England and Wales High Court (Administrative Court) Decisions

IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION
ADMINISTRATIVE COURT

		Royal Courts of Justice Strand, London, WC2A 2LL
		21/12/2016

Mr. Justice Edis:


 


1. This is an appeal against a decision of the Registration Appeal Panel of the General Medical Council when it refused the appellant's application for full registration under s.21B of the Medical Act 1983. The appeal is brought under paragraph 5 of Schedule 3A to the Act, and lies to the County Court. By virtue of s.5(2)(h) of the County Courts Act 1984 I am a judge of the County Court and although this case has been managed by the Administrative Court Office I have jurisdiction to determine the appeal and neither party has objected to my doing so. My powers are wide and are prescribed by paragraph 5(4) of Schedule 3A.

The Facts

2. The appellant trained as a doctor in India. On 16^th September 2015 she made an application to the General Medical Council for full registration as a person with an overseas qualification. She was already registered as a doctor by the Punjab Medical Council. The application was presented on a form on which she was required to fill in a section called "Your Internship Details". She said that hers had started on 1^st September 2011 and finished on 26^th April 2014, and had been done at two institutions in India, the Kasturba Medical College in Mangalore and the Government Medical College in Amritsar. Further details were given in a Table called "Your recent professional experience" which she filled in. This may be summarised as follows:-

i) She started at Kasturba on 1^st September 2011 and did 4 months internship there. She then transferred to Amritsar because she had a grandparent who was unwell. This took about 1 month to arrange and her internship resumed at the new location on 1^st February 2012 and continued with a two week holiday break until 15^th September 2012. This was 7½ months or thereabouts. She had therefore very nearly completed 12 months. Holidays are allowed within internship programmes, so she was just a couple of weeks short of graduating.

ii) At this point she took a study break precisely in order to avoid graduating. This was because she wanted to attend two clinical electives in the United States of America and these were only available to undergraduates. She took a deliberate decision to halt her internship at that stage so that she would not become qualified and therefore no longer eligible for the clinical electives. She went to the United States, hoping eventually to qualify to practise medicine there. She did undertake one of the two clinical electives and returned to India in March 2013. Her internship was then extended between 1^st April and 1^st November 2013 to allow her to study for the examination necessary to qualify her to practise medicine in the United States. She did not pass that exam, and returned to complete her internship and her professional qualification. The restart was delayed for a short period because her mother was diagnosed with cancer and required support.

iii) On 13^th November 2013 she began a further 1 month period of internship which was interrupted on 13^th December by her mother needing her support during aggressive therapy for her condition. Between 1^st April 2014 and 26^th April 2014 she completed her internship at Amritsar. That last period included a fortnight's family holiday. She did therefore spend more than 12 months in total as an intern working under supervision.

iv) She then spent time in London preparing for and passing the PLAB courses which show that her language skills are adequate. She also spent time volunteering at a Children's Hospital in the Punjab and finally got married on 22^nd June 2015 and came to the UK. There was a delay in the Punjab Medical Council sending documents relating to her registration there and she submitted her application in September 2015 as I have recorded.

3. It was common ground that the appellant fulfilled all the requirements for registration under s.21B of the Act except one, which was disputed. That Act by s.21B(1)(b) requires the applicant to satisfy the Registrar that "he possesses the knowledge, skills and experience necessary for practising as a fully registered medical practitioner in the United Kingdom". The GMC accepted that the appellant had shown that she had the knowledge and skills but denied that she had demonstrated the necessary experience.

The Guidance

4. The GMC publishes Guidance to those seeking registration on its website. It will be necessary to set some of it out, in two tranches. That is because the Guidance which was published at the time of when the application was made in September 2015 was changed with effect from 1^st December 2015 in ways which are relevant.
5. Guidance in force as at September 2015

In a document called "Documents You Must Submit" the following appears:

"Internship

You will be asked to provide details of your pre-graduate or postgraduate internship. To be eligible for full registration you must have satisfactorily completed either Foundation Year 1 (F1) in the UK, or a period of pre-graduate or postgraduate clinical experience that provides an acceptable foundation for future practice as a fully registered and licensed medical practitioner. This will usually be referred to as an internship.

To be acceptable your internship must be either

A 12 month programme that includes a minimum of three months in surgery and three months in medicine. If the programme was not completed consecutively over a period of 12 months, or was completed more than 2 years after graduation, your application may be delayed while we investigate this.

