Neutral Citation Number: [2014] EWCA Civ 1522

Case No: B2/2014/2008

IN THE COURT OF APPEAL (CIVIL DIVISION)
ON APPEAL FROM THE CENTRAL LONDON CIVIL JUSTICE CENTRE
Her Honour Judge Faber
3BF02118
Royal Courts of Justice
Strand, London, WC2A 2LL
Date: 28 November 2014
Before :
LORD JUSTICE LONGMORE
LORD JUSTICE LEWISON
and
LORD JUSTICE BURNETT
--------------------Between :
GENERAL MEDICAL COUNCIL
- and AMGAD NAKHLA

Appellant
Respondent

----------------------------------------Mr Alan Maclean QC & Ms Jessica Boyd (instructed by GMC Legal Department) for the
Appellant
Mr Amgad Nakhla (not represented) the Respondent
Hearing dates : 19 and 20 November 2014
---------------------

Judgment

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Lord Justice Lewison:

Introduction
1.

Mr Nakhla has been practising as a surgeon in the UK since May 2006. Before 2005
he practised as a surgeon in Egypt, which is also where he trained. In November 2008
he was accepted as a Fellow of the Royal College of Surgeons, having passed the
FRCS (Trauma and Orthopaedics) examination. He has been working as a Locum
Consultant Orthopaedic Surgeon at Basildon and Thurrock University Hospitals since
April 2012. His specialty is in the lower limbs, especially knees and hips. In January
2012 he applied to the General Medical Council (the GMC) to be registered as a
specialist in Trauma and Orthopaedic Surgery (T & O). Registration is a necessary
pre-condition to permanent appointment as an NHS consultant. His application was
rejected by the Registrar, whose decision was upheld by the GMC Registration
Appeal Panel (the RAP). He appealed to the county court against the decision of the
RAP; and on 30 May 2014 HH Judge Faber allowed his appeal. The GMC now
appeal to this court.

The legal framework

2.

The GMC is a body corporate, established by statute, whose main objective is to

protect, promote and maintain the health and safety of the public: Medical Act 1983 s.
1 (1A). It is required by statute to have a number of committees, including a
Registration Panel and the RAP.

3.

Part IVA of the Act deals with Postgraduate Medical Education and Training. Under
section 34L of the Act the Registrar must:
award a certificate of completion of training (CCT) to any
person who applies to the General Council for that purpose if
(a)

that person is a registered medical practitioner;

(b)
the Registrar is satisfied that that person has been
appointed to, and has satisfactorily completed, a course of
training leading to the award of a CCT; and
(c) that course of training has been approved by the General
Council under section 34I(1)(a).
4.

The award of a CCT entitles its holder to be entered on the register of specialist
practitioners. This register is kept by the Registrar under section 34D of the Act,
which provides:
(1)
The General Council shall keep a register of specialist
medical practitioners (known as the Specialist Register).
(2)
The Specialist Register shall, subject to subsections (4)
and (5), contain the names of
(a)
registered medical practitioners who hold a CCT in a
recognised specialty;

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; and

(c)
registered medical practitioners falling within such other
categories as the Privy Council may by order specify.
(3)

(4)
A person falling within any of paragraphs (a) to (c) of
subsection (2) shall only be included in the Specialist Register
if they have applied to the Registrar for the purpose and have
paid any fee specified in regulations under section 34O.
5.

Thus holding a CCT is not the only route to entry on the Specialist Register. In
exercise of the power contained in section 34D (2) (c) the Privy Council made the
Postgraduate Medical Education and Training Order of Council 2010 (the Order).
Article 7 of the Order provides that persons are eligible to be registered in the
Specialist Register if they are eligible specialists as specified in article 8. Article 8
provides, so far as relevant:
(1) Persons are eligible specialists for the purposes of article
7(1)(a) if they are exempt persons and hold a recognised
specialist qualification granted outside the United Kingdom as
specified in article 10.
(2) Subject to paragraph (4), a person (S) is an eligible
specialist for the purposes of article 7(1)(a) if S does not fall
within paragraph (1) but has
(a)

undertaken specialist training; or

(b)

been awarded specialist qualifications,

in a recognised specialty and satisfies the Registrar that that

specialist training is, or those qualifications are, or both when
considered together are, equivalent to a CCT in the specialty in
question.
(3)
(4)
(5) If S
(a)

(b) has acquired specialist medical experience or knowledge,

wherever obtained,
the Registrar shall take account of that experience or
knowledge, when determining the adequacy of the training or
qualifications under paragraph (2).

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6.

A person who satisfies these requirements is given a Certificate of Eligibility to

Specialist Registration (a CESR, pronounced as in Julius). Since the Specialist
Register shall contain the names of those who fall within the specified categories, it
seems to me to follow that if an applicant satisfies the criteria in article 8 of the Order,
the Registrar must include his name in the Register.

7.

A decision not to include someones name in the Specialist Register is an appealable

decision: Medical Act 1983 Schedule 3A para 2A. The appeal lies to the RAP:
Schedule 3A para 4 (1). Paragraph 4 (8) provides:
(8)
In disposing of an appeal under this paragraph, a
Registration Appeals Panel may determine to
(a)

dismiss the appeal;

(b)

allow the appeal and quash the decision appealed against;

(c)
substitute for the decision appealed against any other
decision which could have been made by the person making the
decision;
(d)
remit the case to the person making the decision to
dispose of in accordance with the directions of the Registration
Appeals Panel,
8.

An appeal from the RAP is given by paragraph 5:

(1)

Where

(a) a Registration Appeals Panel determines an appeal under

paragraph 4 above; and
(b) the Panel's determination is any determination other than
a determination under paragraph 4(8)(b) above to allow the
appeal and quash the decision appealed against,
the person concerned may, before the end of the period of 28
days beginning with the date on which notice of the
determination was given to him under paragraph 4(9), appeal
against the determination to the [county] court.
9.

The powers of the appeal court are also given in Schedule 3A paragraph 5. In addition
to the power to dismiss or allow the appeal, or to remit the case to the RAP, the appeal
court may.
substitute for the determination appealed against any other
determination which could have been made by the [RAP]

10.

Thus the court has power to order the Registrar to include a medical practitioner in the
Specialist Register. The exercise of that power would only be appropriate where the
court is satisfied that there could, realistically, only be one outcome were the appeal to

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be remitted to the RAP: Hollingworth v Specialist Training Authority of the Medical

Royal Colleges [2003] EWCA Civ 452 at [28].
Appeals to the courts
11.

