WPBA: Detailed guidance for each CAT type

Please read the Care Assessment Tool (CAT) general guidance ahead of the information below. 

Preparation in advance

Registrar

• Undertake a Routine session in practice and provide details of the session in advance of the CAT.

Supervisor guidance

• Review the information available on the clinical system and other IT systems (e.g. Accurx, AskMyGP)

Undertaking CAT

• Review a selection of the patient contacts during the session - encourage reflection on learning:
  • Was the method of consultation appropriate e.g. telephone, face to face, visit?
  • Is there evidence of appropriate data gathering, clinical examinations and procedural skills, clinical management and diagnosis and decisions?
  • Were any referrals made to other services? If yes, were they appropriate? What other options were available?
  • Review prescribing during the consultation
  • Comment on the quality of the registrar’s records.
• Discuss and encourage reflection on other activities undertaken during the day:
  • Prescription requests
  • Blood results
  • Review of hospital letters/other scanned documents
  • Practice meetings/other meetings
  • Informal discussion with colleagues
  • Contact with Secondary Care or other organisations.
• Discussion and reflection on time management
• Once the capability areas chosen have been discussed, give feedback and suggest areas for improvement and what they should work on, or demonstrate, in future learning events.

Capability areas suggested

Ahead of the assessment, review the Capability descriptors and suggested questions (if appropriate) to become familiar with what needs to be demonstrated for the various grades. Specific feedback for each Capability is required with agreed plans for each following the discussion.

See CAT question generator (PDF file, 533 KB) for suggested questions surrounding each capability area for discussing clinical cases

Select the Capability areas that have been demonstrated during this discussion. 

A wide variety of capability areas can be demonstrated during this CAT, in particular;

Fitness to practise

• Demonstrates the accepted codes of practice in order to promote patient safety and effective team-working.
• Works within the limits of their own ability and expertise as a GP.

An ethical approach

• Applies “Good Medical Practice” in their own clinical practice.
• Reflects on how their values, attitudes and ethics might influence professional behaviour.
• Identifies and discusses ethical conflicts arising within their roles as a clinician, patient advocate and leader in the health service.
• Relates to people as individuals and challenges attitudes that dehumanise or stereotype others.

Communicating and consulting 

• Uses the most appropriate mode of consultation including in-person and remote, taking account of individual patient needs, preferences and safety. 
• Manages consultations effectively with patients who have communication needs, different languages, cultures, beliefs or educational backgrounds.
• Demonstrates a constructive and flexible approach to consulting.

Data gathering and interpretation

• Understands the importance of, and makes appropriate use of, existing information about the problem and the patient’s context. 
• Demonstrates different styles of data gathering and adapts these to the wide range of patients and situations. 
• Chooses examinations and targets investigations appropriately and efficiently. 
• Understands the significance and implications of findings and results and takes appropriate action.

Clinical examination and procedural skills

• Conducts examinations targeted to the patient’s problems
• Interprets physical signs accurately
• Varies procedure options according to the circumstances and the preferences of the patient
• Identifies and reflects on ethical issues with regard to examination and procedural skills.
• Shows awareness of the medico-legal background, informed consent, mental capacity and the best interest of the patient.

Decision-making and diagnosis

• Demonstrates confidence in, and takes ownership of, own decisions whilst being aware of their own limitations.
• Demonstrates rapid and safe decision-making when managing urgent clinical situations and when it is appropriate to defer an action. 
• Keeps an open mind and is able to adjust and revise decisions and diagnoses when considering new relevant information. 
• Uses an understanding of probability based on prevalence, incidence, and natural history of illness to aid decision-making.

Clinical management

• Adapts the clinical approach to provide comprehensive care to patients who have individual perspectives and health and care needs. 
• Co-ordinates care for patients of all backgrounds, ages and life stages. 
• Varies management options responsively according to the circumstances, priorities and preferences of those involved. 
• Considers a “wait and see” approach where appropriate. 
• Prescribes safely and applies local and national guidelines including drug and non-drug therapies. 
• Reviews the patient’s medication in terms of evidence-based prescribing, cost effectiveness and patient understanding. 
• Refers appropriately, taking into account all available resources. 
• Organises follow-up of patients through multiprofessional, team-based and structured approaches. 
• Responds rapidly and skilfully to emergencies with appropriate follow-up for the patient and their family. 
• Co-ordinates care both within the practice team and with other services.

Medical complexity

• Actively facilitates continuity of care for patients with complex needs.
• Demonstrates a reasoned approach to simultaneously managing multiple health problems.
• Manages uncertainty and communicates risk effectively.
• Recognises the limitations of protocols in making decisions and explores ways of dealing with these situations with the patient and carers, consulting with colleagues when appropriate.
• Actively facilitates continuity of care for patients with complex needs, either personally or across teams.

Team working

• Is an effective team member, working flexibly with the various teams involved in day-to-day primary care.
• Understands the context within which different team members are working.
• Appreciates the increased efficacy in delivering patient care when teams work collaboratively rather than as individuals.
• Communicates proactively with team members so that patient care is enhanced using an appropriate mode of communication for the circumstances.
• Anticipates and manages the problems that arise at the interfaces between different healthcare professionals, services and organisations.
• Supports the transition of patient care between professionals and teams.

