THE CHAIRMAN:  Good morning, everyone.  We will commence with the case of Dr Skinner.  Dr Skinner is not present but is represented by Mr Jenkins, Counsel instructed by Radcliffes Le Brasseur.  Mr Glasgow, Counsel, instructed by the Solicitor to the Council, represents the Council.

Mr Jenkins, could you confirm, please, that Dr Skinner wishes this hearing to be held in public?  

MR JENKINS:  Yes, he does, sir.  May I also apologise that he was not able to attend today.  He had made plans for August.  He has a rather important meeting with some pharmaceutical clients, some of whom have travelled from America, and I think to be fair to him, he had not anticipated that this hearing would be as soon after the other one and he made arrangements for August so I apologise for his absence.

THE CHAIRMAN:  Mr Jenkins, just for the sake of the shorthand typist, I am not sure that you have your microphone on.

MR JENKINS:  You are being very polite, sir; I probably have not.  I was apologising, sir, for Dr Skinner's non‑attendance.  He had not anticipated a hearing quite so soon after the other and he had a prearranged important meeting with some clients who have travelled from America.

You asked me, sir, whether he wished the hearing to be in public and that was his request.

THE CHAIRMAN:  Mr Jenkins, do you have any comments on that?

MR GLASGOW:  No, sir, I do not.  The last hearing was held in public and there were a number of members of the public who attended who were interested to hear what had taken place.  There was no objection last time to it being in public and it should remain so.

THE CHAIRMAN:  Thank you.  Then we will admit the public. 

MR JENKINS:  Sir, I wonder if when the public are admitted if I might address you just briefly once they are assembled before you begin formally.

THE CHAIRMAN:  I will be asking you to introduce Dr Skinner's name and number imminently.

(The members of the public were admitted)

THE CHAIRMAN:  Mr Jenkins, perhaps at the beginning of the hearing you would repeat the doctor's name and GMC number, please, for the record.

MR JENKINS:  The doctor's name is Dr Gordon Robert Bruce Skinner, sir, and his number is 0726922.  He is unable to be present today.  I have tendered apologies in that regard.

Sir, it may help you in your deliberations today if I indicate that we have been subject to these interim orders now for more than 12 months.  There have been a number of interim hearings.  There is a substantive hearing fixed I think for 8 January.  I may wish to address you later on the necessity for any further interim hearings, but for today's purposes we are not seeking any variation in the conditions which have been imposed.  We understand that it is accepted that we have complied with those that have been imposed and we are content that they should remain in place.

THE CHAIRMAN:  Thank you, Mr Jenkins.  That may help us.  Mr Glasgow, would you like to submit on behalf of the GMC?

MR GLASGOW:  Sir, yes.  Can I thank Mr Jenkins for his observations at the outset which may make my task a little easier, but nonetheless I will do my best to assist the Panel with any questions that they may have about the various cases and complaints that presently exist against Dr Skinner.

THE CHAIRMAN:  Mr Glasgow, Mr Jenkins suggested that Dr Skinner had complied with the conditions.  Are you in agreement with that?

MR GLASGOW:  I am in agreement with that, yes.

THE CHAIRMAN:  That is helpful.

MR GLASGOW:  I am sorry; I should have made that clear from the outset.  I certainly do not make any observations against what has been said by my friend. 

Can I deal initially with the test to be applied today because although I know that this experienced Panel need not be reminded of the test they seek to apply today, there are a number of members of the public here who may be interested to know the test that needs to be applied and to know from the outset when I recite the facts the test that this Panel will have in mind.

As the Panel know, the test is as follows.  If the Panel is satisfied in all the circumstances that there may be impairment of the practitioner's fitness to practise which poses a real risk to members of the public or may adversely affect the public interest or the interests of the practitioner, and, after balancing the interests of the practitioner and the interests of the public, that an interim order is necessary to guard against such a risk the appropriate interim order should be made.

With that in mind, can I deal briefly with the history of the allegations faced presently by Dr Skinner?

In summary, they arise out of his inappropriate use of thyroid hormone treatment and the potentially harmful consequences that that can have to any patient.  In addition to that, there have been a number of concerns raised about Dr Skinner's choice of not contacting various patients' general practitioners to inform them of the treatment that the patient is presently undergoing.

Can I invite the Panel's attention, please, to the first page in the bundle, which I hope sets out better than I can the concerns that have been raised about his treatment of his patients.  It is found at page 51 of the bundle.  There is a letter from Professor Lazarus, the President of the British Thyroid Association and was a letter that was written in April 2003 to the GMC.  The Panel will no doubt be familiar with its contents, but can I read a few excerpts from it? 

