How the curriculum is structured: Capabilities in practice

Becoming a capable and competent GP

The RCGP curriculum acts as the educational framework for the 3-year specialty training programme for doctors entering general practice in the UK.

The 2019 GP curriculum is designed to integrate with the General Medical Council's (GMC) generic professional capabilities framework.3 This framework describes the essential capabilities that support professional medical practice in the UK (see Figure 1).

Fig 1 Generic professional capabilities framework

The generic professional capabilities framework provides a consistent approach across all postgraduate medical curricula. It prioritises a number of themes, such as patient safety, quality improvement, safeguarding vulnerable groups, health promotion, leadership, team-working and other fundamental aspects of professional behaviour and practice.

The intended learning outcomes of the RCGP curriculum are organised into five Areas of Capability (see Figure 2) based around the GMC's generic professional capabilities framework and are grouped within specific capabilities. The curriculum is also supported by a series of duplication topics guides that explore professional and clinical capabilities in more depth and illustrate them through examples in practice. 

The capabilities that form the basis for the structure of the RCGP curriculum run as developmental threads throughout the GP training programme, and link earlier medical training with GP licensing assessments and post-licensing GMC revalidation standards. Although it is possible to define other capabilities of relevance to general practice, these five have been selected as a basis on which to build the RCGP curriculum because of their importance to GP training and assessment within the context of the NHS in all four UK nations.

Whilst separated for conceptual reasons, these Areas of Capability should be considered as part of an integrated global progression in personal and professional development that will continue throughout your career.

In relation to GP training, MRCGP assessments [that is, Workplace-Based Assessment (WPBA), Applied Knowledge Test (AKT) and Clinical Skills Assessment (CSA)] are primarily concerned with evaluating capability. Specifically, they consider the ability to demonstrate knowledge and skill to the standard expected of a newly qualified GP in a range of common clinical and professional scenarios.

The development of capabilities will continue lifelong. During training, this process is overseen by an educational supervisor and supported by other educational activities that encourage self-directed learning, formative feedback and critical reflection. Beyond training, capability is demonstrated through continuing professional development, appraisal and revalidation.

The curriculum also describes 13 specific capabilities that are core to general practice and that a doctor is expected to acquire during GP specialty training (see Table 1).
These capabilities map explicitly to the GMC's generic professional capabilities framework (see Appendix 1 for a detailed map).

Fig 2: The five areas of capability in the RCGP curriculum for general practice


Area of capability


Specific capabilities for general practice
To be a GP, you must be capable of

A. Knowing yourself and relating to others

 

 

 

 Fitness to practise

  • Demonstrating the attitudes and behaviours expected of a good doctor
  • Managing the factors that influence your performance

Maintaining an ethical approach

  • Treating others fairly and with respect and acting without discrimination
  • Providing care with compassion and kindness

Communication and consultation

  • Establishing an effective partnership with patients
  • Maintaining a continuing relationship with patients, carers and families
 

B. Applying clinical knowledge and skill

Data gathering and interpretation

  • Applying a structured approach to data gathering and investigation
  • Interpreting findings accurately to reach a diagnosis

Clinical examination and procedural skills

  • Demonstrating a proficient approach to clinical examination
  • Demonstrating a proficient approach to the performance of procedures

Making decisions

  • Adopting appropriate decision-making principles
  • Applying a scientific and evidence-based approach

Clinical management

  • Providing general clinical care to patients of all ages and backgrounds
  • Adopting a structured approach to clinical management
  • Making appropriate use of other professionals and services
  • Providing urgent care when needed
 C. Managing complex and long-term care

 Managing medical complexity

  • Enabling people living with long-term conditions to improve their health
  • Managing concurrent health problems within an individual patient
  • Adopting safe and effective approaches for patients with complex needs

Working with colleagues and in teams

  • Working as an effective team member
  • Coordinating a team-based approach to the care of patients
 D. Working well in organisations and in systems of care

 Improving performance, learning and teaching

  • Continuously evaluating and improving the care you provide
  • Adopting a safe and scientific approach to improve quality of care
  • Supporting the education and development of colleagues

Organisational management and leadership

  • Applying leadership skills to improve your organisation's performance
  • Making effective use of information and communication systems
  • Developing the financial and business skills required for your role
 E. Caring for the whole person and the wider community