Performance, learning and teaching

• Judges the weight of evidence, using critical appraisal skills to inform decision-making.
• Participates in the evaluation and personal development of other team members including providing feedback.

Organisation, management and leadership

• Applies the principles of generalism, including providing patient-centred care that considers external influences e.g. population health, environmental factors and health inequalities.
• Understands the impact of broader organisational influences and pressures.
• Organises self effectively with due consideration for patients and colleagues.
• Demonstrates effective time management, hand-over skills, prioritisation, delegation and leadership.
• Responds proactively and supportively when services are under pressure in a considered way.
• Reports, records and shares safety incidents effectively.
• Uses the primary care organisational and IT systems routinely and effectively in patient care.
• Produces records that are accurate, comprehensive, concise, appropriately coded and understandable.

Holistic practice, health promotion and safeguarding

• Recognises what matters to the patient and works collaboratively to enhance patient care.
• Utilises appropriate support agencies tailored to the needs of the patient and / or their family and carers.
• Demonstrates the skills and assertiveness to challenge unhelpful health beliefs or behaviours, whilst remaining compassionate, non-judgemental and maintaining a continuing and productive relationship.
• Seeks to identify those who are vulnerable and seeks to reduce the risk of abuse, neglect or other forms of harm.
• Demonstrates appropriate responses to adult and child safeguarding concerns including ensuring information is shared and referrals made appropriately.

Community health and environmental sustainability

• Demonstrates the breadth of GP roles across the system e.g. patient advocate, family practitioner, generalist, “gate-keeper”.
• Balances the needs of the individual patient, health needs of the local communities and available resources when making referral(s)
• Undertakes safe and cost-effective prescribing.
• Follows protocols with appropriate flexibility incorporating the patient’s preferences.
• Makes efforts to practise healthcare in an environmentally sustainable way.
• Applies an understanding of how the characteristics of the local population shape the provision of care.
• Considers the environmental, social and economic sustainability of the health service – e.g. changes to prescribing and considering carbon foot-printing.

Recording in the Portfolio

Supervisor guidance:

• Describe for each Capability
  • how the registrar performed using the Capability descriptors and specific aspects of the cases discussed
  • recommendations for further development based on the capability descriptors
• Describe the agreed actions discussed.

Please read the Care Assessment Tool (CAT) general guidance ahead of the information below. 

Preparation in advance

Collate a range of documents that you have processed in the last 2 weeks. (10 should be sufficient).

Undertaking CAT

Supervisor’s Guidance:

• Review with the registrar the selection of the documents they have presented and encourage them to critique the way they have been processed. 
• Has the appropriate information for coding been highlighted?
• Was prescribing including repeat prescribing undertaken if appropriate?
• Was appropriate follow-up arranged if required?
• Was anything missed?

Capability areas suggested

See CAT question generator (PDF file, 533 KB) for suggested questions surrounding each capability area for discussing clinical cases 

Clinical management

• Has any prescribing required been undertaken safely?  Have they applied any local and national guidelines including drug and non-drug therapies? Maps to:
  • Prescribes safely and applies local and national guidelines, including drug and non-drug therapies
• Has there been any review of the patient’s medication following the communication? Maps to:
  • Reviews the patient’s medication in terms of evidence-based prescribing, cost-effectiveness and patient understanding
• Has any required follow up been arranged whilst also enhancing patient autonomy? Maps to:
  • Provides comprehensive continuity of care, taking into account the patient’s problems and their social situation.
  • Adapts the clinical approach to provide comprehensive care to patients who have individual perspectives and health and care needs.
  • Coordinates care for patients of all backgrounds, ages and life stages.

Organisation management and leadership

• Have the correct codes been identified to be added to the patient records? Maps to:
  • Uses the primary care organisational and IT systems routinely and effectively in patient care.
  • Produces records that are accurate, comprehensive, concise, appropriately coded and understandable
• Was the document managed in an appropriate timescale with delegation of workload if needed? Maps to:
  • Demonstrates effective time management, handover skills, prioritisation, delegation and leadership.

Community health and environmental sustainability

• Has the information from the letters taken into consideration local prescribing policies? If appropriate have wider teams or local resources been used? Maps to:
  • Reflects on the requirement to balance the needs of individual patients, the health needs of the local community and the available resources.
  • Demonstrates understanding of how the characteristics of the local population shapes the provision of care in the setting in which the doctor is working.
  • Considers local and national protocols.
• Has the information from the letters taken into consideration prescribing from an environmental viewpoint? Maps to:
  • Makes efforts to practise healthcare in an environmentally sustainable way.
  • Considers the environmental, social and economic sustainability of the health service, for example changes to prescribing and considering the carbon footprint.
• Has appropriate follow up arrangements considered the environmental impact of decisions made? Consider if face to face follow up is required. Maps to:
  • Makes efforts to practise healthcare in an environmentally sustainable way.