Unlike many appeals to the court from specialist tribunals, an appeal to the county
court from the RAP is not limited to an appeal on a point of law.

12.

The county court, acting in its appellate role, will normally conduct a review of the
decision of the RAP rather than a rehearing: CPR Part 52.11 (1). It will allow an
appeal under CPR Part 53.11 (3) where the decision under appeal was (a) wrong or
(b) unjust because of a serious or other procedural irregularity.

13.

The first general point that I wish to make arises out of the fact that an appeal to this
court is a second appeal. In appeals of that kind the real question for this court is
whether the intermediate appeal court (here the county court) was entitled to interfere
with the decision of the first tier tribunal (here the RAP). In other words the focus of
this appeal is whether the RAP were wrong: Procter & Gamble UK v HMRC [2009]
EWCA Civ 407; [2009] STC 1990.

14.

The second general point is about appeals on fact. An appeal from the RAP is not
limited to an appeal on a question of law, but that does not dilute the reluctance which
an appeal court should have about overturning factual conclusions. Factual
conclusions for this purpose include not only findings of primary fact but also
evaluations of those facts, value judgments based on them, and the application of the
facts to legal standards. The appeal court should not retry the case on the transcript.
All this is contained in the recent judgment of the Supreme Court in McGraddie v
McGraddie [2013] UKSC 58; [2013] 1 WLR 2477 as well as in Procter & Gamble
UK at [9] (Jacob LJ), [60] (Toulson LJ) and Assicurazioni Generali SpA v Arab
Insurance Group [2002] EWCA Civ 1642, [2003] 1 WLR 577 at [16] (Clarke LJ).
Moreover where, as here, the appeal is an appeal from a specialist tribunal an appeal
courts reluctance to intervene on questions of expertise should be all the greater:
Procter & Gamble UK at [11] (Jacob LJ), [48] (Toulson LJ). This tribunal included a
medically qualified member, and received advice from a specialist adviser.

The question to be determined

15.

The first route to entry on the Specialist Register is by holding a CCT. One would
naturally expect that alternative routes would be broadly equivalent. That this is so is,
in my judgment, borne out by article 8 (2) of the 2010 Order, because the purpose for
which the Registrar must consider a practitioners specialist training and/or
qualifications is to decide whether they are equivalent to a CCT in the specialty in
question.

16.

The next step, therefore, is to see what is required in order to qualify for the award of
a CCT. In the case of a T& O surgeon the requirements are set out in the curriculum
for Specialist Training in Trauma and Orthopaedics 2010, published by the Royal
College of Surgeons. It is the syllabus leading towards the award of a CCT, which
typically takes eight years. It is a lengthy and detailed technical document, which it is
impractical to summarise. It must also be borne in mind that it is a practical
document, written by medical practitioners; and one cannot expect it to exhibit the

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same verbal precision as a well-drawn contract, let alone an Act of Parliament.

However, I must set out some extracts which are relevant to the appeal.
The acquisition of operating experience is an important factor
in surgical training and so any curriculum to be used in the
workplace should be competence focused. (Section 2-2)
PBAs [Procedure-Based Assessments] assess trainees
technical, operative and professional skills in a range of
specialty procedures or parts of procedures during routine
surgical practice up to the level of CCT. PBAs provide a
framework to assess practice and facilitate feedback in order to
direct learning.
The assessment tool uses two principal components

A global assessment that is divided into four levels of overall global

rating. The highest rating is the ability to perform the procedure (or
selected elements) to the standard expected of a specialist in practice
within the NHS (the level required for the CCT). (Section 3-35)
The award of a CCT occurs at the completion of training
once the Trainee has demonstrated a range of generic medical
skills including team working and communication as well as
evidence of competence in the general practice of orthopaedic
and trauma surgery and the successful completion of the
interspecialty examination. By the time they acquire the CCT
they may already have developed a special interest in one of the
above named areas. (Section 6-1)
Part of the later years assessment will include the
successful completion of the intercollegiate specialty
examination. (Section 6-1)
Before the award of the CCT the trainee will need to
demonstrate in a formal summative assessment of the
curriculum the applied knowledge, skills, attitudes and
judgements of an Orthopaedic surgeon practising independently
in the generality of the discipline. (Section 6-2)
It is anticipated that in order to access the final phases of
training [years 6 to 8] it would be necessary to be able to
demonstrate that the applicant had a level of knowledge
sufficient to complete the [FRCS] Exam in Trauma and
Orthopaedics within 12 months of entering at this level.
A newly appointed consultant in T & O with CCT should be
able to accept responsibility for the reception and initial
management of the majority of unselected trauma cases and act

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as the primary consultant for the small number of orthopaedic

emergencies which may occur. [The holder of a CCT] would
be expected to assess emergencies as they arise, resuscitate and
definitively treat the majority, referring on some of the more
specialised cases as described above. (Section 6-3)
17.

Section 8 contains the detail of the syllabus. It begins by saying that there are three
components: applied clinical knowledge, applied clinical skills and professional and
management. These components all map back to Good Medical Practice. It goes on
to say that these areas are interdependent, and illustrates the interdependency by
means of a Venn diagram. Section 8-3 describes the middle years of training and
continues:
Towards the end of this period, or at the start of the next, a
public demonstration of the acquisition of the skills,
knowledge, and attitudes expected of a T & O surgeon
practising in the generality of the discipline at the level of an
NHS consultant must take place in the form of a Fellowship
examination. Together with a portfolio of evidence of
workplace based competency this will permit the trainee to
enter the final stages described below.

18.

The applied clinical knowledge part of the syllabus includes a section devoted to
paediatric orthopaedic surgery (as well as hand, knee, ankle and foot, hip, spine,
trauma, shoulder and elbow). Paediatric surgery is not specifically mentioned in the
section of the syllabus devoted to applied clinical skills.

19.

Section 10 of the 2010 curriculum explains the basis of assessment of Applied

Clinical Skills for the CCT in T&O. The 14 key indicative procedures for the purpose
of measuring clinical skills, to be assessed by reference to PBAs, include hand, knee,
hip, back, leg and foot procedures. Section 8-3 of the syllabus says of these key
procedures:
It is essential to realise that these key procedures do not
encompass the whole practice of the discipline but do indicate
the whole range of skills to be acquired by a competent T & O
surgeon. Assessment (PBA) in the key procedures gives
evidence as to the quality of a trainees performance, their
overall competence is assessed from this evidence set in the
context of their entire logbook (quantity) of procedures.
All key procedures (PBA) must be mastered to level 4 and the
remainder at a minimum of level 2, except in rarer and very
specialized areas when this will simply not be practicably
possible.