As the Panel know, it was a letter written in order to pass on the feelings of the membership and committee of the British Thyroid Association to the GMC and the concerns that they had about Dr Skinner's activities.

It begins with the second paragraph:

“We have serious concerns at his practice.  It is quite clear from the large amount of feedback we have from thyroidologists in clinical practice all over the country that Dr Skinner has been putting patients on to large doses of thyroid preparation containing both T3 and 4 and has produced potentially serious side effects.  The use of thyroid hormone is also against all national and international guidelines.  Three examples of this are contained in the enclosed anonymous correspondence.  We are concerned that conditions other than hypothyroidism are not diagnosed or treated, that the symptoms do not relate to hypothyroidsim, and there is no biochemical evidence of hypothyroidism.  We note that Dr Skinner is not on the specialist register for medicine and does not have higher medical training in general internal medicine or endocrinology.” 

The BTA and the patients it serves are continuing to have serious concerns about these practices that are continuing to be proffered by Dr Skinner and his associates.  We note that this issue has been of concern to the Fitness to Practise Committee and would draw your urgent attention to this matter again.”

That by way of introduction sets the tone for the number of cases which presently exist against Dr Skinner. 

As this Panel knows, there are two separate live cases presently under consideration by the GMC and a number of individual complaints dating back to 2002.  It is not my present intention to take this Panel through each and every one of those cases in detail.  I am in a position to assist with any questions that the Panel or any of its members may have.  I recognise that you have had the papers and an opportunity to read them, which no doubt you have all done with care.

Hoping that I can take matters slightly shortly, can I turn to deal initially with the first live case which exists against Dr Skinner, which has the number 2004/0395.  The relevant page in the bundle is page 19.  It is a letter from Dr Jordan, who is the medical director of the Renfrewshire & Inverclyde Primary Care NHS Trust.  It is a letter sent on 26 January 2004.  As the Panel can see from the first two lines of the letter, one which was written in order to raise a concern over the prescribing habits of Dr Skinner, out of the belief that there is enough evidence of a repeated departure from good professional practice and that the case should be brought to the GMC's attention.

The reason behind the letter is detailed in paragraph 2.  As the Panel can see, it relates to an occasion when a private prescription for Thyroxine and Liothyronine was presented to a local community pharmacy.  The pharmacist, quite rightly, questioned these drugs in combination in this particular dose and discussed it with the patient.  The patient was slight cagey but did admit that her GP had confirmed that her thyroid function tests were normal, but despite this the above named doctor had chosen to prescribe these drugs. 

The Panel members will see midway through the third paragraph that the patient's most recent thyroid function I believe showed some slight elevation above normal levels, which the patient is aware of but still continues to take the medication prescribed to her on a private basis.

Lastly, dealing with the opening two lines of the closing paragraph:

“I am writing to you, therefore, regarding the prescribing, over what I believe is a year by a doctor operating on a private basis in a manner which I do not consider reflects good or accepted medical practice.”

That particular patient is known by her initial “A” and her GP provided a letter which was sent to the GMC which is at page 21, her GP being Dr Blair.

The Panel will know from the contents of that letter that patient “A” had been prescribed anti‑depressants for a number of years, but perhaps most importantly the conclusion of the opening paragraph of that letter, the last sentence:

“I did not at any stage refer A to Dr Skinner.” 

It was, of course, a surprise to Dr Blair that Dr Skinner had become involved in the treatment of patient A.

There had been discussion about the patient's thyroid function tests between her doctor, Dr Blair, and herself and the possibility of anti‑depressants and HRT had been discussed back in 2001, 2002 and 2003.  The concern which is raised by Dr Blair can be seen in the last paragraph on page 21 with the second sentence beginning: “I strongly”.

“I strongly advised her against taking Thyroxine as I felt there was no clinical indication for this.  I had taken the opportunity prior to the consultation on 8 April to discuss Thyroxine in this situation with Dr James Thomson in Inverclyde Royal, the local endocrinologist.  His advice was that despite some trials which had been carried out in the States further trials in this Stobhill had shown that there was no scientific basis for such a prescription.”

It is right to say, however, that notwithstanding those concerns that were raised and notwithstanding the advice that was given to patient A that she not take the advised dose of Thyroxine she went on to see Dr Skinner on a private basis, no communication having been passed between Dr Skinner and Dr Blair, and a prescription was duly written out for the large quantity of Thyroxine that was noted as a concern by the pharmacist.