Team working

• Has appropriate follow up been arranged if required? Maps to:
  • Supports the transition of patient care between professionals and teams.
  • Appreciates the increased efficacy in delivering patient care when teams work collaboratively rather than as individuals.
• Has there been communication with other primary care team members if appropriate? Maps to:
  • Communicates proactively with team members so that patient care is enhanced, using an appropriate mode of communication for the circumstances.
  • Uses the skills of the wider team to enhance patient care. 

Recording in the Portfolio

Supervisor guidance:

• Describe for each Capability.
  • how the GP registrars performed using the Capability descriptors and specific aspects of the cases discussed.
  • recommendations for further development based on the capability descriptors.
• Describe the agreed actions discussed.

Please read the Care Assessment Tool (CAT) general guidance ahead of the information below. 

Preparation in advance

Registrars

• Undertake a Duty Doctor Session and provide details of the session in advance of the CAT

Supervisor guidance

• Review the information available on the clinical system and other IT systems (e.g. Accurx, AskMyGP)

Undertaking CAT

• Review a selection of the patient contacts during the session – looking at a variety of methods - encourage the registrar to reflect
  • Was the method of consultation appropriate e.g. e-consult, telephone, face to face, visit
  • Is there evidence of appropriate data gathering, clinical examinations and procedural skills, clinical management and diagnosis and decisions?
  • Where any referrals made to other services, were they appropriate, what other options were available?
  • Was there appropriate delegation to members of the Primary Care team?
  • Comment on the quality of the registrar's records.
• Discuss and encourage reflection on other activities undertaken during the session, such as:
  • Prescription requests
  • Urgent/abnormal blood results
  • OOH/111 Reports
  • Review of hospital letters
  • Contact with other members of the practice
  • Contact with other members of the Primary Care Workforce
  • Contact with Secondary Care or other organisations
  • Supervision of other members of the practice team e.g. nurses, HCAs
  • Discussion and reflection on time management and prioritisation

Capability areas suggested

Ahead of the assessment, review the Capability descriptors and suggested questions (if appropriate) to become familiar with what the registrar needs to demonstrate for the various grades. Specific feedback for each Capability is required with agreed plans for each following the discussion.

See CAT question generator (PDF file, 533 KB) for suggested questions surrounding each capability area for discussing clinical cases

Select the Capability areas the registrar has demonstrated during this discussion.

A wide variety of capability areas can be demonstrated during this CAT, in particular:

Organisation, management and leadership

• Demonstrates effective time management, hand-over skills, prioritisation, delegation and leadership.
• Uses the primary care organisational and IT systems routinely and effectively in patient care.
• Responds proactively and supportively when services are under pressure in a responsible and considered way.

Team working

• Is an effective team member, working flexibly with the various teams involved in day-to-day primary care.
• Communicates proactively with team members so that patient care is enhanced using an appropriate mode of communication for the circumstances.
• Anticipates and manages the problems that arise at the interfaces between different healthcare professionals, services, and organisations.

Clinical management

• Suggests a variety of follow-up arrangements that are safe and appropriate.
• Responds rapidly and skilfully to emergencies, with appropriate follow- up for the patient and their family.
• Co-ordinates care both within the practice team and with other services.

Other capabilities that could be covered include: 

An ethical approach

• Reflects on how their values, attitudes and ethics might influence professional behaviour.
• Identifies and discusses ethical conflicts arising within their roles as a clinician, patient advocate and leader in the health service.

Communicating and consulting

• Works in partnership with the patient, agreeing a shared plan that respects the patient’s priorities and preference for involvement.
• Consults in an organised and structured way, achieving the main tasks of the consultation in a timely manner.

Data gathering and interpretation

• Understands the importance of, and makes appropriate use of, existing information about the problem and the patient’s context.
• Understands the significance and implications of findings and results, and takes appropriate action.

Clinical examination and procedural skills 

• Conducts examinations targeted to the patient's problems.
• Identifies and reflects on ethical issues with regard to examination and procedural skills. 

  Shows awareness of the medico-legal background, informed consent, mental capacity, and the best interests of the patient.

Decision-making and diagnosis  

• Demonstrates confidence in, and takes ownership of, own decisions whilst being aware of their own limitations.
• Demonstrates rapid and safe decision-making when managing urgent clinical situations and when it is appropriate to defer an action.
• Addresses problems that present early and/or in an undifferentiated way by integrating all the available information to help generate a differential diagnosis.

Recording in the Portfolio

Supervisor guidance

• Describe for each Capability
  • how the registrar performed using the Capability descriptors and specific aspects of the cases discussed
  • recommendations for further development based on the capability descriptors
• Describe the agreed actions discussed.

Please read the Care Assessment Tool (CAT) general guidance ahead of the information below.

Preparation in advance

Registrar

• Gather a sample of online/digital/electronic consultations you have dealt with over the training year. This exercise should take a minimum of around thirty minutes.

Supervisor guidance

• Look through and familiarise themselves with the Online/digital/electronic Consultations the registrar has supplied.