…….."

A further document called "Applying for registration as an International Medical Graduate" repeated the words highlighted in bold above but not those which are not highlighted. This document then said:-

"Please Note: Our requirements for acceptable patterns of training/experience are currently under review. The fact that your training/experience may be acceptable currently does not mean that it will be acceptable in the future.

"Whether your training/experience is acceptable will be decided at the point of dealing with an application for registration. The information on this page is subject to change. You are advised to check these pages regularly for up to date information. Any application for full registration will be assessed in line with the legislation, procedures and criteria in place at the time such an application is received."

6. The last part of the material just quoted is relied upon by the claimant as meaning that her application had to be decided under the September Guidance because of the date when it was received. This is conceded by Mr. Hugh Davies who appears for the GMC on this appeal. In a footnote to a minute of a meeting of 6^th October 2015, which I deal with further at paragraph 8 below, the following appears

"The experience section of our website was updated on 10 August 2015 to advise applicants that our criteria are subject to change. This update explains that any decision on whether a doctor's experience meets our criteria will be decided at the point of dealing with an application for registration, in line with the legislation, procedures and criteria in place at that time."

7. This does not appear to be consistent with Mr. Davies' concession which is, I think, based on some transitional provisions which came to be applied as I explain below. In view of the concession by the GMC, it is not necessary for me to address this further.
8. October/December 2015 ("the December Guidance")

i) At a meeting of the Strategy and Policy Board of the GMC on 6^th October 2015 Agenda Item 8 was consideration of a report called "Revising the experience/foundation for future practice criteria for Section 19 and Section 21B applicants". This report recommended modernising the process by adopting two new patterns of experience which "better reflect the purpose of assessing if the breadth, type and duration of experience undertaken by an overseas doctor is comparable to that expected from a UK graduate at the point of full registration". These two new patterns were called Pattern A and Pattern B.

ii) I am concerned only with Pattern A. It requires

"A minimum of 12 months' continuous medical practice in a training programme undertaken immediately prior to or immediately following graduation, which includes

... at least three months of practice in medicine and three months in surgery

... ……..

……….

... all periods of practice must be continuous, uninterrupted internship rotations (or equivalent) completed as part of the training programme and posts which involve observation, such as clinical attachments, shadowing, observerships, and clerkships, rather than active medical practice with direct patient contact are not acceptable.

... The applicant cannot be absent for more than 20 days in any 12 month period (in addition to annual leave, which can be up to 5 weeks)

(the first 12 months or practice should otherwise be uninterrupted with a maximum break thereafter of no more than 12 months before returning to complete the programme."

iii) An explanatory document also before the Board on 6^th October 2015 describes the new approach as follows

"We specify that all breaks must be authorised by the training authority or employing organisation and that we will request evidence of the authorisation. We are also clear that breaks taken for reasons other than carrying out medical related education, training or experience or contractual maternity/paternity leave will be referred to an Assistant Registrar. This addresses the current situation where applicants who have taken substantial breaks in their training seek to rely on a combination of short periods of practice in order to fulfil our requirements."

iv) It appears that the Board approved the policy so that it came with effect from 1^st December 2015.

The decision of the Assistant Registrar

9. The Assistant Registrar refused the application on 8^th December 2015. He set out the December Guidance and referred to transitional arrangements which are to the effect that an applicant who fails to satisfy the new Guidance will be considered under the old Guidance.
10. He identified that the appellant had completed the 12 months required under the old Guidance but had done so over a period of approximately 32 months. This had been permitted by the authorities in India but he did not consider himself bound by their decision. The Assistant Registrar noted that the internship had been interrupted in the last month or so before it ended and said that it was not clear why this had happened. In fact it was for the reason explained above. The appellant had then gone to the USA and spent some time trying but failing to pass the exam which would have qualified her to practise medicine there. She had thus come to resume and complete her internship after a gap of about 14 months.
11. The Assistant Registrar found that the appellant had completed 12 months training but that it was done in a disjointed pattern. He decided that although the old Guidance did not expressly state that the training must be completed in a continuous or uninterrupted period of 12 months, it did require a "programme" and he concluded that the old Guidance therefore militated against allowing the claim, just as did the new. The appellant had certainly not simply followed a programme. He considered whether to allow the claim despite this, and decide that he could not.

