Area of capability managing complex and long term care

As your training and experience develops, you will be expected to demonstrate how the familiar medical care approaches learned in earlier training are enhanced by developing a greater expertise in generalist medical care.

In particular, modern generalist medical care will require you to develop the capability to manage an increasingly complex population of patients with multiple and complex health-related problems that interact and vary over time. This requires the ability to manage uncertainty, deal with polypharmacy and lead, organise and integrate a complex suite of care at the individual, practice and system level.

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Managing medical complexity

This area is about aspects of care beyond managing straightforward problems. It includes multiprofessional management of comorbidity and polypharmacy, as well as management of uncertainty and risk. It also covers appropriate referral, the planning and organising of complex care, and promoting recovery and rehabilitation.

As a GP you need to address multiple complaints and comorbidity in the patients you care for. You must also provide and coordinate all aspects of health promotion and disease prevention. You must do this both opportunistically and as part of a structured approach, using other professionals in your primary care team where appropriate. You will also need to work with your patients in their rehabilitation and safe return to work using other occupational support services, bearing in mind the potential impact of a patient's work on the progress of and recovery from a health condition.

When patients seek medical assistance, they are usually aware that they have become ill but may not be able to differentiate between the different conditions they may have and the significance of each on their quality of life. As a family doctor, the challenge of addressing the multiple health issues of each individual is important. It requires you to develop the skill of interpreting the issues and prioritising them in partnership with your patients.

As a family doctor, you should use an evidence-based approach to the care of patients, including when the main focus is the promotion of your patient's health and general well-being. Reducing risk factors by promoting self-care and empowering patients is an important task of the GP. You should aim to minimise the impact of your patients' symptoms on their well-being by taking into account personality, family, daily life, economic circumstances and physical and social surroundings.

Coordination of care also means that you must be skilled not only in managing disease and prevention, but also in caring for your patient. This may include providing rehabilitation or providing palliative care in the end phases of a patient's life. As a GP, you must be able to coordinate the patient care provided by other healthcare professionals, as well as by other agencies.


Enable people living with long-term conditions to improve their health

Learning outcomes

  • Maintain a positive attitude to improving the health of patients living with chronic conditions
  • Contribute to strategies to maintain and improve the well-being of patients with long-term conditions, including:
    • encouraging and actively facilitating health promotion
    • supporting them in taking steps to increase their health resilience
    • reducing their treatment burden
    • supporting survivorship, that is, the ability to live with (or following) a serious condition
    • identifying relapse
    • managing their long-term decline
  • Identify the impact of a patient's environment on his or her health, including home circumstances, education, occupation, employment and social and family situation. Offer support to the patient in addressing these factors
  • Recognise the harm to a patient's health and the costs to the health service that arise when care is inappropriate, fragmented or uncoordinated

Manage concurrent health problems in an individual patient       

Learning outcomes

  • Recognise how health conditions commonly coexist and interact
  • Demonstrate a problem-based approach to identify, clarify and prioritise the issues to be addressed during an interaction with a patient with multiple problems
  • Demonstrate a logical and structured approach to the review of patients with multiple problems, especially the elderly, appreciating that multiple problems are often interconnected
  • Demonstrate an ability to prioritise investigations and treatments in partnership with the patient and his or her carers
  • Demonstrate responsibility for leading and coordinating the management planning for all of the patient's current health problems
  • Recognise the additional impact of multimorbidity on the therapeutic options available to the patient and make allowances for this
  • Implement measures to reduce the overall treatment burden and to use resources cost-effectively, considering human resources and economic and environmental impacts
  • Demonstrate the ability to effectively 'navigate' patients with multiple problems along and between care pathways, enabling them to access appropriate team members and services in a timely and cost-effective manner

Adopt safe and effective approaches for patients with complex health needs

Learning outcomes

  • Recognise that patients often present with problems that cannot be readily labelled or clearly categorised. Evaluate how this uncertainty influences the diagnostic and therapeutic options available to patients
  • Recognise the risk of diagnostic overshadowing and clinical stereotyping when dealing with patients who have been labelled with complex diagnoses (for example, learning disability)
  • Recognise the limitations and challenges of applying existing clinical evidence to the care of patients with multimorbidity and complex needs
  • Recognise the limitations of protocol-driven ways of decision-making when managing patients with complex problems and discuss ways of dealing with these situations with colleagues
  • Manage the inevitable uncertainty in complex problem-solving through an enhanced use of risk assessment, surveillance, communication and 'safety-netting techniques'
  • Communicate risk in an effective manner to patients with complex conditions and involve them in its management, assisting them to tolerate diagnostic uncertainty when appropriate and to refocus on improving their health and well-being
  • Recognise the importance of reflecting on your interactions with complex patients and on the outcomes of their care, in order to integrate this knowledge with your previous experience and improve your capability to provide effective care

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Progression point descriptors

Managing medical complexity 

This is about aspects of care beyond the acute problem, including the management of co-morbidity, uncertainty, risk and health promotion.


Generic Professional Capabilities: Professional Skills

MRCGP assessments: CSA, WPBA (CbD, CAT, COT, miniCEX, PSQ, QIP, Leadership, CSR)

Insufficient evidence - From the available evidence, the doctor’s performance cannot be placed on a higher point of this developmental scale 

Indicators of potential underperformance


End ST1 – Making progress at the expected rate 

End ST2 - Making progress at the expected rate 

End ST3 - Competent for licensing

End ST3 - Excellent 

Inappropriately burdens the patient with uncertainty

Finds it difficult to suggest ways forward in unfamiliar circumstances

Often gives up in complex or uncertain situations

Is easily discouraged or frustrated, for example by slow progress or lack of patient engagement

Although identifies and recognises multi- morbidity, tends to manage health

problems separately, without necessarily considering the implications of co-existing conditions

Identifies potential clinical risk

Demonstrates awareness of evidence-based guidelines

Includes lifestyle information in assessing healthcare needs of patients

Demonstrates awareness and readiness to engage in providing undifferentiated care.