The second live case bears the number 2004/1973.  Can I immediately take the Panel to the relevant page in the bundle for that, which is page 75.  It is a letter sent on 2 August 2005.  Panel members can see handwritten at the top someone has annotated the relevant case number for it. 

The Panel will see the opening sentence, an expression of concern which the Panel will be familiar with:

“I wish to express my concern about the practice of Dr Skinner and his involvement with Thyroid UK.  About a month ago while on emergency duty I was called to see an elderly lady with acute heart failure associated with atrial fibrillation.  It transpires that she was taking Bovine thyroid tablets which she had been given by her daughter who had acquired them from the United States via the internet.  She had not had her thyroid tested.  Her doctor was unaware that she was taking these tablets and she had hypertension but no symptoms that would justify the use of such medication.  I sent the patient into hospital and understand her heart failure is now under control.  I have just received a letter from the patient's daughter complaining that I have caused family disharmony by exposing the fact that she was providing medication for her mother in this way and expressing my views so strongly.  The daughter declared that she had been consulting a Dr Skinner, who I assume to be Dr Gordon Skinner, who had advised her to take these tablets.  My concern is that he may also have encouraged, endorsed or recommended that she give the drug to her mother without any medical basis.”

That deals in short form with the two live cases that are presently before the GMC in relation to Dr Skinner. 

There are, of course, a number of other separate and individual complaints which I am in a position to assist the Panel with if they would like such assistance, but perhaps the best additional supporting information for the concerns that the GMC has, the reasons of bringing Dr Skinner before the IOP can be found in a letter sent from Dr Toft which can be found in the bundle at page 30 and a letter dated 19 July 2004.  It begins as follows:

“I understand that you may have already received complaints about the inappropriate prescribing of thyroid hormones by Dr Skinner.  This has been of concern to practising endocrinologists chronologies in the United Kingdom for some considerable time.  I am reminded of the failure of the GMC to have taken action in the past by having seen two patients who have been inadequately treated with thyroid hormones in recent months.” 

Dr Toft then goes on to detail the patient history of patient V and patient D, both of whom were treated with high doses of thyroid extract by Dr Skinner.

The letter continues, having detailed that treatment, with the following:  

“Dr Skinner frequently prescribes thyroid hormone therapy to patients with no evidence of thyroid disease and adjusts the dose often without any biochemical testing.” 

Lastly, the concluding sentence which perhaps sums up everyone's concern that has written to the GMC about this:

“My concern is that Dr Skinner's treatment is inappropriate, dangerous, and based on no formal training in endocrinology whatsoever”.

Dr Skinner was duly contacted by the GMC following the complaints that had been raised against him and a number of individual live cases that have been bought to the attention of the GMC.  He was invited to undergo a performance assessment in September 2004.  He originally gave consent to undergoing such assessment, but in due course withdrew his consent and refused to be assessed.

Thereafter, he first appeared before the IOP in June 2005.  On that occasion, it was considered necessary for the protection of members of the public and in the public interest to impose conditions upon his registration.  The conditions themselves have, in the main, remained the same throughout, though with a few variations in due course.  I do not propose to take this Panel through each and every decision by any previous Panel, but it is right to say that the conditions were reviewed in December 2005 and an order was made to continue the conditions as imposed.

Then again a further review was held in March of this year when again conditions, much the same as before, were imposed on Dr Skinner's registration.  Most recently in June of this year the matter was reviewed again by the IOP; again, on that occasion conditions were imposed on Dr Skinner's registration.  There were, however, variations made in respect of the conditions imposed on that occasion because there had been problems in working through the documentation provided by Dr Skinner to support what he had done as regards his patients in the previous months.

For the Panel's assistance, and also for that of the members of the public who are here, some of whom may remember what happened last and some of whom may not, can I detail the conditions that were imposed.  They can be found at page 1141 of the Panel's papers.  There are, as the Panel can see, six separate conditions that by way of introduction it is appropriate to read the paragraph before they start.  “In complying with the conditions below, each condition must be supported by a separate bundle.”  I pause there to say it is correct that Dr Skinner has provided a separate bundle in respect of each condition.

“The pagination should be continuous throughout and a comprehensive and detailed index be provided to cross reference each bundle with a supplementary index listing patients by initials and NHS number and recording the relevant pagination in each bundle against each patient.” 

