Doctors practising abroad, GMC registration and fitness to practise

The case of Sastry v General Medical Council has raised important fitness to practise issues for GMC registered doctors who practise abroad.

Dr Sastry

Dr Sastry was registered under the Medical Act 1983 to practise as a doctor in the UK and India. The GMC proceedings arose out of his treatment of a female, Patient A, whilst working as a consultant medical oncologist in Mumbai, India.

Patient A suffered from lymphoma and came under the care of Dr Sastry following a relapse in October 2013. Dr Sastry recommended R-ICE salvage chemotherapy followed by an autologous cell transplantation, which involves the harvesting and freezing of the patient’s own blood stem cells prior to chemotherapy, following which they are thawed and reinfused.  The chemotherapy took place between December 2013 and February 2014. This was followed by cell harvesting between March and April 2014. Between 17 and 22 June 2014 high dose chemotherapy with BEAM was administered. On 24 June 2014 the previously collected cells were reinfused.  Following the cell transplant, Patient A developed a series of complications. Her bone marrow and cell production failed to recover in response to the transplantation. On 10 July 2014 Patient A died.

The Medical Practitioners Tribunal Service (MPTS) noted in respect of the high dose chemotherapy that the “high intensity treatment by its nature destroys the patient’s own bone marrow and survival is dependent on successful regeneration of the bone marrow from the patient’s own stem cells that are infused after the chemotherapy.” To ensure that the reinfusion is effective, the harvested cells should contain a sufficiently high proportion of CD34 positive cells (a clinical marker for the presence of stem cells).  When Dr Sastry recommended high dose chemotherapy with BEAM, the MPTS concluded there was no uncertainty as to the CD34 positive cell count, Dr Sastry knew it to be 0.05%. This figure was significantly below the contemporaneous European and American guidelines.

Sastry v General Medical Council

Sastry v General Medical Council [2019] EWHC 390 (Admin)

The MPTS concluded that a sanction of suspension would not satisfy the overarching objective and would be neither appropriate nor proportionate. Dr Sastry had placed Patient A at “high risk of serious harm” and throughout the proceedings had demonstrated “a persistent lack of insight” into the consequences of his misconduct for Patient A, her family, the public and the medical profession. The MPT determined that Dr Sastry’s misconduct was “fundamentally incompatible with continued registration” and erasing his name from the medical register “would be the only proportionate sanction to impose in order to serve the public interest, maintain public confidence in the medical profession and send a message to the medical profession that this behaviour is unacceptable”.

On appeal, the principal issue that arose was whether Dr Sastry’s conduct should be judged according to the standards of professional conduct set by the GMC or instead by reference to local standards and practices in India.

Dr Sastry sought to argue that the tribunal had failed to consider the Indian context appropriately arguing that the law of informed consent is very well developed in the UK but different in India.

Mrs Justice May however concluded that:

“the MPT was right to use GMP as a reference by which to judge Dr Sastry’s behaviour, albeit being careful to take into account local conditions. The obligation to comply with GMP [Good medical practice] comes with registration. … A doctor may not practise in the UK without a licence but doctors practising wholly outside the UK do not need to hold a licence, indeed they need not be registered with the GMC at all. However, the Guidance is clear: if doctors choose to be registered with the GMC they must follow GMP. Doctors seeking to obtain or retain GMC registration, with or without licence, are obliged to practise in accordance with GMP… the principles of good practice set out in GMP are sufficiently high-level to be able to be adapted as necessary to accommodate differing guidelines and conditions which may exist in another country”. (Emphasis Added)

Dr Sastry recently lost a further appeal against Mrs Justice May’s ruling.

GMC’s Authority and Jurisdiction 

What then is the authority and jurisdiction of the Medical Council (GMC) in relation to GMC registered doctors who practise partly or wholly abroad?

Clearly doctors who practise wholly outside the UK (except in crown dependencies) do not have to be registered with the GMC and must comply with whatever regulatory requirements exist in the country in which they practise.

Licence

The licence gives a doctor the legal authority to do certain activities in the UK such as holding certain medical posts, prescribing medicines and signing death certificates.

Registration

For roles that are based wholly outside the UK, there is no requirement for a doctor to have a licence to practise. Holding registration without a licence allows doctors to show that they are in good standing with the GMC. Holding registration without a licence means doctors must, amongst other things, continue to follow the guidance in Good Medical Practice and continue to be subject to GMC fitness to practise processes.

Fitness to practise for doctors who practise abroad

Practising in the UK and abroad is not unusual for many doctors.  However, these doctors must be careful to ensure they understand the implications of their registration with the GMC.

The case of Dr Sastry reaffirms that compliance with Good medical practice comes with registration regardless of where in the world they practise.  However, local factors might also carry some significance.  Mrs Justice May confirmed in her ruling that:

“In considering whether or not a registrant undertaking professional duties outside the UK has fallen short of levels of professional conduct which the UK public is entitled to expect from its doctors, a Tribunal must take account of any particular limitations or local practices which apply in the foreign location. In short, a registrant’s behaviour is to be judged by reference to UK standards but taking into account local conditions and practices.”

GMC proceedings against a doctor practising overseas is unusual but this case should act as a stark reminder to doctors that with GMC registration comes responsibilities irrespective of where in the world they practise.