The Registration Appeal Panel ("The Panel")

12. The Panel received oral evidence on oath from the appellant and I have read the transcript of the hearing.
13. The Panel's decision sets out the background and the submissions of the parties. It noted in particular the warning on the website under the old Guidance which is set out at paragraph 5 above immediately following the bold type.
14. The dispositive paragraphs of the Panel's decision are:-

"(j)…….Applying the Guidance in force at the date of the decision [i.e. the December Guidance] we find the Appellant did not have a pattern of experience necessary to practise as a fully registered medical practitioner.

"(k) ..[when dealing with old guidance said that it requires a pattern of experience which complies with the following requirement]

'…….(a) A 12 month programme that includes a minimum of three months surgery and three months in medicine…..'

"The GMC concedes that the Appellant has completed an aggregate of 12 months experience with at least three months in each discipline but is of the view that the word "programme" suggests a planned, time limited, sustained, fully supervised period of the type required to be completed by a F1 trainee. Although the word "continuous" is not used website guidance (page 225) warns that if the programme is not completed consecutively over a period of 12 months' further investigations of an application may be required."

"(l) We have reviewed the decision of the Assistant Registrar and our conclusion against the framework of the Guidance applicable at the time the original application was submitted [i.e. the old Guidance]. Although the language of the Guidance is not the same, we must inform the appellant that the overall effect is. In this case there is a 14 month gap during which the appellant was not in foundation/internship training. That gap cannot be made up by saying it was used for study purposes. The purpose of foundation/internship is to develop experience – not increase academic knowledge. The gap is simply too long to enable us to exercise any residual discretion in favour of the appellant under either of the two sets of Guidelines referred to."

15. The Panel then referred to the overarching objectives established by s.1(1A) and (1B) of the Medical Act 1983 and reminded itself that patient safety is the objective of its work.

The Grounds of Appeal

16. Ground 1: it is submitted that the Panel applied the wrong Guideline and ought not to have been influenced by the policy which persuaded the Board to adopt new Guidance in October because that post-dated the date of the application. This policy plainly placed more importance on the internship being continuous and uninterrupted than had the previous Guidance and that is what caused the appellant's application to fail. This is said to have been "wrong, unfair and unreasonable".
17. Ground 2: It is submitted that the Panel misconstrued the word "programme" as it appears in the old Guidance and relied on that construction to support its conclusion that there is no difference between the two sets of Guidance on the issue in this case. Although not expressly stated this way, I think this must be understood to mean that the Panel erred in law when it concluded that the two sets of Guidance mean the same thing. The submission of the GMC set out in sub-paragraph (k) of the Panel's decision at paragraph 14 above must have been accepted by the GMC and was the basis of its decision in subparagraph (l). That submission was, it is submitted, wrong if it suggested that the appellant's internship was not properly to be described as a "programme".
18. Ground 3: This relies on the passage from the December Guidance which I quote at 8(iii) above. It says that since the 14 month gap included a 10 month period of study and the clinical electives in the USA that period would not be referred to an Assistant Registrar under that document. Part of the period related to the illness of the appellant's mother and this was regarded by all concerned as an acceptable reason for a break. Therefore the 14 month gap was given a significance it did not deserve by reference to the GMC's policy. There is an obvious inconsistency between this ground and Ground 1. Either the December Guidance, including this passage, was relevant or it, including this passage, was not. In effect the submission is that even if the new Guidance was relevant, the Panel misapplied it and failed to direct itself that under the GMC policy breaks for "carrying out medical related education, training or experience" would not be referred to an Assistant Registrar, but would be accepted if (as these were) the breaks had been authorised by the training authority.
19. The submission is that the break in December 2013-March 2014 because of the mother's illness was the only part of the gap which ought to have been referred to the Assistant Registrar. He, it is said, ought to have treated that as compassionate leave.