20.

Level 4 is described as competent to manage without assistance including

complications and level 2 as can manage with assistance. There is a further level
designated 4s which is a competence at level 4 needed only by those trainees
selecting the area in question as a sub-specialist interest. The curriculum then details a

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large number of surgical procedures, which are far more extensive than the 14 key
indicative procedures. In years 7 and 8 almost all require either level 4 or level 4s.
21.

As to clinical knowledge, section 10-9 of the curriculum states that [t]he application
of knowledge and its use in judgement will be assessed in the final T&O FRCS
examination. Finally:
At the end of training a CCT will be awarded when the trainee
has satisfied [the Postgraduate Medical Education Training
Board] that they have been trained in the generality of
Orthopaedics and Trauma, assessed as having completed the
competencies laid out in the Orthopaedic and Trauma
curriculum and having the attitudes, skills and judgement of a
surgeon capable of independent practice.
The recommendation for the award of CCT will take into
consideration that:
1. The syllabus is for the generality of Trauma and
Orthopaedics and this will have been assessed in the [FRCS]
exam which trainees must have completed by the end of their
training. This exam forms part of the trainees portfolio which
also includes work place based assessments and the evidence of
previous learning agreements and [Annual Review of
Competence Progression/Review in Training Assessments].
(section 11-1)

22.

It is clear from these extracts that a CCT is awarded to someone who has
demonstrated practical competence across a broad range of T & O cases, even though
he or she may have developed a sub-specialty (such as lower limb or hip surgery).
The natural expectation is that a medical practitioner who goes down the
equivalence route to registration would be expected to demonstrate the same range
of practical skills.

23.

Good Medical Practice referred to in [17] above is a GMC publication. Among its
overriding duties or principles are the following:
You must keep your professional knowledge and skills up to
date and
You must regularly take part in activities that maintain and
develop your competence and performance.

The GMCs guidance for applicants

24.

The GMC publishes guidance for applicants for registration in the specialist register.
The guidance explains that evidence will be evaluated in relation to four Domains:
(1) knowledge, skills and performance, (2) safety and quality, (3) communication,
partnership and teamwork, and (4) maintaining trust. 75% is attributed to domain 1. It
is common ground, however, that the GMC guidance to applicants cannot impose any

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greater or more stringent requirements than those imposed by the Order. It is therefore
unnecessary to dwell on it further.
Mr Nakhlas case
25.

Mr Nakhla applied for specialist registration under the equivalence route in January
2012. He submitted evidence relating to his medical practice in Egypt prior to 2005,
and in the UK since he began work there in May 2006. On 17 September 2012 he was
told that his application had been unsuccessful. He was sent a copy of the evaluation.
Although the evaluators were satisfied that Mr Nakhla had demonstrated the relevant
degree of knowledge, they were not satisfied that he had demonstrated the relevant
depth and breadth of skills and experience. The essential point was that Mr Nakhla
had substantial experience of lower limb reconstruction; but:
The evaluators were not satisfied that Dr Nakhlas logbooks
and consolidation sheets display that his skills and experience
cover the generality of the 2010 Trauma and Orthopaedic
surgery CCT curriculum.

26.

In particular he had limited exposure to spines and paediatric orthopaedics; and his
logbooks did not show substantial evidence of training in hand surgery or general
trauma. The evaluators recommended that Mr Nakhla should either spend
approximately 12 months in a post that would expose him to the areas in respect of
which he had been unable to demonstrate equivalence to the 2010 CCT curriculum,
namely general trauma, hand surgery, spinal surgery and paediatric orthopaedics, or
provide evidence that his skills and experience in these areas were equivalent to the
standards required by the 2010 curriculum.

27.

Mr Nakhla asked for a review. On 30 January 2013 he was told that his application
was still unsuccessful. The reviewers said:
Not only must an applicant show that they gained the
competencies, they also need to show that they are currently
maintaining those competencies. In looking to see that an
applicant gained the competencies the GMC will look at an
applicants whole career, not only the last 8 or indeed 5 years.
However, an applicant also has to show that they are
maintaining these competencies to the standard of the
curriculum. The GMC will look at an applicants more recent
practice to ensure that the breadth of competencies is
maintained. It is worth bearing in mind that the standard is that
of the 2010 Trauma and Orthopaedic surgery CCT curriculum,
not that of consultant colleagues whose practice may have
become focussed on certain areas.
Structured reports or references on their own do not provide
strong enough evidence; primary evidence is also required.
In his letter on page 64 Mr Nakhla comments on his experience
in general trauma [in Cairo University] He also uses these

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pages to demonstrate his experience in Spinal Surgery,

Paediatric Orthopaedic surgery and Hand. He undertook this
work between 2002 and 2005. While this may be evidence to
show that he gained competencies, it is too long ago to show
that he is maintaining them as described above.
He also comments Refer to pages 269-271 for General
Trauma and Hand experience in Charing Cross Hospital. This
experience was between 20/5/2006 2/7/2009. There is not
enough recent evidence in these alone to show that he is
maintaining competencies across the board.

The logbook data presented for the period 1st May 2012 to 1st
December 2012 are mostly hip and knee operations with a
small number of trauma cases. As such again do not show the
necessary breadth required to meet the standards of the 2010
CCT curriculum in Trauma & Orthopaedic surgery.
28.

They then commented on a number of index PBAs that had not been completed as
required by the 2010 curriculum.

29.

Mr Nakhla then appealed to the RAP. The RAP heard evidence over three days,
including evidence from Prof Frostick on behalf of the GMC and also from Mr
Kamath, a specialty adviser. Prof Frostick had been one of the initial evaluators and
also a member of the review evaluation panel. The RAP considered the evidence that
had been placed before them. Mr Nakhla also called impressive evidence from a
number of his professional colleagues at Basildon and a professor at Charing Cross
Hospital, all of who supported his application for inclusion on the Specialist Register.
They testified to his competence as a practising surgeon in his sub-specialist areas. He
produced more evidence of work that he had carried out in Egypt before his move to
the UK. But the RAP concluded that although he had demonstrated that he had carried
out the procedures described in that material, there was no assessment of his
competence in doing so. In considering the evidence of what Mr Nakhla had done
since his arrival in the UK, the RAP, like the evaluators, took the view that there was
little evidence of paediatric orthopaedics or spine work; and minimal hand work. Mr
Kamath advised the RAP that Mr Nakhla had reached the skill equivalent of the CCT
in hand, paediatric orthopaedics, spine and general trauma but that:
there is insufficient evidence to indicate that he has
maintained his experience on spine, child orthopaedics and
hand. General trauma skills are maintained.