Undertaking CAT

• Encourage the registrar to critique their work.
• Discuss the content commenting on what is good and what could be improved.
• Is there evidence in the Online/digital/electronic Consultations and response from the registrar of appropriate data gathering, clinical examinations and procedural skills, clinical management and diagnosis and decisions?
• Comment on the quality of the registrar’s records.
• Discuss the appropriateness and effectiveness of how the Online/digital/electronic Consultation was managed. What other options were available?
• What does the registrar feel, in retrospect, about each Online/digital/electronic Consultation?
• What feedback would you give the registrar in general about their handling of the Online/digital/electronic Consultations?
• Were patients brought in appropriately if necessary?
• Has the Online/digital/electronic Consultation review demonstrated that the registrar is being exposed to the full range of patient groups in general practice and a broad range of clinical experience groups?
• How might the registrar develop experience in populations or specialties in which there does not appear to have been sufficient exposure?
• Each assessment should last a minimum of 30 minutes with subsequent debrief time. The assessments are recommended to be completed within a protected tutorial.  

Supervisor guidance

• Ahead of the assessment, review the Capability descriptors and suggested questions (if appropriate) to become familiar with what the registrar needs to demonstrate for the various grades. Specific feedback for each Capability is required with agreed plans for each following the discussion. 
• Select the Capability areas the registrar has demonstrated during this discussion. (Please see list below for suggestions of what is likely to be covered by the Online/digital/electronic Consultation CAT).
• Give feedback on what they did well and what they should work on to improve or demonstrate in future learning events.

Capability areas suggested

See CAT question generator (PDF file, 533 KB) for suggested questions surrounding each capability area for discussing clinical cases

Fitness to practice

• Works within the limits of their own ability and expertise as a GP – this might include making appropriate decisions about whether they can manage the problem using this online/digital/electronic format, or whether to bring the patient in.

An ethical approach

• Identifies and discusses ethical conflicts arising within their roles as a clinician
• An example of this might be online / electronic consultation with someone other than the patient.
• Actively promotes equality of opportunity for patients to access healthcare

Communicating and consulting

• Uses the most appropriate mode of consultation taking into account individual patient needs, preferences and safety
• Uses written language that the considers the needs and characteristics of the patient.
• Manages consultations effectively with patients who have communication needs such as different languages or educational backgrounds.

Clinical management

• The online / digital / electronic consultation was triaged and managed appropriately including decisions about whether to bring the patient in for a face-to-face consultation.
• Adapts the clinical approach to incorporate the patient’s stated perspectives and needs.
• Considers a “wait and see” approach where appropriate.
• Uses effective prioritisation of problems when the patient presents multiple issues.
• Offers follow-up arrangements that are safe and appropriate.
• Prescribes safely and applies local and national guidelines including drug and non-drug therapies.

Medical complexity

• Where multiple problems are presented in an Online/digital/electronic consultation, have these been managed appropriately?
• Continually encourages improvement and rehabilitation and, where appropriate, recovery.
• Actively facilitates continuity of care for patients with complex needs – this might include making follow-up arrangements with the most appropriate healthcare professional.
• Manages uncertainty and communicates risk effectively in the written form.

Organisation, management and leadership

• Demonstrates effective time management, hand-over skills, prioritisation, delegation and leadership.
• Responds proactively and supportively when services are under pressure in a responsible and considered way.
• Uses the primary care organisational and IT systems effectively in patient care.
• Produces records that are accurate, comprehensive, concise and understandable. This includes saving all relevant electronic communications appropriately with the patient records.

Holistic practice, health promotion and safeguarding

• Utilises appropriate support agencies tailored to the needs of the patient.
• Demonstrates the skills and assertiveness to challenge unhelpful health beliefs whilst remaining professional, compassionate and non-judgmental, and maintaining a continuing and productive relationship.
• Facilitates health improvement and supports self-management during illness and recovery.
• Is able to identify those who are vulnerable and seeks to reduce risks of abuse, neglect or other forms of harm.
• Demonstrates appropriate responses to adult and child safeguarding concerns.

Community health and environmental sustainability

• Balances the needs of the individual patient, health needs of the local communities and available resources.

Recording in the Portfolio

Supervisor guidance

• Describe for each Capability
  • how the registrar performed using the Capability descriptors and specific aspects of the cases discussed
  • recommendations for further development based on the capability descriptors
• Describe the agreed actions discussed.

Please read the Care Assessment Tool (CAT) general guidance ahead of the information below. 

The purpose for this CAT is to make an assessment of the registrar’s decisions on the laboratory and radiology results they are responsible for interpreting and completing any action points for. 

Preparation in advance

Registrar

• Select a random sample of approximately 15 laboratory and radiology results that you have recently received and managed.
• Consider and state which are the main Clinical Experience Groups represented by the laboratory and radiology results.
• Prepare to discuss how you interpreted the investigation results and completed any action points for them, and how you met the Capability descriptors.