The response of the GMC

20. The GMC reminds me of the duty of the court to exercise restraint in intervening with the finding of a specialist tribunal which was itself hearing an appeal. The restrictions on second appeals in CPR52.13 should apply by analogy.
21. The GMC notes that the first finding of the Panel, namely that the appellant must fail under the December Guidance, is not challenged on appeal. Actually, that is not quite right because Ground 3, as I have explained, contends that the 14 month gap should have been reduced to a much shorter period applying the whole of the new Guidance.
22. The GMC submits that the Panel decided the case under both sets of Guidance and correctly concluded that they were the same in their "overall effect".
23. In essence the GMC supports the Panel for the reasons they gave, and anticipates a submission based on legitimate expectation by reference to R (oao Patel) v. GMC [2013] EWCA Civ 327 and contrasts this case by observing that the appellant was given no assurances on which she relied and that the approach of the UK to registration did not in fact affect any of her decisions. The breaks occurred because she wanted to qualify in the USA and because her mother became ill.

Discussion and decision

24. I apply CPR 52.11(3) which requires me to allow an appeal where the decision of the lower court was (a) wrong or (b) unjust because of a serious procedural or other irregularity in the proceedings before the lower court. There is no complaint of procedural unfairness or other irregularity. Although the statutory powers of the court are wide, it is clear on authority that they must be exercised with restraint and with respect for the Panel which is a specialist tribunal. It is, I think, not necessary to cite authority for this well-known proposition.
25. In this case that means that the court is not in as good a position as is the Panel to appreciate the reality of the need to develop experience in a period leading up to registration as a doctor. The Panel as a specialist tribunal is able to apply its understanding of medical training and why the requirements set out in the Guidance have been developed to determine whether a departure from the norm, such as the present, represents any form of possible compromise to patient safety. An unspoken assumption appears in the decision of the Panel that experience which is acquired over a long period and interrupted by other activities is less valuable than the same experience acquired in a single working year. That assumption plainly underlies the new Guidance, but also the old (see paragraphs 5 and 8 above). It is not for the court to challenge it on an appeal of this kind when no materials are available to enable it to form its own view. I shall approach this appeal on the basis that this assumption is right. There is also an express statement by the Panel that the need for experience is a different thing from academic medical training and therefore that the whole of the 14 month gap was relevant even that part which included medical training. That is a matter within the expertise of the Panel and of the GMC Strategy and Policy Board which issues the Guidance. As a general proposition I also accept this, although the document at 8(iii) above appears to suggest that breaks for medical training do have a value which is presumably why they should not normally be referred to an Assistant Registrar.
26. The issues seem to me to be

i) Should the Panel have had regard to the December Guidance as it did?

ii) If the application was to be decided under the old Guidance, was the Panel right in law to conclude that they are the same?

iii) Was the Panel right in law to take into account the whole of the 14 month period when some of it was spent on a purpose which would not result in a reference to an Assistant Registrar under the October Guidance as explained in the document quoted at 8(iii) above?

27. Ground 1: The Right Guidance

i) I have recorded above the concession made by Mr. Davies that the application fell to be decided under the old Guidance. This appears to reflect the approach of both the Assistant Registrar and the Panel. The Assistant Registrar refers to transitional arrangements and says that where an applicant fails under the new Guidance, the application should be allowed if it would have succeeded under the old Guidance, see paragraph 3 of the decision of the Assistant Registrar. The Panel approached matters in the same order, as appears above.

ii) It therefore follows that the old Guidance was the applicable Guidance. The decision makers were required to have regard to it, and to apply it unless there was some good reason not to. As has been shown, they both accepted that they were required to apply it and attempted to do so.

iii) Although I have not seen the transitional arrangements referred to by the Assistant Registrar, the effect of them as set out in his decision and adopted by the Panel in theirs is that the operative decision was made under the old Guidance. That being so, it is simply not correct to say that the Panel applied the wrong Guidance. The question is not which Guidance they applied, but whether they construed it correctly. I reject Ground 1 because it is wrong in fact.

iv) It appears to me that the extract from the Panel's decision suggests that its consideration of the case under the old Guidance was heavily influenced by the December Guidance. This is criticised by the appellant. It seems to me that this question can be factored into consideration of the second ground below, and I will do so.