 Practising holistically, promoting health and safeguarding

  • Demonstrating the holistic mindset of a generalist medical practitioner
  • Supporting people through experiences of health, illness and recovery
  • Safeguarding individuals, families and local populations

Community orientation

  • Understanding the health service and your role within it
  • Building relationships with the communities in which you work

Table 1: The five Areas of Capability and 13 specific capabilities for general practice 

Topics covered in GP specialty training

The curriculum is supplemented by a series of topic guides that explore specific capabilities in more depth, applying them in an appropriate clinical or professional context. Each topic guide is intended to illustrate important aspects of everyday general practice, rather than provide a comprehensive overview of that topic, and should not be viewed as a complete list of every topic needed to learn about as a practising GP.

Topic guides about professional issues

  • Consulting in general practice
  • Equality, diversity and inclusion
  • Evidence-based practice, research and sharing knowledge
  • Improving quality, safety and prescribing
  • Leadership and management
  • Urgent and unscheduled care

Topic guides about life stages

  • Children and young people
  • Reproductive health and maternity
  • People living with long-term conditions including cancer
  • Older adults
  • People at the end of life

Topic guides about clinical topics

  • Allergy and immunology
  • Cardiovascular health
  • Dermatology
  • Ear, nose and throat (ENT), speech and hearing
  • Eyes and vision
  • Gastroenterology
  • Genomic medicine
  • Gynaecology and breast
  • Haematology
  • Infectious disease and travel health
  • Kidney and urology
  • Mental health
  • Metabolic problems and endocrinology
  • Musculoskeletal health
  • Neurodevelopmental disorders, intellectual and social disability
  • Neurology
  • Population health
  • Respiratory health
  • Sexual health
  • Smoking, alcohol and substance misuse

How to learn general practice

The majority of your learning for general practice will occur in the workplace. A key element of professional behaviour requires you to reflect actively on your everyday experiences and incorporate your learning into your daily work and encounters with patients.5

There will also be opportunities for you to learn outside the workplace, through planned educational activities with other healthcare professionals and during formal teaching sessions.

In every placement, the patients and carers you meet will educate you about how they approach and manage their own illnesses and, if you are open to it, they will help you to become a better GP. Patients with long-term health conditions are often experts in managing their illness and experienced at negotiating their way through the healthcare system. You should also make the most of learning from the wide range of other colleagues in the multidisciplinary team who are involved in caring for your patients, both in hospital and in the community.

Building on this curriculum, your GP training programme will provide you with opportunities to gain insights into how patients and their problems are managed in different settings, as well as experience of the interfaces between these care environments. It will also give you a deep understanding of the meaning of the patient pathway and your role in helping your patients to negotiate this.

Your key educational relationships will be with your educational supervisor (your GP trainer), the clinical supervisors in your placements and the programme directors of your training programme. These relationships will be embedded in active, professional practice, where your experiences will not only allow the acquisition of skills but will also, by participation in professional practice, enable you to acquire the language, behaviours and philosophy of the profession.

As an adult learner6 you will have your own distinct learning style and preferences. These will influence how you make use of the learning opportunities during your training programme and beyond, into your lifelong learning as a GP.

Ensuring a broad range of experience

To deliver the broad base of capabilities required for the NHS GP role, your training pathway should be configured to provide you with adequate, supervised exposure to the patients you will encounter when you are working in independent professional practice. For this reason, it is important that your training in secondary care is grounded in the capabilities that apply to the GP’s role and typical working environment. Attachments in secondary care can provide you with a concentration of clinical experience that would take months or years to achieve in the general practice setting (such as the opportunity to gain confidence in recognising seriously ill children through work in an appropriate acute child health service). In these settings, you will see and manage people with serious illness, and study their pathway from presentation and admission to discharge, as well as participating in planning their rehabilitation. Such opportunities should include appropriate outpatient and community outreach experiences.

As well as the differences in the clinical cases encountered in different health settings, you will also find that teams working in primary, community and secondary care are often organised differently, and you will be able to compare different team leadership styles and approaches.

The RCGP recommends that all GP training programmes should be configured to provide trainees with adequate opportunities to gain skills in the assessment and management of the general UK population, as well as providing more targeted training in the care of certain patient groups that require a specific clinical approach and skillset. In addition to the wide-ranging and essential generalist experience gained in general practice placements (of which a minimum of 18 months is recommended within a 36-month training programme), examples of additional relevant training opportunities are given in Table 2. 