30.

Thus Mr Kamath was unable to say that Mr Nakhla had maintained the broad range of
skills required by the 2010 curriculum. Prof Frostick took a view more unfavourable
to Mr Nakhla. His view was that the Egypt experience was not sufficiently
triangulated to enable him to come to a favourable conclusion on the hand, spine
and paediatric orthopaedics. The RAP preferred the evidence of Prof Frostick. They
did not consider the Egypt experience demonstrated a training equivalence to the 2010

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curriculum. In any event that experience was at its latest in 2005. They concluded at
paragraph (x):
Naturally the Appellant would have acquired some skills
during his Egypt training. The curriculum requires him to
demonstrate those skills have been maintained. The reality is
that since arriving in the UK in 2005 he has focussed on lower
limb work. He is plainly entirely competent at the work he
does. He is well thought of by colleagues and patients and we
have heard and read a good deal of evidence of his competence.
However he has failed to produce sufficient evidence (and the
burden is on him) that he has maintained all the skills necessary
to demonstrate, either on the date of the application, review or
for this appeal, the breadth and depth of competence in hand,
spine or paediatric orthopaedics equivalent to a trainee applying
for a CCT. His contention that specialist units treat these
conditions and his experience enables him to refer
appropriately ignores the requirements of the curriculum which
requires competence across all areas of Trauma and
Orthopaedic Surgery. He must demonstrate that at more than a
basic level he could treat any patient with trauma and
orthopaedic conditions. That must be evidenced by robust and
objectively verifiable evidence of the type lacking in this case.
31.

Accordingly his appeal was dismissed. In a nutshell, although Mr Nakhla was very
good at what he did, what he did was too specialised to qualify him to have his name
entered on the specialist register in T & O.

The judges judgment

32.

The judge began by summarising the parties submissions on the many grounds of
appeal. She then turned to the legal question: what had to be shown under article 8 of
the 2010 order in order to qualify for registration? I quote the relevant part of article 8
(2) again for convenience:
a person (S) is an eligible specialist if S has
(a)

undertaken specialist training; or

(b)

been awarded specialist qualifications,

in a recognised specialty and satisfies the Registrar that that

specialist training is, or those qualifications are, or both when
considered together are, equivalent to a CCT in the specialty in
question.
33.

She answered that question as follows:

180. Article 8(2) makes an applicant eligible for the Specialist
Register if she has either undertaken specialist training or been
awarded specialist qualifications in a recognised specialty and

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satisfied the Registrar that either the qualifications or the

training or both when considered together are equivalent to a
CCT in the specialty.

181. Article 8(5) requires the Registrar to take into account

specialist medical experience or knowledge wherever obtained
when determining the adequacy of the training or of the
qualifications.
182. The italics are mine in an effort to distinguish the three
different ways in which an applicant can prove equivalence.
They are by her qualifications or by her training or by a
combination of the two. She does not have to demonstrate
equivalence by reference to training if she relies on
qualifications or by reference to qualifications if she relies on
training.
183. The effect of (5) is that all acquired medical experience or
knowledge is to be taken into account. It is not limited by
geography or age. It is to be taken into account whether the
Panel is considering the equivalence of qualifications or the
equivalence of training or the equivalence of the combination
of the two.
184. If and in so far as any GMC guidance or requirements
depart from the statutory provisions of the 2010 curriculum for
the CCT then they cannot bind the [RAP] or the court. If the
[RAP] treated a different provision in the CESR as binding and
so departed from the actual requirements of the CCT
curriculum in considering the issue of equivalence then they
would have committed an error of law.
34.

Based on her interpretation of article 8 (2) and the CCT the judge concluded at [228]:
Had the [RAP] been correctly applying the law as set out in
Article 8 (2) they would have realised that the FRCS (Trauma
and Orthopaedics) was a key to their consideration of the case.
That is because in itself it fulfils the requirement in article 8 (2)
for the specialist qualification so all they needed to look at in
addition to that was his experience pursuant to Article 8 (5) and
that they did not need to look at his specialist training. If their
decision was based on their failure to recognise that as the legal
position then it would be wrong.

35.

In the following paragraph the judge concluded that the RAP required a training
equivalent to the CCT as well as his specialist qualification. That was wrong as a
matter of law. The judge was clearly of the view that the fact of Mr Nakhlas
qualification as FRCS was sufficient to satisfy the requirements of article 8 (2). Thus
at [194] and [195] she said that Mr Nakhlas specialist qualification was one of the

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three ways of establishing equivalence, without regard to any additional training. At

[197] she appeared to consider that training up to the time when Mr Nakhla gained his
status as FRCS (T & O) would be relevant but not any training thereafter.
36.

One further point of interpretation cropped up later in the judges judgment. The
question was whether the requirement in article 8 (2) that training and/or
qualifications are equivalent to a CCT meant that an applicant had to show that
learned skills had been kept up to date. The judge answered that question in the
negative at [220]:
As a matter of legal interpretation I reject [the] argument that
the wording of Article 8 (2) requires the applicant to show he
maintained the same skills up to the time when his application
ws being completed. The CCT wording is It would be
necessary to have completed all the modular competencies
equivalent to completing ST6. It does not require maintenance
of those competencies. It requires evidence that they have
been completed in the past before the specialist stage of
training.

37.

At [215] the judge identified what she saw as a further error of law, in relation to
PBAs. She pointed out that there was no evidence to show what was required in this
country to help trainees in their training before the introduction of PBAs. Nor did she
know what records there were in England of individual operations before 2005. She
continued:
Thus there is no evidence that the [RAP] was entitled to
demand such detailed information from Egypt prior to 2005 to
demonstrate equivalence with the CCT in England. So I must
hold that they were wrong to do so and that in so far as their
decision turned on the absence of such evidence it is wrong as a
matter of law.

38.