Identifies and tolerates uncertainties in the consultation.

Attempts to prioritise management options based on an assessment of patient risk. 

Manages patients with multiple problems with reference to appropriate guidelines for the individual conditions. 

Considers the impact of the patients lifestyle on their health. 

Simultaneously manages the patient’s health problems, both acute and chronic.

Is able to manage uncertainty including that experienced by the patient. 

Communicates risk effectively to patients and involves them in its management to the appropriate degree. 

Recognises the inevitable conflicts that arise when managing patients with multiple problems and takes steps to adjust care appropriately. 

Consistently encourages improvement and rehabilitation and, where appropriate, recovery. 

Encourages the patient to participate in appropriate health promotion and disease prevention strategies. 

Accepts responsibility for coordinating the management of the patient’s acute and chronic problems over time. 

Anticipates and employs a variety of strategies for managing uncertainty.

Uses the patient’s perception of risk to enhance the management plan. 

Comfortable moving beyond single condition guidelines and protocols in situations of multi-morbidity and polypharmacy, whilst maintaining the patient’s trust 

Coordinates a team-based approach to health promotion in its widest sense. 

Maintains a positive attitude to the patient’s health even when the situation is very challenging. 

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Working with colleagues and in teams

This is about working effectively with other professionals to ensure good patient care. This includes sharing information with colleagues, effective gate keeping and service navigation, effective use of team skill mix, applying leadership, management and team-working skills in real-life practice, and flexible career development.

In caring for patients, you work with an extended team of other professionals in primary care, both within your own practice and in the local community. You also work with specialists in secondary care, using the diagnostic and treatment resources available. For this reason, GP education must promote learning that integrates different disciplines within the complex team of the NHS.


Work as an effective team member

Learning outcomes

  • Meet your contractual obligations to be available for patient care, anticipating situations that might interfere with your availability and ensuring that patient care is not compromised
  • Comply with the protocols, policies and guidelines agreed within your organisation
  • Seek advice from colleagues when encountering problems in following agreed protocols and policies for personal or professional reasons
  • Use acquired clinical skills such as active listening, problem-solving and principled negotiation to improve communication with colleagues
  • Enhance working relationships by demonstrating understanding, giving effective feedback and maintaining trust
  • Routinely prioritise, reprioritise and manage personal workload in an effective and efficient manner, delegating appropriately to other team members
  • Provide support to colleagues who are overburdened


Coordinate a team-based approach to the care of patients

Learning outcomes

  • Demonstrate the capability to lead and coordinate care at a team level and, when appropriate, at a service level. This includes, but is not limited to, team-based approaches to:
    • supporting patients to self-care
    • harm reduction for those with substance misuse and other risky behaviours
    • shared care planning with patients and carers
    • monitoring and surveillance of long-term conditions
    • recovery and rehabilitation after serious illness or injury
    • palliation and end-of-life care
  • Contribute to a team culture that encourages contributions and values cooperation and inclusiveness and which commits to continuing improvement and preserving a patient- centred focus
  • Appropriately seek advice from other professionals and team members according to their roles and expertise
  • Anticipate and manage the problems that arise during transitions in care, especially at the interfaces between different healthcare professionals, services and organisations. Demonstrate the ability to work across these boundaries (for example, by actively sharing information and participating in processes for multi-agency review)
  • Support the transition of responsibility for patient care between professionals and teams through structured planning, coordination and appropriate communication channels
  • Use the medical record and other communication systems to facilitate the transfer of information and care between patients, carers and multidisciplinary teams

Progression point descriptors 

Working with colleagues and in teams 

This is about working effectively with other professionals to ensure good patient care and includes the sharing of information with colleagues.


Generic Professional Capabilities: Leadership

MRCGP assessments: WPBA (CbD, CAT, COT, miniCEX, Leadership, MSF, CSR)

Insufficient evidence - From the available evidence, the doctor’s performance cannot be placed on a higher point of this developmental scale 

Indicators of potential underperformance


End ST1 – Making progress at the expected rate 

End ST2 - Making progress at the expected rate 

End ST3 - Competent for licensing

End ST3 - Excellent 



Works in inappropriate isolation ( beyond requirements of shielding and social distancing)

Gives little support to team members

Doesn’t appreciate the value of the team

Inappropriately leaves their work for others to pick up

Feedback (formal or informal) from colleagues raises concerns

Shows basic awareness of working within a team rather than in isolation.

Respects other team members and their contribution but has yet to grasp the advantages of harnessing the potential within the team. 

Is accessible and engages with other members of the team

Recognises individual roles, skills and responsibilities as part of a greater whole, in primary as well as secondary care

Responds to the communications from other team members in a timely and constructive manner. 

Understands the importance of integrating themselves into the various teams in which they participate. 

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, e.g. Health Visitors and their role in safeguarding. 

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. 

Contributes positively to their various teams and reflects on how the teams work and members interact. 

Helps to coordinate a team-based approach to enhance patient care, with a positive and creative approach to team development. 

Shows awareness of the strengths and weaknesses of each team member and considers how this can be used to improve the effectiveness of a team. 

Encourages the contribution of others employing a range of skills including active listening.   Assertive but doesn’t insist on own views. 

Shows some understanding of how group dynamics work and the theoretical work underpinning this. Has demonstrated this in a practical way, for example in chairing a meeting. 



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