Services provided for...


Some examples:


Infants, children and young people Hospital and community paediatric services and clinics, children's emergency department, integrated services (for example, 'Learning Together), children's centres
Maternal health Antenatal, postnatal, perinatal and maternity services and clinics, obstetrics, early pregnancy assessment units, women’s health clinics, family interventions
People with mental health needs Psychiatry services, community mental health teams, child and adolescent mental health services, talking therapies, addiction services, student services, high deprivation practices
People with long-term conditions and disabilities Medicine and surgery services and clinics, outpatient clinics, community services, rehabilitation and reablement services
Frail and elderly people (including people with multimorbidity and those who are dying)
Acute and internal medicine services and clinics, gerontology, care homes, dementia units, community hospitals, elderly care services, end-of-life care
People requiring urgent and unscheduled care
Emergency department, acute paediatrics or adult medicine services, out-of-hours services, walk-in centres, urgent treatment centres, minor injury units, intermediate care, hospital at home, 111, crisis support teams
People who may have health disadvantages and vulnerabilities
Emergency department, addiction services, child health teams, learning disability services, secure environments. Examples of training opportunities include, but are not limited to, services provided for people with addictions or who undertake risky behaviours; people with reduced mental capacity; people with safeguarding needs; veterans; refugees, asylum seekers and undocumented migrants; homeless people; victims of trafficking, torture, violence or abuse; people in secure environments

Table 2: Training placements and opportunities outside general practice settings

It is important to note that this table does not provide an exclusive list of GP training placements, as GPs must be trained to be capable of providing care to patients of all backgrounds and ages. It is possible, therefore, to incorporate relevant curriculum-based placements within a wide range of healthcare services and settings.

Given the capabilities required for general practice, hospital-based training posts should be configured to enable GP trainees to gain sufficient experience in relevant outpatient clinics and other non-ward environments. Additionally, a suitable training post may of course be configured to provide exposure to more than one patient group simultaneously, for example a post based in a gerontology service with regular outpatient clinic experience or an acute medical on-call commitment providing relevant training experience in relation to both the elderly multimorbid and the acutely ill patient group.

Integrating specialist approaches into generalist care

The training you undertake in the earlier stages of the GP training pathway (that is, ST1 and ST2) should be sufficiently supervised to ensure that you develop a proficient, safe and appropriate approach to clinical assessment and management from the outset. This will enhance effectiveness and ensure patient safety during the latter stages of training, when the level of direct supervision is reduced, and the clinical environment becomes more generalist in nature.

Throughout your training, it is essential to take the time to reflect on your practice. This includes developing a clear understanding of what has been learned and how it can be applied effectively to a general practice setting. Your programme director and educational supervisor will be able to assist you in accessing resources for learning during your placements and can advise on ways that you can meet leaning needs relating to the specialties that are not included in your rotation. 

In the later stages of training, you will need to adjust your mindset to the different health needs, disease prevalence and range of clinical environments encountered in the general practice setting. This involves transferring the expertise gained from your earlier training experiences, when you encountered a 'filtered' secondary care population in which certain conditions may be more prevalent, to the ‘unfiltered’ general population presenting to general practice. 

Undertaking adequate workplace-based supervision and formative assessment in the general practice setting is therefore essential, as this in the context in which you will ultimately practise independently. This enables your clinical skills, risk management skills and decision-making to be applied, honed and tested safely.

Work-based learning

Your training practice, and the patient contacts you make while working there, will provide the foundation for your career-long development as a generalist medical practitioner. 

Initially, you will work closely with your GP trainer (educational supervisor) or clinical supervisor when consulting with patients. As you gain experience, you will work with less direct supervision and take more responsibility, until you are able to work safely and independently. Being observed, receiving structured feedback and reflecting on your work are fundamental features of this process of workplace-based learning.

In addition, you will have structured teaching sessions with your GP trainer, tailored to your learning needs. Your training practice is a complex organisation and you will be able to gain an understanding of how it functions as both an NHS provider organisation and a business. This includes how the practice team monitors the quality, safety and effectiveness of the care it delivers. You should familiarise yourself with the tools used in quality management, such as case review or learning event analysis, adverse incident reporting and patient satisfaction surveys, and use these tools to identify and meet new learning needs.