She identified another error of law at [227]. This related specifically to paediatric
PBAs. The judge said that the 2010 syllabus contained no requirement for a paediatric
PBA, and thus to the extent that the RAP took the absence of such a PBA into account
it was wrong in law.

39.

Thus she allowed the appeal because of the errors of law that she had identified. In the
final paragraph of her judgment at [243] she set out the principles that the RAP should
follow on any resumed hearing:
The FRCS (Trauma and Orthopaedics) is the Article 8 (2)
specialist qualification. The GMC is not entitled to require
PBAs or their equivalent for any period prior to their
introduction in this country in 2005. There being no evidence
as to what was required in this country to monitor training prior
to the introduction of PBAs, the GMC is not entitled to require
PBAs or equivalent evidence in relation to any period before
2005. The GMC is entitled to require PBAs or equivalent
evidence from 2005 in relation to each of the 14 key procedures

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set out in the 2010 curriculum. There is no legal requirement in

the curriculum or in the statute for maintenance of skills to be
evidenced. As it can take anything up to 11 years to complete
the CCT evidence of competence of that age is not too old to be
taken into account. There is no legal requirement for a PBA or
its equivalent in paediatric orthopaedics. The 2012 curriculum
is irrelevant to this application. The involvement of Professor
Frostick in the two evaluations is not unfair nor is there
evidence of bias in the unavailability of statistics as to
applications he has allowed nor in the statistics of appeals
allowed.
40.

By paragraphs 1 and 2 of her order she remitted Mr Nakhlas application to a different

RAP for redetermination of Mr Nakhlas appeal; and by paragraph 4 of her order
directed them to apply the law as set out in paragraphs [180] to [185] of her judgment.
The guidance that she set out at [243] (quoted above) was set out in paragraph 5 of
her order, which directed the RAP to apply that guidance.

Article 8 (2) and the 2010 curriculum

41.

The judge was, in my judgment, correct to say that the ultimate objective of the
enquiry was to determine whether an applicants qualifications or training or both
were equivalent to a CCT. I think that she was also right to say that GMC guidance to
applicants could not lawfully prescribe more onerous requirements than article 8 (2)
itself. The judge was also right to say that in considering whether Mr Nakhlas
qualification or training (or both) was equivalent to a CCT the Registrar, and hence
the RAP, were required under article 8 (5) to take account of Mr Nakhlas
experience or knowledge, wherever acquired.

42.

In the end, however, whether qualifications or training or both are equivalent to a

CCT must, as it seems to me, depend on what the 2010 syllabus requires, since it is
completion of that curriculum that leads to the award of a CCT. The judge concluded
at [182] that having passed the examination for FRCS (Trauma and Orthopaedics)
fulfilled the requirement for a specialist qualification. She thus assumed that
equivalence could be proved by that qualification alone. But the Registrar is still
required by article 8 (2) to decide whether the qualification or the training or a
combination of the two is equivalent to a CCT. Suppose that in some foreign country
an applicant studies for and receives a Diploma in Trauma and Orthopaedic
Surgery. Suppose that in order to obtain the Diploma the candidate must follow a
curriculum which is identical to the 2010 curriculum in this country. In such a case,
having examined that curriculum, the Registrar may well decide that a holder of the
Diploma applying for inclusion on the Specialist Register has demonstrated
equivalence with a CCT by qualification alone. But the judges approach to the
particular qualification that Mr Nakhla held assumes what is still to be decided: is the
qualification FRCS (T & O) equivalent to a CCT? Had she asked herself that
question, she should have answered it no.

43.

In his powerful submissions Mr Nakhla said that the FRCS (T & O) was the finest
surgical qualification in the world. Candidates from all over the world came to take it.
The GMC has always acknowledged the quality of the FRCS (T & O) qualification.
Prof Frostick said in evidence that it was a very difficult exam and that passing it

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GMC v Nakhla

was a fantastic achievement. It therefore satisfied article 8 (2) (b). Mr Nakhla

argued that under article 8 (5) the Registrar is required to take specialist medical
experience wherever obtained into account and that the combination of his FRCS
(T & O) qualification and his experience was sufficient. Since it was possible to
qualify for registration either by virtue of a qualification or by virtue of training, in
the case of a candidate who pursued the qualification route, training was irrelevant.
44.

I accept that the FRCS (T & O) is a specialist qualification within the meaning of
article 8 (2) (b). I accept that in addition to his qualification of FRCS (T & O) his
specialist medical experience also had to be taken into account. But that in itself does
not answer the question: is the FRCS (T & O) qualification, taken together with Mr
Nakhlas experience, equivalent to a CCT? By holding that the FRCS (T & O) was
the specialist qualification the judge precluded any further enquiry. Nor do I accept
that in the case of a person who chooses to rely on a qualification training is
irrelevant. It is clear from the concluding part of article 8 (2) that the Registrar is
required to consider the equivalence of the qualification, the training or both when
considered together. That points away from a rigid separation between qualification
on the one hand and training on the other.

45.

The next point to make is that the judge did not have evidence of what is required in
order to pass the FRCS (T & O) exam. So there was no evidential foundation for her
conclusion that passing the FRCS (T & O) exam was a qualification equivalent to the
CCT. Mr Nakhla relied heavily on the description of the FRCS (T & O) exam in
section 8-3 of the curriculum which said that it would test:
the skills, knowledge, and attitudes expected of a T & O
surgeon practising in the generality of the discipline at the level
of an NHS consultant

46.

Thus, he argued, it could be seen from the curriculum itself that the exam was not
merely a test of knowledge. It encompassed skills and attitudes as well. Moreover it
tested skills, knowledge, and attitudes across the generality of the discipline, and, in
addition, did so at the level of an NHS consultant. Since an applicant for a CESR was
not applying for a CCT what was important was the outcome, rather than the means
by which the outcome was achieved. If the skills, knowledge and attitudes of a T & O
surgeon were tested by the FRCS (T & O) exam in the manner and to the level
described, what more was needed to demonstrate competence at the level of an NHS
consultant?

47.

The answer to that very pertinent question is, in my judgment, that the 2010 syllabus
itself explains that passing the FRCS (T & O) exam is not the be-all and end-all.

48.

I repeat the essential parts of the 2010 curriculum:

The award of a CCT occurs at the completion of training
once the Trainee has demonstrated a range of generic medical
skills including team working and communication as well as
evidence of competence in the general practice of orthopaedic
and trauma surgery and the successful completion of the
interspecialty examination. By the time they acquire the CCT

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GMC v Nakhla

they may already have developed a special interest in one of the

above named areas. (Emphasis added)
49.