I pause again to indicate, as I did at the outset, that no complaint is taken with Dr Skinner's compliance with the conditions.  He has provided continuous pagination and a comprehensive and detailed index.  It is possible to cross refer between each of the separate bundles and no complaint is made about the service of the documentation by Dr Skinner.

The six conditions that were imposed on the last occasion are as follows: 

1, that he only accept new patients for endocrine treatment if they have been referred to him by a fully registered medical practitioner.  At least 21 days prior to any review of the order that Dr Skinner was to provide the Panel with anonymised copies of the patients referral letters in a separate, paginated and indexed bundle, patients only being identified by their initials and NHS number.

The second condition:

“Prior to initiating any or varying any treatment regime Dr Skinner was to ensure that he had communicated his diagnosis and suggested care plan to the relevant patients' general practitioner and, if different, the referring medical practitioner.” 

At least 28 days prior to any review of the order he was to provide the Panel with copies of the letter sent to the patients' general practitioner or, if different, the referring medical practitioner in a separate paginated and indexed bundle, and as before the copy should only identify the patient by initial and NHS number.

THE CHAIRMAN:  Just for the sake of accuracy, is that 21 days?

MR GLASGOW:  I do apologise.  I should have said 21.  It is 21 days throughout.  I am grateful to you, sir.

The third condition:

“You shall keep a contemporaneous logbook of all patients seen in relation to work carried out as a registered medical practitioner”.

The book identifying patients their initials and NHS number and a name and contact number of the referring, the logbook to be initialled and dated by the patient and the logbook also to indicate whether it was a new patient, the reason for the consultation and, if applicable, the reason for any prescribing outside of recommended guidelines, and again at least 21 days prior to any review of the order to provide the Panel with copies of the logbook and the original logbook also to be provided 21 days prior to any review.

Condition 4: that Dr Skinner keep clear, contemporaneous and accurate medical records in addition to the logbook and to ensure that any reasons for prescribing outside of recommended guidelines are recorded and clinically justified having had regard to such guidelines, and at least 21 days prior to any review of the order to provide the Panel with typed and anonymised copies of the patients' records and the full details as to any reasons for the care plan in a separate paginated and indexed bundle.  Just as before: any patient to be identified by initial and NHS number.

The fifth condition: to notify all employers and contractors and all prospective employers and contractors, whether for paid or voluntary employment for which registration with the GMC is required, of the matters under consideration by the GMC and of these conditions. 

“In the case of prospective employers or contractors this notification must be given at the time of application.” 

Lastly: to inform in writing the IOP Secretariat of the GMC before undertaking any position for which registration is required.”

It is respectfully submitted on behalf of the GMC that it is necessary for the protection of the public, in the public interest and in the doctor's own interests that the present conditions as a minimum should remain.  Of course, I need not remind the Panel, but I do for the avoidance of doubt, that they are not bound by the submissions of the GMC and they are not bound by the fact that both sides consent to the maintenance of conditions as they are.  It is for the Panel to make its own decision having conducted a review of the case, but in light of the compliance of Dr Skinner with the conditions imposed the GMC respectfully submit that in this instant case it is appropriate for the conditions as they presently are to remain in force.

Dr Skinner has been warned already that this matter, the 18 months is likely to expire in February of next year.  Although presently a hearing date for the substantive hearing is fixed for 8 January there can, of course, be no guarantee that that will be an effective date.  This is a complicated and voluminous case.  The collection of the relevant pagination, the reports and the witnesses will be something of difficulty for both sides.  It may well be that 8 January is adjourned in due course.

In light of that, it is respectfully submitted that it is appropriate for a direction pursuant to Rule 27(6) for this matter to be reviewed by the High Court in due course, it being likely that the 18 month order would expire before the substantive hearing is heard. 

Sir, unless I can assist any further, those are the submissions on behalf of the Council. 

THE CHAIRMAN:  Thank you very much, Mr Jenkins.  If we just go through those dates again.  The first IOP conditions were on 20 June 2005.

MR GLASGOW:  It was 29 June 2005.

THE CHAIRMAN:  29th, yes.  Counting the 18 months.

MR GLASGOW:  That takes us to February of next year.

THE CHAIRMAN:  We are now in August.  My second question was: at the hearing on 15 June there was to be a review inside three months.  We are now seven weeks into that three months.  If we calculate from now are we within six months of the date when the 18 months are up?

MR GLASGOW:  Yes, we are.

THE CHAIRMAN:  So you are quite entitled to ask for an application to the High Court.