28. Ground 2: Is the meaning of the new and old Guidance the same?

i) Whether the words "continuous" and "uninterrupted" in the new Guidance add anything so that the meaning of the old Guidance is changed or supplemented depends on the construction of the word "programme". The old Guidance lacked those words but required 12 months internship to be undertaken within a "programme". It is said by the Assistant Registrar and the Panel that because of the overall duration of the Internship (a little over 30 months) and the 14 month gap in particular, it cannot be described as a "programme".

ii) I do not agree. The appellant completed an internship to the satisfaction of the institutions in India at which she worked. It is to be assumed that the internship was acceptable in every way except that it was interrupted, because the interruption was the only basis for refusing to accept that it demonstrated sufficient experience for full registration. Approximately 11/12ths of it was completed continuously except for a period of relocation because the appellant needed to be nearer her family because of her grandfather's illness. That break was only 4 weeks. The first and longest part of the internship was completed in an entirely conventional way. The internship was supervised by the institutions where it took place and did involve rotations. It was monitored and required the appellant to serve 365 days, which is why she did two extra days at the end when it was determined that she had only done 363 days to that point. All breaks were authorised by the institution. It was accepted by the relevant authorities in India as a proper basis for full registration. All of these facts are common ground. It seems to me to import far too much into the word "programme" to say that the appellant's internship cannot be described by that word as a matter of ordinary language. Whether it was an adequate basis to show experience for the purposes of s.21B(1)(b) of the 1983 Act is another question, and is the real question which the Assistant Registrar and the Panel were required to determine.

iii) The new criterion of continuous training introduced in October 2015 was not a major change of policy, but was intended to make a change in the way decisions were made. The old Guidance was changed because it was causing a problem as recorded in the Agenda item 8 material for the meeting of 6^th October 2015:-

"One key problem is the lack of an explicit requirement for the programme or training to be continuous. As such, applicants try to "mould" their experience to fit our requirements, which has led to an increase in the Assistant Registrar (AR) referrals, increased decision making times, complaints from applicants and challenges to decisions."

iv) The old Guidance did contain a provision about continuity. As quoted above it said

"To be acceptable your internship must be either

A 12 month programme that includes a minimum of three months in surgery and three months in medicine. If the programme was not completed consecutively over a period of 12 months, or was completed more than 2 years after graduation, your application may be delayed while we investigate this."

v) In other words, that Guidance did not say that a programme which was interrupted was not a programme, but said that the interruptions would have to be investigated. That can only be because the GMC wished to reserve the right to evaluate breaks and to decide whether they undermined the quality of the internship so that it did not demonstrate that the applicant had the necessary "experience" for UK registration. It did not bar the acceptance of interrupted internships but neither did it promise their acceptance. It contained to no Guidance about how they would be approached by the decision makers. An attempt has been made to clarify the position to reduce delays and challenges to decisions. This means that some cases will be decided differently, although that was not the prime purpose of the change. It appears from the Board documents from October 2015 that the overall policy was (1) to ensure that foreign qualifications should be tested against the requirements of Foundation Year 1 in the UK and be broadly comparable to that, while (2) at the same time to retain flexibility because of the wide range of training methods employed in different parts of the world. F1 was specifically referred to in the old Guidance, see paragraph 5 above, so this is not, in itself, a fundamental change.

vi) However, it goes too far to say, as did the Panel, that the overall effect of the old Guidance and the new is the same. I am not concerned with the application of the new Guidance and, specifically, with how the passage quoted at 8(iii) above fits in with the specification of Pattern A as set out in the new Guidance. Pattern A is far more prescriptive than the old Guidance. For example, it says "You cannot be absent for more than 20 days in any 12 month period (in addition to annual leave, which can be up to 5 weeks). The first 12 months of your practice should otherwise be uninterrupted…." Nothing of that kind is to be found in the old Guidance. I consider that in directing itself that the old and the new Guidance were the same, the Panel necessarily imported the far more prescriptive terms of the new Guidance into its decision. Under the old Guidance, the fact that the periods of internship were not consecutive required investigation and, as I have said, evaluation. That evaluation can take place against the policy which clearly favours continuous training and always has, but requires a fact specific assessment of the experience of the applicant and a decision about whether it is sufficient or not. The Guidance is silent on how that assessment should be done or what factors should carry weight. The new Guidance is, as I have said, more specific and prescriptive about gaps in internships and a decision taken under it is likely to be less open-textured, which accords with the objective of the changes as explained above.