The interspecialty examination is the FRCS (T & O) examination, which Mr Nakhla

has passed. But it is clear that this is only one part of what a successful applicant for a
CCT needs to show. As section 6-1 explains the FRCS (T & O) qualification is part of
the later years assessment. Section 8-3 explains that the FRCS (T & O) together with
the portfolio of evidence of workplace based competency permits the trainee to enter
the final stages of training. The same point is repeated in section 11-1:
This exam forms part of the trainees portfolio which also
includes work place based assessments (Emphasis added)

50.

An applicant must in addition have demonstrated a range of generic medical skills

including team working and communication as well as evidence of competence in the
general practice of orthopaedic and trauma surgery. I accept that the part of the
curriculum on which Mr Nakhla relies gives some support to his case, but in my
judgment it is outweighed by a consideration of the curriculum as a whole.

51.

I conclude therefore that the judge was wrong to hold in such bald terms that:
The FRCS (Trauma and Orthopaedics) is the Article 8 (2)
specialist qualification.

52.

The generic medical skills, according to the 2010 syllabus, will have included
mastering all 14 key procedures to level 4. That level is to be reached in the final two
years of training, and thus the candidate must demonstrate that in those years he is
competent to manage them without assistance.

53.

In my judgment, therefore, the question for the RAP was whether Mr Nakhla, in
addition to his formal qualification of FRCS (T & O), had demonstrated the range of
generic medical skills equivalent to those that would have been required in order to
obtain a CCT. I should stress at this point that the key phrase in article 8 (2) of the
Order is that whatever a candidate relies on it should be equivalent to a CCT.

54.

The word equivalent in this context does not, in my judgment, mean identical.
What it conveys is that the applicants qualifications or training, or both, coupled with
his medical knowledge and experience, are equal in value to the knowledge and skills
that would have been recognised by the award of a CCT. Whether one knowledge and
skill set has equal value to another is in itself a value judgment. Thus I do not consider
that the RAP is required to reject an application merely because an applicant has not
demonstrated that he has done and can still do everything that he would have been
required to do in order to obtain a CCT. To that extent I accept Mr Nakhlas argument
that what matters is the outcome, rather than how the outcome was achieved. The
value judgment that the RAP must make would also accommodate the case of an
experienced specialist who has left more general practice behind him. Otherwise one
would be left with the paradoxical situation that the more experienced a practitioner
was, in a discipline in which more experienced practitioners concentrate on subspecialities, the less chance he had of successfully applying for inclusion on the
Specialist Register. That said, it is essentially a question of medical judgment whether
two different skill sets are equivalent; and in forming that judgment the Registrar (and

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GMC v Nakhla

the RAP) are entitled to place weight on the requirement of the curriculum that
mastery of all 14 key procedures must be demonstrated.
55.

In deciding that Mr Nakhla was not required to demonstrate that he had maintained
his competencies, the judge came to the opposite conclusion to that reached by HH
Judge Gore QC in Dhannapuneni v The General Medical Council, decided in the
Manchester County Court in a judgment given on 14 March 2014, a few weeks before
the judges decision in this case. Because I agree with HH Judge Gores reasoning I
will set it out:
What is material is that both routes are subject to the
additional requirement, hence the word and in the article; and
the additional requirement is that the applicant satisfies the
Registrar that the training and the qualifications, and I quote
and emphasise, are equivalent to a CCT in the specialty. For
two reasons I have come to the conclusion that experience and
maintenance thereof are relevant to that additional requirement
and, therefore that the Panel properly directed itself. First, in
Article 8 (2) the relevant words as I have indicated is are.
Therefore, the training and qualifications, whenever obtained
must now, present tense, be equivalent to a CCT in the
specialty. That present equivalence it seems to me can only be
judged against experience and maintenance thereof. Secondly,
Article 8 (5) directs the Registrar when determining the
adequacy of training and experience for the purposes of Article
8 (2) to take account of experience or knowledge and indeed in
Article 8 (5) (b) it adds wherever obtained. These provisions
again, in my judgment, demand that the Registrar and therefore
the Panel do what the Panel did in this case and therefore look
beyond the training and qualifications and the experience and
its maintenance.

56.

But there are three further points to make about this. At [183] the judge said of article
8 (5) that:
The effect of (5) is that all acquired medical experience or
knowledge is to be taken into account. It is not limited by
geography or age. (Emphasis added)

57.

In my judgment the judge was wrong in thinking that article 8 (5) had anything to do
with the age of medical knowledge or experience. Article 8 (5) deals with experience
or knowledge wherever acquired; not with experience or knowledge whenever
acquired. Its concern is geographical rather than temporal. The second is that the
statutory obligation to take account of such experience or knowledge does not
prescribe the weight that is to be given to it. That must depend on all the
circumstances, and is, in the end, a matter for the specialist judgment of the RAP. I
can see no legal objection to the RAP giving more weight to recent experience than to
historic experience. Third, since the primary function of the GMC is to protect,
promote and maintain the health and safety of the public, it is entirely compatible with
that function to require registered specialists to demonstrate broad up-to-date
knowledge and experience. Medical techniques are in a state of constant development

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GMC v Nakhla

and it is natural to expect that a registered specialist has mastered the latest
techniques. Accordingly in my judgment the judge was wrong to reject the GMCs
case that an applicant should demonstrate that he has maintained skills.
58.

In fact Mr Nakhla did not argue that the maintenance of skills was not required. He
said that if, for example, a candidate had trained as a surgeon but had then gone on a
five year round the world cycling trip he should not be registered on the Specialist
Register without demonstrating that his skills were up to date. His argument was that
the maintenance of skills could be generically achieved, and that by safely and
successfully practicing as a consultant specializing in lower limb procedures he had
demonstrated that his skills were being maintained. Competence meant being capable
of working effectively. It is impractical to require a surgeon to cover the full range of
procedures; and provided that a surgeon maintains competence in his chosen area of
interest, he has done enough.

59.