MR GLASGOW:  Sir, yes, I am, as I understand it, having calculated the date.  I will no doubt be corrected if my maths are wrong.

THE CHAIRMAN:  There may be further questions from the Panel.  Mr Wardell on your right, a lay member of the Panel.

MR WARDELL:  Thank you, Chairman.  Good morning, Mr Glasgow.

Just a couple of questions, if I may.  If we turn to page 298, which is a letter to one of Dr Skinner's patients.  This is a letter that was written to one of the patients dated 14 April 2004 from the Healthcare Commission.  If we look at that letter and look particularly at paragraph 4, the Healthcare Commission indicate there that in April 2002 the Care Standards Act 2000 became law and for the first time private doctors were required to be registered with the then National Care Standards Commission.  It goes on: this meant that Dr Skinner, for the first time, within the remit of the new legislation should have applied to be registered before 31 March 2002.  To date, the Commission has not received an application for registration from Dr Skinner.  I just wanted to ask since I do not know the Care Standards Act 2000, I just wondered whether the Healthcare Commission is implicitly saying that Dr Skinner practised, therefore, outside the law between 31 March 2002 and 14 April 2004.

MR GLASGOW:  I am ignorant, myself, as well of the particular statutory conditions imposed by the Care Standards Act 2000 and would wish, if necessary, to review that if I have to, but certainly from what I have read in the bundle I am not aware of any further correspondence that goes straight to this point.  It is not a concern the GMC have sought to bring before the Panel on any previous occasion. 

MR WARDELL:  I am very grateful, Mr Glasgow.  My second question relates to the letter that you referred to from Dr Toft on page 30.  This letter has been referred to on a number of occasions during previous hearings, including the last time at page 1132 at letter F.  You can see there the same as you have indicated today that quotations have been taken from this letter from Dr Toft.  If you turn to page 30, you will see there that in paragraph 2 and paragraph 3, the names of two patients are anonymised, The first given the letters “MV” and then details of the prescription and the treatment that that lady was given.  If we now turn to pages 635 to 660 in the bundle, we see the non‑anonymised information on this patient, including her name, her date of birth, her address and following very detailed accounts of the treatment she received.  I just wanted to ask two questions really.  The first is: why was the name and address and other details of the patient not anonymised in the bundle for today's hearing, and, secondly, could I be assured that this patient's consent has been given to the GMC before this information was put into our bundle in what is, after all, a public hearing?

MR GLASGOW:  Sir, that is something that has taken me by surprise, but I know that the Panel will know from their reading that there are a number of letters contained within this bundle where patients' full names and details are provided.  In many instances it is because the individual patients themselves have written directly to the GMC in support of Dr Skinner to make sure that their concerns are known.  I would have to check through the bundle itself to see whether or not patient VM has indeed written previously.  What I know from earlier cross referencing that in certainly the majority if not all of the cases those patients who now have their personal details disclosed within the bundle have been in direct correspondence with the GMC themselves.  It is for that reason that initially their details are redacted and they appear anonymised and then subsequently when they appear later in the bundle they have their full details disclosed because it is, in effect, with their consent having written direct to the GMC.

MR WARDELL:  I accept that, Mr Glasgow, with regard to the point that you make, but I could not, after trawling through this bundle in detail, see any place where this patient has indicated that is the case.  I just wanted to make the point.  Thank you very much for that explanation.  Thank you, Chairman.

THE CHAIRMAN:  Mr Glasgow probably knows and Mr Wardell may know that this bundle of course is not public.  Are there any further questions?  Mr Glasgow, just my mathematics.  You mentioned the date February 2007.  I think the order expires in December 2006.  I think you said that it expired in February 2007.  It may not matter to our deliberation.

MR GLASGOW:  It certainly would be December 2006.

THE CHAIRMAN:  There are no further questions.  Mr Jenkins?

MR JENKINS:  So far as the factual basis and the allegations made on the facts are concerned I understand, of course, that you are not a tribunal of fact so far as that is concerned.  You heard, of course, only the “prosecution case”.  It is not accepted on behalf of Dr Skinner that any of the treatment was inappropriate, albeit it may have been outside what are regarded as conventional guidelines. 

So far as page 30 is concerned, which is being trotted out at each interim orders hearing, that reference to the second patient, JMG, is based upon no real factual evidence at all.  It is a summation by the doctor concerned that Dr Skinner may have spoken to a daughter who may then have passed drugs on to her mother.  We refute that and we look forward and would expect cogent evidence to support an allegation like that.

As I say, I accept you are not a tribunal of fact.  We are content, as I said at the beginning, that the order should remain in place. 

