objective evidence from biochemical screening that Dr Anjaneyulu may still be drinking alcohol at hazardous levels and I am of the opinion that he cannot be considered fit to practise at present.
Dr Anjaneyulu should be helped to seek the appropriate support to enable him to gain insight into his alcohol problems, for example through attending meetings of the Doctors and Dentists Group and AA. Dr Anjaneyulu should remain under medical supervision. His medical supervisor should be allowed free exchange of information with his general practitioner and his clinical supervisor, when he undertakes professional duties in the future."
- In his report dated 1st May 2001 Dr Gadhvi stated that Dr Anjaneyulu had kept all his appointments and had always been punctual and co-operative with his supervision, which had been on an average at three monthly intervals. On examination at the most recent appointment on 29th March 2001 he had been unable to find any evidence of recent drinking or any other psychiatric morbidity. He added that in a recent liver function test there was somewhat of an improvement from the previous one, "although one of the indicators of liver was high". Dr Gadhvi expressed his opinion in the last three paragraphs of his report as follows:-
"I am of the opinion that Dr Anjaneyulu has made gains in the form of rebuilding a life for himself and his wife has been extremely supportive and he is now living a full life with a large network of acquaintances and friends. I understand that he has been meeting his children on a regular basis and he has been a responsible parent, although they the children live with their mother, they have stayed with him on a regular basis.
From the history and assessment of premorbid personality I could not find any evidence of antisocial personality disorder as reported in my previous correspondence to you. I am of the opinion that Dr Anjaneyulu personality has been often anxious and insecure type.
I am of further opinion that Dr Anjaneyulu's fitness to practice is not seriously impaired at present, however his alcohol dependence is of relapsing nature during stressful times of life. It may appear on the surface and then it may impair his fitness to practice. Dr Anjaneyulu has never drunk alcohol whilst working as a General Practitioner in the past. Dr Anjaneyulu may be able to work under some supervision as a GP assistant in light of clinical progress he has achieved."
- At the hearing on 6th June 2001 the Committee also had before them copies of all the correspondence and previous reports and decisions in Dr Anjaneyulu's case dating back to a letter dated 22nd June 1992 from a Chief Superintendent of the Metropolitan Police at Plaistow Police Station, in which the possibility of Dr Anjaneyulu's having an alcohol problem was first brought to the attention of the GMC. The previous history having been fully and dispassionately summarised in the GMC's opening of the case, their Lordships do not think it necessary to repeat it here. After the opening had been completed there was some discussion before it became clear that neither Dr Anjaneyulu nor his wife, Mrs Isabelle Latham, wished to take the oath. Mrs Latham, with whom Dr Abou-Saleh and Dr Bearn had had some discussions before writing their reports, then addressed the Committee as Dr Anjaneyulu's representative. After members of the Committee and the two medical assessors had asked Dr Anjaneyulu many pertinent and searching questions the Committee went into private session to consider their decision.
- In giving their decision, the Chairman stated that the Committee was pleased that Dr Anjaneyulu had attended the hearing and that they noted his statement that he had been abstinent from alcohol since January 2001. Having stated that the Committee had carefully considered all the information before them, the Chairman expressed himself as recorded in paragraph 1 of this judgment and continued:-
"In reaching this decision the Committee have had regard to rule 24(2) of their procedure rules which entitles them to regard as current serious impairment either the practitioner's current physical or mental condition, or a continuing and episodic condition or a condition which, although currently in remission, may be expected to cause recurrence of serious impairment.
The Committee remain concerned that your insight into your alcohol problem is limited. They also consider that you require a longer period of abstinence before the Committee could consider it would be safe for you to resume practice. Accordingly, they have directed that your registration should be suspended for a further period of 12 months."
- On his appeal to the Board Dr Anjaneyulu has put in a short written case. He also addressed their Lordships briefly and moderately. Two principal strands ran through his written and oral submissions: first, that neither Dr Abou-Saleh nor Dr Bearn could find any clinical signs of chronic misuse of alcohol and that each of them was concerned only for what might happen in the future; second, that Dr Gadhvi was of the opinion that his fitness to practise was not seriously impaired at present and that in the light of his clinical progress he might work under some supervision.
- Their Lordships are unable to accept the first of these contentions as being an accurate summary of the views of Dr Abou-Saleh and Dr Bearn. Each of them recorded Dr Anjaneyulu's claim that he had stopped drinking since Christmas or New Year's Eve 2000. However, Dr Abou-Saleh, having referred to the laboratory results, was of the opinion that he was suffering from chronic alcoholism and that the results indicated continuing alcoholic misuse. Dr Bearn, while finding that there had been a substantial improvement in liver function tests since 1998, said that they remained abnormal and that she could not rule out the possibility that Dr Anjaneyulu was under-reporting his current alcohol use; there was objective evidence from biochemical screening that he might still be drinking alcohol at hazardous levels. Nor can their Lordships accept the second contention, though accurate so far as it goes, as being a full reflection of the view of Dr Gadhvi, who added the caveat that Dr Anjaneyulu's alcohol dependence was of a relapsing nature during stressful times of life.
- By virtue of subsection (5) of section 40 of the Medical Act 1983 (which makes provision for appeals to their Lordships' Board from decisions, amongst others, of the Committee giving directions for suspension or the extension of a suspension) no appeal lies from such a decision except on a question of law. The only question of law which could be said to arise on this appeal is whether a reasonable Health Committee, properly directed, was entitled to conclude, first, that Dr Anjaneyulu's fitness to practise remained seriously impaired and, secondly, that an extension of the suspension of his registration for a further period of twelve months was appropriate in all the circumstances.
- In arriving at the first of these conclusions the Committee were entitled to have regard, as they did, to rule 24(2) of the Rules, which provides:
"In reaching their judgment the Committee shall be entitled to regard as current serious impairment either the practitioner's current physical or mental condition, or a continuing and episodic condition, or a condition which, although currently in remission, may be expected to cause recurrence of serious impairment."
In their Lordships' view the reports of Dr Abou-Saleh and Dr Bearn entitled the Committee to regard Dr Anjaneyulu's current condition as current serious impairment. Alternatively, those reports, combined with Dr Gadhvi's caveat, entitled them, with the same consequence, to regard Dr Anjaneyulu as suffering from a continuing and episodic condition, or one which, although currently in remission, might be expected to cause recurrence of serious impairment. It is important to emphasise that the Committee merely "noted" Dr Anjaneyulu's statement that he had been abstinent from alcohol since January 2001. They did not say that they accepted it. In all the circumstances it is not open to their Lordships to interfere with the first of the Committee's conclusions.
- As to their second conclusion, a further suspension for twelve months might be said to have been on the high side. However, that being a matter for the judgment of the experienced members of the Committee, the second conclusion can be no more interfered with than the first. Nevertheless, their Lordships think it right to observe that the reports of both Dr Bearn and Dr Gadhvi, each of whom had been familiar with Dr Anjaneyulu's condition for more than two years, recognised that there had been significant improvements during that period. Indeed, Dr Gadhvi's report may be said to have been more optimistic than any previous report in the long history of the case. In their decision the Committee said that they would ask Dr Gadhvi, as Dr Anjaneyulu's medical supervisor, to report to them on his progress, with his consent. Should those reports give grounds for further optimism, the Committee may think it right to reconsider the case at an earlier date than would otherwise have been appropriate.
- Their Lordships will humbly advise Her Majesty that the appeal should be dismissed. There will be no order as to the costs of the appeal.