Supervisor / trainer

Arrange a mutually convenient time with the registrar, ensuring that the registrar has already received guidance at the practice on how to manage laboratory and radiology results

Undertaking CAT

Supervisor guidance

• The review of the registrar’s decisions on the laboratory and radiology results they manage can be approached through different contexts:
  • Laboratory and radiology results that the registrar has requested themselves
  • Results that they are responsible for managing though they have not requested the investigations themselves: for example during a ‘duty day’ or managing a particular long-term illness patient cohort
• The registrar briefly describes the data gathering that took place prior to interpreting the investigation result
• If the registrar requested the investigation, the supervisor enquires the rationale for requesting the investigation (for example if it helped to rule-in or rule-out a diagnosis; how it helped to formulate a management plan)
• The registrar explains the rationale for their interpretation of the investigation report, and the decision they took for subsequent actions
• The supervisor offers a supportive challenge to the decision where appropriate (for example, if repeating the investigation would facilitate a management plan, or if it may be unnecessary)
• Consider how long it took for the registrar to arrive at their decision and complete any action points.

Capability areas suggested

See CAT question generator (PDF file, 533 KB) for suggested questions surrounding each capability area for discussing clinical cases

Depending on the context of the dialogue during this CAT, any of the following Capability areas may be appropriate to assess:

Fitness to practise

• Demonstrates the accepted codes of practice in order to promote patient safety and effective team-working
• Reacts promptly, respectfully and impartially when there are concerns about self or colleagues
• Works within the limits of their own ability and expertise as a GP
• Adopts a self-directed approach to learning, engaging with assessment.
• Encourages scrutiny of professional behaviour, is open to feedback and demonstrates a willingness to change.
• Takes advice from appropriate people
• Uses mechanisms to reflect on and learn from complaints or performance issues to improve patient care

An ethical approach

• Applies “Good Medical Practice” in their own clinical practice.
• actively promotes equality of opportunity for patients to access healthcare, ensuring fairness and respect in their day-to-day practice.
• Identifies and discusses ethical conflicts arising within their roles as a clinician, patient advocate and leader in the health service
• Responds to complaints in a timely and appropriate manner, recognising their duty of candor.

Data gathering and interpretation

• Chooses examinations and targets investigations appropriately and efficiently
• Understands the importance of, and makes appropriate use of, existing information about the problem and the patient’s context
• Understands the significance and implications of findings and results, and takes appropriate action
• Uses a stepwise approach, basing further enquiries, examinations and tests on what is already known and what is later discovered

Decision-making and diagnosis

• Makes diagnoses in a structured way using a problem-solving method
• Demonstrates confidence in, and takes ownership of, own decisions whilst being aware of their own limitations
• Demonstrates rapid and safe decision-making when managing urgent clinical situations
• Keeps an open mind and is able to adjust and revise decisions and diagnoses when considering new relevant information
• Uses an understanding of probability based on prevalence, incidence and natural history of illness to aid decision-making

Clinical management

• Responds rapidly and skilfully to emergencies, with appropriate follow- up for the patient and their family. Ensures that care is co-ordinated both within the practice team and with other services.
• Considers a “wait and see” approach where appropriate
• Organises follow up of patients through multiprofessional, team-based and structured approaches

Medical complexity

• Demonstrates a reasoned approach to simultaneously managing multiple health problems
• Actively facilitates continuity of care for patients with complex needs, either personally or across teams

Team working

• Organisation, management and leadership
• Organises self effectively with due consideration for patients and colleagues.
• Demonstrates effective time management, hand-over skills, prioritisation, delegation and leadership
• Responds positively when services are under pressure in a responsible and considered way
• Reports, records and shares safety incidents effectively
• Uses the primary care organisational systems and IT systems routinely and effectively in patient care

Holistic practice, health promotion and safeguarding

• Understands the patient in relation to their socio-economic and cultural background
• Utilises appropriate support agencies  tailored  to the needs of the patient and/or their family and carers

Community health and environmental sustainability

• Balances the needs of the individual patient, health needs of local communities and available resources when making referral(s)
• Considers the environmental, social and economic sustainability of the health service

Recording in the Portfolio

Supervisor guidance

• Describe for each Capability
  • how the registrar performed using the Capability descriptors and specific aspects of the cases discussed
  • recommendations for further development based on the capability descriptors
• Describe the agreed actions discussed.

Please read the Care Assessment Tool (CAT) general guidance ahead of the information below. 

The Leadership CAT may be a follow-up to the Leadership Activity and Leadership MSF and can focus on areas that have been identified for development.

The Leadership CAT may also focus on additional leadership activities that have taken place, either within the Practice or in other settings, such as PCNs, ICBs/Health Boards and the Half Day Release. This may be particularly relevant in the past 2-3 months prior to CCT.