We are concerned at the number of and the frequency of the interim order hearings.  You will understand, sir, that a hearing took place on 15 June.  The hearing today is only six weeks on.  The requirement that the documentation be put in 21 days prior to the hearing means that we are, in terms of events and history, only three weeks on from where we were on 15 June.  We question whether that is a valuable worthwhile exercise of your time or those of your colleagues or the expense that is necessarily involved to both the GMC and Dr Skinner.

Originally, I think these reviews were six‑monthly.  Then they became, I am not quite clear why, three‑monthly, but in any event what we seem to be doing is the opposite of what happens in most jurisdictions, where, as one goes on and it is seen that a defendant or a client is complying with the limitations, usually the monitoring is relaxed, not increased, because one demonstrates a confidence in the situation and capacity of the subject to fulfil the conditions.

It is with surprise that I learned this morning that the hearing of 8 January might be put off.  At a Directions Hearing on Friday last we were assured that the situation was that the GMC would be ready and there is to be an exchange of reports in that regard in short order.  I am not instructed in that.  It may be that my learned friend is not instructed either, but that is the assurance we were given.  If it is not possible to leave the situation as it is between now and January, we urge you to fix a date or give a bracket of dates that means there are not going to be two more hearings before January because of this complication of the 21 day necessity for getting this documentation in. 

Dr Skinner, for example, has, as it were, been caught out in the sense that he has not been able to attend today.  That is no disrespect, of course, to the Panel, but it shows that constant hearings can be difficult and inconvenient and should be held only if you consider them really necessary.  I do suggest, I am not criticising anybody in particular, but I do suggest that a hearing which is, in effect, taking place only three weeks after the last one is not something that is of assistance to you or protects the public.  I would ask you to give that anxious consideration when you retire, but I repeat what I said at the beginning and I have repeated it once already: we do not contest the restrictions and we are content to go on as we are.

THE CHAIRMAN:  Thank you, Mr Jenkins.  We will keep in mind your submissions about the duration between the hearings.  There may be questions from ‑‑ sorry, have you finished your submissions?

MR JENKINS:  Indeed, I had, sir.

THE CHAIRMAN:  There may be questions from the Panel.  Could I just lead by taking you to Addendum 3 of Dr Skinner's submissions?  I assume you have copies of the six addenda which are really divided bundles of the conditions.

MR JENKINS:  I have a copy of the conditions, sir, yes.  I am not sure I have anything described as an addendum, but I do have copies of the conditions.  Were you inviting my attention to any one in particular?

THE CHAIRMAN:  I think you must have them so that we know what we are talking about, Mr Jenkins.

MR JENKINS:  Certainly.

THE CHAIRMAN:  I assume that these are bundles that have been submitted by Dr Skinner.  I would be surprised if you are not aware of them.

MR JENKINS:  I have them, sir, yes.  Thank you.

THE CHAIRMAN:  These are very detailed bundles.  Indeed, they are very helpful to us.  Could I take you to Addendum 3 which are the letters that are sent out to GPs.

MR JENKINS:  I apologise, I always looked at bundles A, B and C.  I see that Addendum 3 is bundle B.

THE CHAIRMAN:  So you have bundle B.

MR JENKINS:  I do.

THE CHAIRMAN:  Can I take you to copies of letters that are sent out to GPs.  It appears to me that on 14 June 2006 there were 12 letters sent on the one day to GPs.  My problem with that is that none of Dr Skinner's letters to the GPs, for example page 33 to 39, in the letters says:when Dr Skinner actually reviewed the patient or saw the patient.  My training, Mr Jenkins, and those of the medics around the table would have suggested that it was prudent and helpful for the doctor, when reviewing a patient, to put on the letter the date that they actually saw the patient.  Further down, Dr Skinner says he advised the doctor that he has advised the patient not to, in line with GMC recommendations, to allow two weeks to pass before any changes in medication will take place.  It is very difficult if the date of the consultation is not in the letter that those calculations can be made.  Do you take my point?

MR JENKINS:  Yes, I do, sir, although of course both the patient and the GP will know when they attended.

THE CHAIRMAN:  Not necessarily the GP because the GP may well not know when the patient was attending.  It is just a point about letters from a consultant to a GP just to make them chronologically accurate.  Perhaps the date of the next review might be more detailed, say three months or six months or whatever, although some of them do say that leaves it to the patient to make the review; I fully accept that, but some of them have to have reviews made for them. 