vii) I am not satisfied that the Panel actually asked itself the right questions. It made two references to the new Guidance in its dispositive paragraph 3(l), wrongly saying that its effect was the same as that of the old, but also saying "the gap is simply too long to enable us to exercise any residual discretion in favour of the Appellant under either of the two sets of Guidelines referred to." The old Guidance requires an investigation of non-consecutive periods of internship, but does not involve any "residual discretion". Such an expression would usually imply a discretion to vary a result which would otherwise follow from the application of a rule. Under the old Guidance the only rule was that non-consecutive internships would require investigation. It requires a decision following that investigation and does not in any way prescribe the way in which it is to be taken or what the result might be. The sheer length of an interruption may be relevant to the real issue which is "has the applicant satisfied s.21B(1)(b) by showing experience". However, the old Guidance is rather less prescriptive about the importance of interruptions than the new.

viii) It is striking that neither the Assistant Registrar nor the Panel addressed what may seem to be the main point in the case: the appellant did complete almost a whole period of 12 months internship before graduation and, had she done an extra few weeks then, she would have succeeded. She delayed that for a particular reason. It is hard to see how the gap between the internship which was all but complete and the small additional part which was completed after that gap made much difference to her experience as it had been acquired before graduation. Under the new Guidance there is a specific provision about 12 month internships being continuous and uninterrupted and involving no absence beyond 20 days plus 5 weeks annual leave. Under the old Guidance the focus was on substance rather than form and in substance, it might be thought, this applicant had effectively competed her internship before her gap. At all events if that is wrong, the Panel ought to have confronted the proposition and explained why it is wrong, because that is really her case.

ix) In short, I consider that the Panel fell into error in finding that there was no difference between the two sets of Guidance and thereby failing to ask the question required by the old Guidance, and failing to answer it. The Panel must determine whether the application should succeed applying s.21B(1)(b). In doing so it must follow the relevant Guidance (the old Guidance) unless there is some good reason not to. It ought to appreciate that the old Guidance is not prescriptive of the result of the investigation which it requires and must apply its judgment to the facts as it finds them to be.

x) For these reasons I uphold the second Ground and quash the decision appealed against. I will remit the case to the Registrar for him to refer it to a Registration Appeals Panel to determine on a proper application of the law. That is because of the respect which the court accords to that specialist tribunal to determine the kind of matters discussed at paragraph 25 above. The new Panel will have to address not only the length of the gap, as did the previous Panel, but the facts concerning the substantial proportion of the programme worked before the clinical elective up to the 15^th September 2012, and the overall duration of the programme given the 6 weeks worked in November/December 2013 and April 2014. This consideration should apply the old Guidance and not be influenced by the new more prescriptive approach. Otherwise, the transitional provisions would not be properly applied.

29. Ground 3: Did the Panel misunderstand the 14 month gap?

i) This ground says that the Panel should have ignored the part of the gap which was medical training because of the document at 8(iii) above. It would not have been referred to an Assistant Registrar under that Guidance and therefore should not in any way count against the appellant.

ii) The short answer to this is that the document at 8(iii) does not apply because it relates to the new Guidance.

iii) Further, and in any event, only a short period of the 14 month gap involved formal medical work, the clinical elective which last about 1 month. She then spent time studying to pass a medical examination. The Panel did not make a finding about the value or duration of these different activities. This period was described by her in evidence at page 86 of the Bundle. She said that she returned to India after the end of the clinical elective in March 2013.

"About the middle of April, when things in the family settled, I started preparing for my USMLE step one. There was a lot of preparation to do. But then I appeared for the exam around May/June, got my results in July. Unfortunately I did not clear the exam. So, I thought I would give it another shot, so I booked for my clinical step two, that is the second step of USMLE……Then on August 28^th…my mum got diagnosed with breast cancer."

iv) It is apparent from that evidence that the factual position is not quite what is suggested in support of this Ground. The clinical elective finished on 1^st March 2013 according to the appellant's application form. She did nothing during March. The appellant appears to have been studying on her own for quite a short period between April and June. I do not think that the document at 8(iii), even if it did apply, required the GMC to ignore the whole of the period between 1^st February and 28^th August because it was "medical related education, training or experience". As I have said in answer to the second ground, the Panel was entitled and obliged to consider the facts as they were found to be and to exercise a judgment. I do not think that the application of the document quoted at 8(iii) was of assistance in this respect, even if it had applied. What was of far more importance was the fact that, before the gap started, the appellant had completed all but a very small proportion of her programme.

Conclusion

30. For the reasons given above, this appeal is allowed. The decision to refuse the appellant's application for registration is quashed and the case is remitted to the Registrar for him to refer it to a Registration Appeals Panel for reconsideration.