Self-directed learning

GPs are adult learners and developing a strong capability for self-directed study is an important part of your professional development. This may include reading around a topic that interests or perplexes you, reflecting on your experiences, searching for evidence or preparing for a teaching session or assessment. As well as the traditional books, papers and journals, there are many online resources that cover the RCGP curriculum, such as the RCGP eLearning courses. Many of these include self-assessment tools to provide you with feedback as you work through them.

The recommended working week in GP training includes a half-day for personal study and independent self-directed learning. Trainees will use this time in a variety of ways, depending on their needs, to ensure that they meet the curriculum outcomes, for example attending clinics, reading, carrying out eLearning, carrying out research projects, exploring the medical humanities literature, preparing for examinations and preparing their portfolio for assessment. This provides an essential opportunity for reflective practice and providing evidence of learning through workplace-based activities. In general, you should ensure that you are meeting the RCGP curriculum requirements before considering devoting your study time to discretionary educational activity. 

Trainees who are progressing satisfactorily may wish to develop an interest in a particular area of practice and undertake a limited amount of training to that effect, but they should ensure that this does not hinder their progress or detract from their study of the RCGP curriculum. You are encouraged to record your self-directed learning activities in your ePortfolio, which in itself will help you reflect on your training and identify new learning needs.

Learning with peers

The half- or whole-day release course allows trainees from different years to come together for small group sessions and can have a powerful influence on shaping attitudes and enhancing personal professional development. Peer learning groups for preparation for examinations and assessments have a long tradition and are highly valued by trainees. There are many examples of trainees learning to learn with their peers, with and without the need for facilitation. The half-day release schemes are a vehicle for:

  • shared experiences
  • learning together and action learning sets
  • self-directed learning groups
  • geographically based 'cluster' groups

Learning with other health and care professionals

The broad knowledge and skills required by a GP are seldom provided solely by medical colleagues. Many aspects of the curriculum are taught by other professionals, such as clinical
nurse specialists, advanced nurse practitioners, practice nurses and administrative colleagues. 

Primary care is a multidisciplinary activity, and this will be reflected in the training programmes for future GPs. Practice-based education is of increasing importance and trainees should be involved both as learners and as teachers. Short attachments to other primary healthcare team-workers and other professionals, such as practice-based or community-based pharmacists, are helpful.

Understanding the interfaces between GPs and other professionals is another key task. Non-clinical staff, such as receptionists and managers, make key decisions on prioritising patient requests and have expertise in the administration and management of the practice as a business and a healthcare organisation. 

Learning outside the health sector (for example, spending time in social care or voluntary sector organisations) is also invaluable, for example in understanding the wider social determinants of health.

Finally, there may be opportunities for you to join other healthcare professionals in joint educational events, learning together through in-house or locality-based programmes.

Learning in formal situations

There are many resources for learning that are organised at both the regional and the national level. Access to these opportunities is provided through the study leave allowance process and is subject to the criteria of personal professional development and appropriateness for GP training. They most commonly include:

  • CSA and AKT preparation courses
  • clinical topic courses
  • attendance at national conferences such as the RCGP annual conference

Lifelong learning

Of course, becoming a qualified GP does not mean that your learning stops. Being a doctor is a process of lifelong learning, not only to keep up to date on medical developments but also to develop expertise and to improve the application of your knowledge and skills as you take on more senior and challenging roles. 

Your learning needs will differ at different stages of your career and you need to be able to continuously review, identify and meet those needs. By linking explicitly with the GMC's Good Medical Practice guidance,7 the RCGP curriculum can help you with this process, providing a useful educational framework for the fascinating and wonderful discipline of general practice.

How GP training is delivered

The RCGP curriculum requires GP trainees to develop a range of generalist capabilities and a broad base of clinical knowledge. This is delivered primarily through local training programmes. In most UK regions these programmes are managed by a School of Postgraduate General Practice Education or equivalent structure. A Director of Postgraduate General Practice Education leads the network of GP educators and trainers. 