This was an attractive argument, but I cannot accept it. The fundamental defect in the
argument is that it downplays the central requirement of the 2010 syllabus that a
successful candidate for a CCT must demonstrate mastery of the 14 key procedures.
The purpose of those key procedures, as the curriculum explains, is to demonstrate the
full range of skills that a T & O surgeon needs to possess. The full range of skills is
necessary because the successful holder of a CCT, and hence a newly appointed NHS
consultant, must be able to deal with the majority of unselected trauma cases, rather
than simply demonstrate competence in a sub-specialty. As I have said the acid test is
equivalence. So there may be cases in which the Registrar is able to take the view that
an applicants skill set is equivalent to that of the holder of a CCT even though he
cannot demonstrate continuing mastery of every single one of the 14 key procedures.
That is a question of judgment or, as it is sometimes put, of fact and degree. I
conclude, therefore, that the judge was wrong to hold that:
There is no legal requirement in the curriculum or in the
statute for maintenance of skills to be evidenced.

60.

I also consider that the judge was wrong in her treatment of PBAs. It is clear from the
2010 syllabus that in order to obtain a CCT an applicant must produce PBAs. Section
10-4 of the curriculum describes them as the mainstay of assessment beyond year 2.
It must follow that in order to demonstrate equivalence with what is required for a
CCT an applicant must demonstrate the equivalent of PBAs. The point of the PBA is
to assess quality of performance in particular procedures: not quantity, which is
assessed largely through the log book. For periods before PBAs existed, or in cases
where the experience or training was obtained in countries which do not have the
system of PBAs, PBAs themselves may not be necessary. But an equivalent is.
Otherwise, the consequence of the judges decision is that an applicant may
successfully rely on historic experience with no evidence of how competently he
performed in gaining that experience. On the judges approach the Registrar (and the
RAP) are not entitled to any form of quality control in relation to experience gained
before 2005. That, to my mind, is hardly conducive to protecting, promoting or
maintaining the health and safety of the public. Her conclusion also sits
uncomfortably with her further conclusion that the GMC are entitled to PBAs for
procedures carried out after 2005. I conclude therefore that the judge was wrong to
hold that:

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GMC v Nakhla

The GMC is not entitled to require PBAs or their equivalent

for any period prior to their introduction in this country in
2005. There being no evidence as to what was required in this
country to monitor training prior to the introduction of PBAs,
the GMC is not entitled to require PBAs or equivalent evidence
in relation to any period before 2005.
61.

The final legal error that the judge identified concerned what she perceived to be the
GMCs (and the RAPs) reliance on the absence of PBAs for paediatric work. The
underlying question raised under this head is not whether the GMC and the RAP were
entitled to require PBAs as such, but whether they were entitled to require specific
evidence of up to date skills in paediatric work. The foundation of the argument is that
the 14 key procedures do not include any procedure which is specifically said to be
paediatric. The only specific reference to paediatric work comes in a section of the
curriculum concerned with applied clinical knowledge; and it is accepted by the GMC
that the FRCS (T & O) exam is a test of knowledge across the generality of the
discipline at the level of an NHS consultant.

62.

The first point to make about this is that the judges conclusion about paediatric work
is not a ground of appeal. So if the RAP did rely on the absence of evidence of
continuing competence in paediatric work her decision to remit the appeal to the RAP
should stand. However, Mr Maclean QC, appearing for the GMC, argued that
although the reference to paediatric work was contained in the section of the
curriculum concerned with applied clinical knowledge, the requirement to
demonstrate continuing competence in the 14 key procedures must include
competence in those procedures as applied to children. After all, he submitted, if a T
& O surgeon is required to deal with the aftermath of a serious road traffic accident,
the victims may well be children as well as adults. There is a difficulty with this
argument. There is no evidence before us that the skills and procedures are materially
different when applied to children as opposed to adults. If they are, then it is
surprising that the 14 key procedures do not include any paediatric procedures. But if
they are not, then to require evidence of up to date skills in paediatric work is
unnecessary. Particularly since the judges conclusion on this question is not
specifically challenged in the Appellants Notice, I would not disturb it.

The RAPs decision

63.

The RAP described the scope of the its enquiry at paragraph c of its decision:
To establish equivalence to a CCT an applicant must
demonstrate that they have the necessary knowledge, skills and
experience equivalent to the standards required for a CCT as
outlined in the specialty curriculum in force at the date of the
application.

64.

That, in my judgment, was the correct question. In relation to the evidence of Mr

Nakhlas experience in Egypt the RAP said at paragraph k:
k. Specialty Specific Guidance sets out briefly the standards to
be met and suggested evidence to be provided by an applicant
for CESR. The quality and presentation of evidence is

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GMC v Nakhla

important. It emphasises that it is not sufficient to show what an

applicant had achieved but also how they have performed.
Testimonials and structured reports, without more, do not
provide primary evidence and need to be triangulated with
other substantive evidence such as work place based
assessments a type of which is PBAs.
65.

This statement does not require an applicant to produce PBAs. PBAs are simply one
type of workplace assessment. What the RAP was looking for was evidence of
competence, rather than merely a recitation of what procedures Mr Nakhla had
undertaken. Even in the historic context of what Mr Nakhla had done in Egypt I can
see no fault with this. The RAP continued in paragraph l:
Against that background we have considered the logbooks and
consolidation reports which cover the period of practice in
Egypt. Additionally we have in mind the favourable references
and that the log books disclose a large number of varied
procedures. Work recorded in the log book is authenticated
and is probably more extensive than that required of a UK
trainee but is not supported by any assessment of competence
and as such is no more than evidence that the procedure was
undertaken. The references are in general terms and non case
specific and as such not evidence of competence of the type
required by the 2010 curriculum.

66.

In this paragraph the RAP is considering two types of evidence: first the log books;
and second the references. The log books showed what Mr Nakhla had done in Egypt,
but not how well he had done it. The references were pitched at a level of generality
which did not enable the RAP to form a view about how well Mr Nakhla had
performed any particular procedure. The RAP returned to the question of Mr Nakhlas
experience in Egypt in paragraph u of their decision. They said:
The Panel has had the advantage of advice from a Consultant
in the T & O specialty. That advice is, including the Egypt
experience, the Appellant reached the skill equivalent with the
CCT in hand, paediatric orthopaedics, spine and general trauma
but there is insufficient evidence to show indicate that he has
maintained his experience in spine, child orthopaedics and
hand. General trauma experience is maintained. That advice
differs from the view of Professor Frostick who does not
consider the Egypt experience as sufficiently triangulated to
enable him to come to a favourable conclusion on the hand,
spine and paediatric orthopaedics. Without evidence of
outcomes, ages and sex of patient, level of supervision of the
Egypt experience is no more than reciting numbers. The
evidence in the form provided is insufficient to be given
meaningful weight in assessing training/competence in the
2010 curriculum.