Preparation in advance

Registrar

• Review and reflect on the Leadership Activity and Leadership MSF and the areas that have been identified for development

OR

• Undertake a further leadership activity or other leadership development

AND

• Upload a learning log entry in the portfolio
• Be prepared to discuss and reflect on performance against the capabilities

Supervisor guidance:

Review the learning log entry on the portfolio

Prepare questions that test the capability areas, specifically including Organisation, Management and Leadership 

Undertaking CAT

• Discuss the reflection on the identified areas of development or the new leadership Activity that has been undertaken.
• Explore the learning and development achieved as a result.
• Discuss and reflect on the areas that have been done well and areas for further improvement.
• Discuss plans for further leadership development, within the training programme and post-CCT, if appropriate

Capability areas suggested

Ahead of the assessment, review the Capability descriptors and suggested questions (if appropriate) to become familiar with what the registrar needs to demonstrate for the various grades. Specific feedback for each Capability is required with agreed plans for each following the discussion.

Select the Capability areas the registrar has demonstrated during this discussion. 

See CAT question generator (PDF file, 633 KB) for suggested questions surrounding each capability area for discussing clinical cases

Organisation, management and leadership should be covered in all Leadership CATs

Organisation, management and leadership

• Organises self effectively with due consideration for patients and colleagues.
• Leads on and supports change in the organisation, involving and working with the team to deliver defined outcomes. 
• Recognises responsibility in advocating for self and colleagues through freedom to speak up
• Uses the primary care organisational and IT systems routinely and effectively in patient care.

Other capability areas can be demonstrated during the CAT, in particular

Team working

• Communicates proactively with team members so that patient care is enhanced using an appropriate mode of communication for the circumstances.
• Contributes positively to teams and reflects on how they work, and the members interact.
• Fosters a positive attitude to the opportunity and potential of a diverse team.
• Uses the skills of the wider team to enhance patient care.
• Appreciates the increased efficacy in delivering patient care when teams work collaboratively rather than as individuals.

Performance, learning and teaching

• Shows a commitment to professional development through reflection on performance and the identification of personal learning needs.
• Addresses learning needs using targeted personal development plans and demonstrates integration into future professional practice.
• Participates in quality improvement activities and uses these to evaluate and suggest improvements in personal and practice performance, sharing their learning.

Fitness to practice

• Demonstrates the accepted codes of practice to promote patient safety and effective team-working.
• Encourages scrutiny of professional behaviour, is open to feedback and demonstrates a willingness to change.
• Achieves a balance between professional and personal demands enabling work commitments to be met and maintaining their own health.

An ethical approach

• Relates to people as individuals and challenges attitudes that de-humanise or stereotype others
• Actively promotes a culture of inclusion where everyone is welcome in general practice, regardless of background or any protected characteristics.

Recording in the Portfolio

Supervisor guidance

• Describe for each Capability
  • how the registrar performed using the Capability descriptors and specific aspects of the cases discussed
  • recommendations for further development based on the capability descriptors
• Describe the agreed actions discussed.

Please read the Care Assessment Tool (CAT) general guidance ahead of the information below.

This is a follow-up to the full prescribing assessment and should focus on the areas for development detailed in the prescribing assessment and how you (the registrar) have progressed with these. This may involve finding and analysing prescriptions done for specific Clinical Experience Groups, for example, children, end of life, controlled drugs use, advice re over the counter (OTC) medications, particular specialty drugs e.g. for COPD, or contraception.

Preparation in advance

Registrar

• Review your prescribing assessment and agreed actions. In particular you need to ensure that any of the prescribing proficiencies which you did not cover in your assessment have now been met.
  • You will need to upload any further results in the Portfolio learning log.
  • You will need to reflect on your performance against the prescribing proficiencies.
  • Your supervisor will review your evidence and discuss this with you.

Undertaking CAT

Supervisor guidance

• Review and discuss the registrar’s further evidence in the Portfolio and evidence from random case reviews and debriefs.
  • Review the prescribing assessment action plan and PDP entry progress.
  • Discuss areas done well and areas for improvement.
  • Together agree plans for further improving the registrar’s prescribing or increasing their exposure to patient groups to meet the prescribing proficiencies.
  • Discuss how this has provided evidence for the prescribing proficiencies as described in the feedback and recommendations.
  • Discuss hypothetical situations where issues have not been covered such as prescribing unlicensed drugs, drug interactions, over the counter (OTC) medication, allergies and monitoring requirements.
  • Discuss potential drug interactions and how these affected actions
  • Discuss stepping down or stopping any prescribing and how these were managed
  • Discuss the environmental impact of prescriptions and any impact on sustainability they did or could have taken
  • Discuss the use of prescribing guidance either electronic or written and any impact that had on their decisions

Capability areas suggested

See CAT question generator (PDF file, 533 KB) for suggested questions surrounding each capability area for discussing clinical cases

Decision-making and diagnosis

• Demonstrates confidence in, and takes ownership of, own decisions whilst being aware of their own limitations.
• If able to justify why prescribed the medication they did and evidence to support or decision not to prescribe unfamiliar medication.

Clinical management

• Prescribes safely and applies local and national guidelines including drug and non-drug therapies.
• Reviews the patient’s medication in terms of evidence- based prescribing, cost effectiveness and patient understanding.