Those are initial comments on the letters, but I must say, Mr Jenkins, that the bundles appear reasonably fulsome, but I will leave my colleagues to ask further questions.  Are there any further questions?  There are no further questions from the Panel.  Mr Glasgow, have you anything further to add?

MR GLASGOW:  No, nothing that I think can assist the Panel, sir.

THE CHAIRMAN:  I will now turn to the Legal Assessor for his advice.

THE LEGAL ASSESSOR:  This is a review case, but the test remains the same based on your assessment in the light of all the current circumstances, which not only includes all the material before the previous Panels, to which you have been referred, but also the submissions before you today, both on behalf of the GMC and Dr Skinner that Dr Skinner has complied with the interim conditions and that there should be no variation in those conditions.

Of course, that is a matter for your discretion.  On the basis of that information, the test you apply is this.  If the Panel is satisfied in all the circumstances that there may be impairment of the doctor's fitness to practise which imposes a real risk to members of the public or may adversely affect the public interest, and the public interest includes amongst other things the maintenance of public trust in the medical profession, or the interests of the practitioner.  After the balancing exercise, balancing the interests of the practitioner and the interests of the public the Panel is satisfied that an interim order is necessary to guard against such a risk then the appropriate order should be made. 

As I have said, all orders are available to you, but you exercise your discretion judicially in the light of the submissions made to you today.

THE CHAIRMAN:  Thank you, Legal Assessor.  We will now go into camera.  For the benefit of the public, everyone will leave the room except us, but we will keep you informed about when we will reconvening.

STRANGERS THEN, BY DIRECTION FROM THE CHAIR, WITHDREW

AND THE PANEL DELIBERATED IN CAMERA

STRANGERS HAVING BEEN READMITTED

THE CHAIRMAN:  For the members of the public I will now read our Determination.

D E T E R M I N A T I O N

THE CHAIRMAN:   Mr Jenkins: When the Interim Orders Panel considered Dr Skinner's case on 29 June 2005 it determined that it was necessary for the protection of members of the public and in the public interest to make an order imposing conditions on his registration for a period of 18 months.  The Panel reviewed and maintained the order restricting Dr Skinner's registration on 2 December 2005, 21 March 2006, and 15 June 2006.  On each occasion, owing to concerns regarding Dr Skinner's compliance, the conditions imposed were varied.

The Panel has carefully considered Dr Skinner's case today.  In doing so it has considered all the information before it and the submissions made by Mr Glasgow on behalf of the GMC and by you on behalf of Dr Skinner, including the submission that Dr Skinner consents to the order imposing conditions on his registration remain in place.  The Panel has heard the advice of the Legal Assessor and the transcripts of the previous hearings.

The Panel notes that it is unable to resolve any conflict of evidence or to determine fact.  The Panel has also reminded itself of the test it must apply and of its nature, function and powers as well as the GMC's guidance, Good Medical Practice and the Duties of a Doctor contained therein.  The Panel has also had regard to the GMC's guidance Imposing Interim Orders.  Patients' relationships with their general practitioner are ones founded on trust and it is imperative that this trust be maintained.

Having considered all the information the Panel has determined that it remains necessary for Dr Skinner's registration to remain subject to an interim order.  The Panel has determined that this is necessary for the protection of members of the public, in the public interest and in Dr Skinner's own interests.  The Panel has expressed its concern regarding the composition of Dr Skinner's letters to the General Practitioners, especially with regard to review dates, the dates upon which treatment ought to commence and the lack of the date of his consultation with patient contained therein.

In light of the submissions made and the fact that the GMC is content with Dr Skinner's compliance with the conditions imposed, the Panel has determined that it is not necessary to vary the conditions imposed on Dr 's Skinner's registration.  The Panel would note that it appears that Dr Skinner may not have fully complied with the terms of condition 4.  However, in the light of the information presented to it today, the Panel remains content, at this time, to maintain the conditions currently imposed.

Accordingly, in complying with the conditions below, each condition must be supported by a separate bundle.  However, the pagination should be continuous throughout and a comprehensive and detailed index be provided to cross reference each bundle, with a supplementary index listing patients by initials and NHS number and recording the relevant pagination in each bundle against each patient:

1.  He shall only accept new patients for endocrine treatment if they have been referred to him by a fully registered medical practitioner.  At least 21 days prior to any review of the order, he must provide the Panel with anonymised copies of the patients' referral letter in a separate, paginated and indexed bundle.  Patients should only be identified by their initials and NHS number.