67.

It is notable that Prof Frosticks view coincides with the RAPs own view expressed in
paragraph l: namely that the Egyptian material provides no evidence of competence.

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GMC v Nakhla

Given the coincidence of evaluation of that evidence I do not find it surprising that the
RAP preferred Prof Frosticks evidence on that point to that of the Consultant, Mr
Kamath.
68.

Turning to Mr Nakhlas experience in the UK between May 2006 and July 2009 the
RAP noted in paragraph m that there was no evidence of paediatric orthopaedic
work. In the following paragraph they dealt with his experience between May and
November 2010, and again noted that there was minimal paediatric orthopaedics;
and at paragraph u they noted the evidence of both their specialist adviser and Prof
Frostick that there was insufficient evidence to indicate that he has maintained his
experience in child orthopaedics This was one of three areas in which Mr
Nakhla was found to be deficient, and formed part of the RAPs final conclusion in
paragraph x. If, as I think, the RAP were in error in concentrating on paediatric
orthopaedics (or at least in error in failing to explain why they regarded that
deficiency as material given that paediatric orthopaedics were not the subject of any
of the 14 key procedures) I consider that their determination cannot stand.

69.

The RAP concluded in paragraph w:

We do not consider that the Egypt experience, insufficiently
triangulated as it is, demonstrates a training equivalence to the
2010 curriculum. In any event that experience is at its latest in
2005.

70.

In this paragraph the RAP is making two points. The first is that Mr Nakhla had not
demonstrated a training experience equivalent to the 2010 curriculum. The second is
that, even if he had, that training was all carried out before 2005. Failure on the first
point alone would have been fatal to Mr Nakhlas application. The second point
relates to the maintenance of skills and on that point both experts were agreed that Mr
Nakhla had not maintained his experience in spine, child orthopaedics and hand.
Since, for the reasons I have given, I consider that (with the exception of paediatric
orthopaedics) the RAP were entitled to look for evidence that Mr Nakhla had
maintained his competencies, there is no error in this reasoning. Moreover I consider
that the RAP are entitled to place greater weight on recent experience than more
historic experience.

71.

The judge said at [207] that she was surprised that the RAP attached such weight to
Prof Frosticks evidence when he was careless in writing his witness statement and
his detailed knowledge was deficient in ways that the judge identified. She went on
to say:
I hold that the fact that the [RAP] attached such weight to his
evidence establishes unequivocally that they failed properly to
analyse his evidence and were wrong to attach such weight to
it.

72.

I do not consider that the judge was justified in making this criticism. First, it is for
the primary fact finding tribunal to evaluate the evidence and, especially when the
primary tribunal has seen the witnesses, an appeal court should be very slow to
intervene. Second, there is no reason to suppose that the RAP overlooked deficiencies
in Prof Frosticks evidence. A witnesss evidence may well be deficient in many

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GMC v Nakhla

respects yet be accurate on one or more critical points. Third, the evidence that Prof
Frostick gave was expert evidence evaluated by an expert tribunal, which should give
an appeal court even more cause to refrain from interfering. Fourth, the crucial point
on which the RAP accepted Prof Frosticks evidence was, in effect, corroborative of
the view that they themselves had independently formed about the quality of the
evidence of Mr Nakhlas Egypt experience. Overall I am concerned that what the
judge appears to have done is to retry the case on the papers. That is not what an
appeal court should do.
The cross-appeal
73.

Mr Nakhla also applied for permission to cross-appeal. We refused him permission to

appeal against the judges refusal to award him damages; but allowed him to argue in
favour of an order directing the Registrar to enter him on the Specialist Register rather
than remitting the matter to the RAP. I do not consider that this is a case in which the
court can be confident that there is only one realistic outcome. Mr Nakhla says that he
has complied with the informal recommendation of the RAP and he now has a batch
of PBAs which demonstrate a broader range of skills than those which were placed
before the RAP. It will be for the RAP to decide whether, in the light of our judgments
and the new material that Mr Nakhla has presented, he has demonstrated the
equivalent of a CCT.

Result
74.

In my judgment, with the exception of the point about paediatric orthopaedics, the
legal errors that the judge identified were not errors at all. Subject to that point the
RAP correctly directed themselves in law. Their evaluation of the evidence before
them was one which an appeal court should respect; and in particular they were
entitled to accept the evidence of Prof Frostick, which coincided with their own
independent evaluation of the evidence produced by Mr Nakhla. I do, however, have a
concern that they may have adopted too mechanistic an approach to testing the
equivalence of Mr Nakhlas knowledge and skills when measured against the
requirements of the CCT curriculum. Moreover, their apparent requirement that Mr
Nakhla should produce contemporaneous evidence of assessment of work done in
Egypt before May 2006 (which is practically impossible at this remove) displays a
rigidity of approach which, if regarded as a fatal defect in his application, would come
close to failing to resolve the paradox, mentioned in paragraph [54] above, that the
more experienced (and indeed distinguished) an applicant from abroad is, the more
difficult will it be for him to obtain a CESR.

75.

I would allow the appeal in part. I would set aside paragraphs 4 and 5 of the judges
order, which contains the legal guidance that she laid down. I would not set aside
paragraph 1 of her order which remitted Mr Nakhlas appeal to the RAP to enable
them to re-determine Mr Nakhlas application in the light of the more recent PBAs he
says he has obtained, and on the correct understanding of any necessary paediatric
experience. I see no reason why the remitted appeal should not be determined by the
same panel as before, if that is convenient and they are available. Nor do I see any
difficulty with it being determined by a different panel. I do not agree with the judge
that it must be determined by a different panel. Accordingly, I would set aside
paragraph 2 of her order as well.

Judgment Approved by the court for handing down.

76.

GMC v Nakhla

Finally, I would like to congratulate Mr Nakhla on the attractive, persuasive and

measured way in which he presented his case; and his undoubted mastery of the
papers. His presentation would have done credit to an experienced member of the Bar.
The transcript of the hearing before the RAP shows that he has formidable crossexamination skills as well. If he ever gives up surgery, a promising alternative career
lies ahead of him.

Lord Justice Burnett:

77.

I agree.

Lord Justice Longmore:

78.

I agree with Lewison LJ and the form of order he proposes. I would only desire to
echo the sentiments in his last paragraph. It was a pleasure to listen to submissions of
such high quality.