Managing medical complexity

• Encourages the patient to participate in appropriate health promotion and disease prevention strategies.
  • For example prescribing statins, optimising blood pressure control
• Manages uncertainty and communicates risk effectively.
  • When explaining benefits and potential side effects of medications
• Demonstrates a reasoned approach to simultaneously managing multiple health problems.
  • For example by taking into account comorbidities, existing medication and allergies
• Manages patients with multiple problems with reference to appropriate guidelines for each condition.

Organisation, management and leadership.

• Produces records that are accurate, comprehensive, concise, appropriately coded, and understandable.

Holistic practice, health promotion and safeguarding.

• Demonstrates the skills and assertiveness to challenge unhelpful health beliefs or behaviours, whilst remaining compassionate, non-judgemental, and maintaining a continuing and productive relationship.
  • For example, with drug seeking behaviour, dependence, addiction etc.

Community health and environmental sustainability.

• Undertakes safe and cost-effective prescribing.
• Follows protocols with appropriate flexibility incorporating the patient’s preference.
• Makes efforts to practise healthcare in an environmentally sustainable way.
• Considers the environmental, social, and economic sustainability of the health service e.g., changes to prescribing and considering carbon foot-printing

Performance, learning and teaching.

• Shows a commitment to professional development through reflection on performance and the identification of personal learning needs.
• Systematically evaluates performance and learning against external standards, using this information to inform their learning.
• Participates in quality improvement activities and uses these to evaluate and suggest improvements in personal and practice performance, sharing their learning.
  • If related to prescribing reviews/audits
• Measures and monitors the outcomes of care to ensure the safety and effectiveness of the services provided.

Fitness to practice

• Works within the limits of their own ability and expertise as a GP
  • For example, if demonstrating only prescribing medication that is within their scope of experience and knowledge
• Encourages scrutiny of professional behaviour, is open to feedback and demonstrates a willingness to change.
  • Positively receiving feedback and making plans to adjust behaviour or demonstrating taken on board feedback from initial assessment and demonstrating change behaviour

Recording in the Portfolio

Supervisor guidance

• Describe for each Capability
  • how the registrar performed using the Capability descriptors and specific aspects of the cases discussed
  • recommendations for further development based on the capability descriptors
• Describe the agreed actions discussed.

Please read the Care Assessment Tool (CAT) general guidance ahead of the information below.

Preparation in advance

Registrar

• None

Supervisor guidance

• None

Undertaking CAT

• Select a date and surgery at random from the registrar’s appointment list and access the patient records. The supervisor should aim to pick cases at random rather than pre-agreeing which clinic they are going to review. 
• It should be agreed ahead of the assessment the approach to reviewing random cases i.e. consecutive patients, either one or two cases in more detail or a whole clinic to give a picture of overall performance, randomly picked or registrar led choice. 
• There is no specific number of cases that should be reviewed (see general CAT guidance for different approaches). It is expected a number of cases (minimum of two) would be reviewed to help establish the range of cases seen and enable themes to be established. A CbD should be used if reviewing one case, in more detail. 
• Review the cases discussing examples of good practice and areas that could be developed.
• Consider if one or two particular areas of focus are appropriate e.g.
  • appropriateness of the diagnosis or decision-making;
  • understanding of the home circumstances of each patient / their support systems;
  • considering examinations carried out in detail;
  • documentation, recording or use of coding;
  • completion of pop-up tasks.

Capability areas suggested

All capability areas could be considered appropriate depending on the focus of the random cases review. 

See CAT question generator (PDF file, 533 KB) for suggested questions surrounding each capability area for discussing clinical cases.

Clinical Management

• Adapts the clinical approach to provide comprehensive care to patients who have individual perspectives and health and care needs.
• Coordinates care for patients of all backgrounds, ages and life stages.
• Provides comprehensive continuity of care taking into account the patient’s problems and their social situation.

Organisation, management and leadership

• Applies the principles of generalisation including providing patient-centred care that considers external influences e.g. population health, environmental factors and health inequalities
• Understands the impact of broader organisational influences and pressures.
• Organises self effectively with due consideration for patients and colleagues.
• Uses the primary care organisational and IT systems routinely and effectively in patient care.
• Produces records that are accurate, comprehensive and concise, appropriately coded and understandable.

Recording in the Portfolio

Supervisor guidance

• Describe for each Capability 
  • how the registrar performed using the Capability descriptors and specific aspects of the cases discussed
  • recommendations for further development based on the capability descriptors
• Describe the agreed actions discussed.

Please read the Care Assessment Tool (CAT) general guidance ahead of the information below.

Preparation in advance

• This assessment is recommended part way through the training year, to allow the registrar adequate time in the clinical post to enable review of some clinic outcomes/responses from their referral letter in addition to the original referral letter.
• Ahead of assessment agree with the registrar the approach to which clinical letters are reviewed: registrar selection brought to the assessment or a search of coded letters. In addition, agree whether you take an in-depth review or broader but focused on specific area.
• No set number of referral letters are required to be reviewed however adequate referral documentation should be reviewed to demonstrate the breadth of cases seen in the workplace and to be able to adequately reflect on and draw themes from the review. It is recommended a minimum of eight referral letters are reviewed (referrals made using template proformas are appropriate to review within the assessment in addition to standard typed letters).
• A review of suspected cancer referrals could be appropriate, reviewing what proportion resulted in a diagnosis of cancer. This could be completed as part of a general or specific sampling of referrals.
• A review of ‘Advice and Guidance’ communication with specialities would be appropriate within the referrals review, recognising this additional communication option with secondary care colleagues.