2.  Prior to initiating any or varying any treatment regime he shall ensure that he has communicated his diagnosis and suggested care plan to the patient's general practitioner and, if different, the referring medical practitioner.  At least 21 days prior to any review of the order, he must provide the Panel with copies of the letter sent to the patients' general practitioners and, if different, the referring medical practitioner in a separate paginated and indexed bundle.  The copies should identify the patients only by their initials and NHS number.

3.  He shall keep a contemporaneous logbook of all patients seen in relation to work carried out as a registered medical practitioner.  This book must identify the patient only by their initials and NHS number and the name and contact number of the referring practitioner.  The logbook should be initialled and dated by the patient.  The logbook must also indicate if this is a new patient, the reason for consultation and if applicable the reason for prescribing outside of recommended guidelines.  At least 21 days prior to any review of the order, he must provide the Panel with copies of the logbook.  The original logbook should also be provided 21 days prior to any review.

4.  He shall keep clear, contemporaneous and accurate medical records, in addition to his logbook, and ensure that his reasons for only prescribing outside of recommended guidelines are recorded and clinically justified having had regard to such guidelines.  At least 21 days prior to any review of the order, he must provide the Panel with typed anonymised copies of the patients' records and the full details as to his reasons for his care plan and in a separate, paginated and indexed bundle.  Patients should be identified by their initials and NHS number.

5.  He shall notify all employers and contractors and all prospective employers and contractors, whether for paid or voluntary employment for which registration with the GMC is required, of the matters under consideration by the GMC and of these conditions.  In the case of prospective employers or contractors, this notification must be given at the time of application. 

6.  He shall inform, in writing, the IOP Secretariat of the GMC before undertaking any position for which registration is required.

In reaching this decision to restrict Dr Skinner's registration the Panel has determined that there is information before it today which suggests that his fitness to practise may be impaired on the basis of the allegations made against him.  These include irregularities surrounding his prescribing practice which may have potentially harmful consequences and a failure to notify some of his patients' General Practitioners about their treatment.

In all the circumstances, the Panel considers that if Dr Skinner's registration were to remain unrestricted he may pose a real risk to patients and the confidence that the public are entitled to place in the medical profession and its practitioners would be undermined.

The Panel has noted the circumstances surrounding the complaints made against Dr Skinner by patients and other professional colleagues.  The Panel has concluded that these are serious allegations which indicate that Dr Skinner's professional practice and conduct may have fallen short of the standard expected of a medical practitioner. 

The Panel would remind Dr Skinner that he must at all times comply fully with the conditions imposed on his registration.  Any further failure to comply with either the requirements of these conditions and/or the spirit of these conditions may indicate a serious lack of judgment on Dr Skinner's part and a repeating pattern that could have grave consequences both for patients and Dr Skinner's registration.

The Panel has taken into account the issue of proportionality and has balanced the need to protect members of the public, the public interest and Dr Skinner's own interests against the consequences for him of the restriction of his registration.  Whilst it notes that its order has restricted Dr Skinner's ability to practise medicine, the Panel considered the matters before it are of such a serious nature that these conditions are the minimum required to protect adequately members of the public and provide sufficient safeguards both for the public interest and owing to a potential lack of insight and judgment, Dr Skinner's own interests.

The Panel had determined that the circumstances surrounding this case may have grave consequences and in the light of the information provided has determined that it would be appropriate to notify the Registrar that an application should be made to the relevant court for an extension of the order, notwithstanding the fact that this case is likely to be considered by a Fitness to Practise Panel due to commence on 8 January 2007.  Hearings can be postponed or adjourned for any number of reasons and it would be unacceptable to allow Dr Skinner to return to unrestricted practice until the Fitness to Practise Panel have considered his case.  The Panel would remind Dr Skinner that in complying with the conditions imposed, he must always observe the issue of patient confidentiality. 

The Panel notes that the order imposed on 29 June 2005 expires on 20 December 2006.  It has therefore determined under Rule 27(6) of the General Medical Council (Fitness to Practise) Rules to notify the Registrar the General Medical Council to make an application to the High Court for an extension of the interim order under section 41A(6) of the Medical Act 1983, as amended.

Should the High Court extend the interim order, the Panel will again review the order at a further meeting to be held within three months of the High Court determination, unless the matters before the GMC are concluded before that date.

Notification of this decision will be served upon Dr Skinner in accordance with the Medical Act 1983, as amended.

That concludes the case and thank you, Mr Jenkins and Mr Glasgow.  Thank you to the public.

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