Within each geographical area, programme directors are responsible for training programmes and an individual trainee's programme is overseen by his or her educational supervisor, who is supported by the expertise and resources of a local team, according to local arrangements. These experiences should be planned and reflected on by developing a Personal Development Plan (PDP) based on identified needs, with educational strategies that are suited to a learner's preferences, work-based experiential learning and available training opportunities.

The structure of the programme

The current structure of GP training over 3 years incorporates experience in both general practice and hospital posts specifically selected as being suitable for GP training.

Primary care placements

General practice placements provide the core experiential learning environment for future professional and career development. Learning opportunities include tutorials, informal
learning, case discussions, meetings and quality improvement.

Secondary care placements

Hospital rotations approved for GP training are chosen to reflect exposure to problems encountered as a GP. Outpatient clinics can be valuable for seeing patients under supervision. Secondary care provides experience of cases encountered as a GP, but with a more concentrated exposure in specialist departments. It allows training in managing acutely ill patients and allows familiarity to be gained with the patient journey under specialist supervision.

Hospitals also provide opportunities for trainees to attend a wide range of multidisciplinary team meetings to gain different perspectives on integrated care and team-working.

Supervision

The role of the trainer in GP training is best considered in relation to the role of the clinical supervisor and the educational supervisor. It is based on the Gold Guide to Specialty Training
(January 2018).8 Additional information is provided in the standards for trainers, as outlined in Promoting Excellence.9

Clinical supervisors

Clinical supervisors are responsible for day-to-day supervision in the clinical setting. Clinical supervisors integrate learning with service provision by enabling trainees to learn by taking responsibility for patient management within the parameters of good clinical governance and patient safety. They should endeavour to be available, provide teaching and developmental conversations, give regular and appropriate feedback and be readily accessible for a rapid response to any issues as they arise. They must demonstrate awareness of equality and diversity, as well as cultural awareness.

A clinical supervisor will have knowledge and skills in the following:

  • understanding how adults learn best and the relevance of this to teaching
  • understanding how best to teach a clinical skill
  • a variety of appropriate teaching techniques/methods 
  • understanding the importance of evaluating teaching
  • giving feedback to trainees of all abilities

Educational supervisors

Educational supervisors monitor trainees' progress over time to ensure that trainees are making the necessary clinical and educational progress. Educational supervisors will need all of the skills of clinical supervision, plus an appreciation of educational theory; the ability to provide role modelling; an appreciation of the importance of reflective practice; and an understanding of reflective practice.

The educational supervisor provides essential educational continuity in the assessment of overall progression towards the Certificate of Completion of Training (CCT) in general practice. The educational supervisor monitors the quality of evidence for learning through the ePortfolio and provides real-time and summarised feedback on workplace-based learning. An educational supervision review usually occurs annually and assesses all naturally occurring and formal evidence of achievement to make recommendations to the Annual Review of Competence Progression (ARCP) process.

The educational supervisor will:

  • understand the GMC requirements and his or her own educational role in relation to those standards
  • ensure that the trainee is receiving appropriate support and teaching
  • have a good understanding of the RCGP portfolio and of what is acceptable progress 
  • review ePortfolio learning log entries and provide formative feedback for reflective
  • practice and review the trainee's PDP
  • assess formal evidence such as the clinical supervisor's review and patient and colleague feedback against the RCGP curriculum competencies
  • meet the GP trainee every 6 months to review the evidence against the 13 areas of professional capabilities and make recommendations on training progress towards the CCT
  • have an understanding of the relationship between WPBAs and the educational supervisor's ARCP report
  • identify the initial steps in managing trainees with problems and signpost appropriate additional support and resources where necessary.

All supervisors undergo an annual appraisal, which includes an appropriate element of educational appraisal.

Formative assessment

Formative assessment is provided throughout the GP training programme by both clinical and educational supervisors. The RCGP ePortfolio provides evidence for review and
feedback and is accessed by trainees, supervisors and assessors for ARCP.

Initial learning needs assessments are undertaken and recorded at the placement planning meeting, which is timetabled at the beginning of each new clinical attachment. This explores the learning outcomes and records them as a PDP for the specific clinical placement, but also aligns with the expansion of learning throughout training.

During clinical placements, the clinical supervisor provides formative assessment, both informally through feedback and formally using structured assessment tools, such as supervised learning events, consultation observation, mini-clinical examinations, problem and random case analysis, clinical audit and learning event analysis.


Next: How training progress is assessed >

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