Undertaking CAT 

• The supervisor reviews the letters the registrar has written (registrar selected or search for coded letters in a time frame) with the registrar present, encouraging the registrar to critique their work.
  • Clarify and discuss the appropriateness, composition and content commenting on what is good and what could be improved (see Characteristics of a good GP referral letter) 
  • Review the correspondence received following the referral and subsequent GP consultations.
  • Discuss the registrar’s response and reflection about each referral in retrospect.
  • Provide feedback (general themes with specific examples) to the registrar about their referrals.
  • Check that any suspected cancer referrals were put on the appropriate pathway. Review the appropriateness of these referrals checking for any delays but also commenting on examples of good patient care.

Capability areas suggested

All capability areas could be considered appropriate depending on the focus of the referrals review. 

See CAT question generator (PDF file, 533 KB) for suggested questions surrounding each capability area for discussing clinical cases 

An ethical approach

• Records, shares and received information in an open, honest, sensitive and unbiased manner.

Data gathering

• Understands the significance and implications of findings and results and takes appropriate action.

Clinical management

• Varies management options responsively according to the circumstances, priorities, and preferences of those involved.
• Refers appropriately, taking into account all available resources.
• Advocates for the patient and their carers, as they navigate the health and care system.
• Organises follow up of patients through multiprofessional, team-based and structured approaches.

Managing medical complexity

• Actively facilitates continuity of care for patients with complex needs, either personally or across teams.

Team working

• Communicates proactively with team members so that patient care is enhanced using an appropriate mode of communication for the circumstances.
• Supports the transition of patient care between professionals and teams.
• Uses the skills of the wider team to enhance patient care.

Organisation, management and leadership

• Uses the primary care organisational and IT systems routinely and effectively in patient care.

Holistic practice, health promotion and safeguarding

• Recognises what matters to the patient and works collaboratively to enhance patient care
• Utilises appropriate support agencies tailored to the needs of the patient and/or their family and carers.

Community health and environmental sustainability

• Demonstrates the breadth of GP roles across the healthcare system e.g., patient advocate, family practitioner, generalist, "gate keeper."
• Balances the needs of the individual patient, health needs of the local communities and available resources when making referral(s).
• Follows protocols with appropriate flexibility incorporating the patient’s preference
• Makes efforts to practise healthcare in an environmentally sustainable way. Considers the environmental, social, and economic sustainability of the health service e.g., changes to prescribing and considering carbon foot-printing.

Recording in the Portfolio

Supervisor guidance:

• Describe for each Capability 
  • how the registrar performed using the Capability descriptors and specific aspects of the cases discussed
  • recommendations for further development based on the capability descriptors
• Describe the agreed actions discussed.

Characteristics of a good GP referral letter

Introduction

Historically letters were a matter of taste, but there are gradually emerging expectations relating to what is an appropriate letter and an evolving research base. Letters may be written for different reasons (to establish or rule out a diagnosis; to request a treatment, operation or test that the GP cannot do; for advice or for a second opinion (requested by GP or patient); to reassure the patient.)  

Referral rates vary enormously and for a variety of reasons. 

It can be important to consider:

• How appropriate the referral is (This is challenging, as referrals for reassurance for the patient or the primary care team is appropriate, as well as asking for a treatment / operation/ investigation which is not possible to provide in GP).
• If a letter is clear about the reason for the referral and what is requested, it is much easier for the secondary care provider to ensure that the most effective response is given; which may include feedback that the referral is not necessary because options should be provided in primary care.
• Timeliness the assessment here will depend not only on whether the registrar responded within an appropriate timescale but also whether they ensured that the patient’s details were accurate and ensured that they were referred to the appropriate department of the appropriate trust.

There is general agreement that the following would normally be expected in a referral letter, though keeping it short and clear is also very important and some of these could  be less important in some letters.  

• An assessment of urgency
• Explanation of the reason for referral 
• Clarity about the expected outcome of the letter
• Clear description of the relevant history appropriate to the problems 
• Relevant psychosocial information including patient concerns or expectations
• Clear and complete summary of relevant past medical history (whilst not including irrelevant information) 
• Clear summary of current and relevant past medication including doses
• Where relevant explanations for changes or choices to use or not to use certain drugs. 
• Details of known allergies
• Description of relevant clinical signs and findings 
• Details of relevant investigation or test results 
• Current working diagnosis or diagnoses
• Patient choice has been respected in relation to place of referral and timing of appointments 
• Sufficient information to allow the secondary care provider to assess pre-operative risk when this is relevant.
• Clarity about what information has been shared with the patient and or family
• A clear structure that helps the receiving clinician understand the situation
• Letters should not contain irrelevant information.