Professional topic guides

These Topic Guides each explore part of the RCGP curriculum, Being a General Practitioner.

Each Topic Guide is intended to illustrate important aspects of everyday general practice, rather than provide a comprehensive overview of each clinical topic. It should therefore be considered in conjunction with other Topic Guides and educational resources.

They also contain tips and advice for learning, assessment and continuing professional development, including guidance on the knowledge relevant to this area of general practice.

Consulting in general practice

This Topic Guide will help you to understand important issues relating to consulting in general practice by describing the key learning points. It also contains tips and advice for learning, assessment and continuing professional development, including guidance on the knowledge relevant to this area of general practice.

Summary

  • Effective communication with your patient and their advocates, including carers, is essential for good care 
  • As a general practitioner you must show a commitment to person-centred medicine, displaying non-judgemental attitudes and a holistic ethos 
  • Developing plans for care and support with the patient involves a collaborative approach, including agreeing shared goals and considering the patient’s unique values and preferences alongside the best available evidence, as well as applying relevant ethical and legal principles 
  • You must manage complexity, uncertainty and continuity of care within the time-restricted setting of a consultation 
  • Technology is facilitating new ways of consulting in general practice, but fundamental information governance principles and communication skills still apply to these new contexts. 

GP Consulting

The consultation between doctor and patient is at the heart of general practice. It is the central setting through which primary care is delivered and from which many of the curriculum outcomes are derived. The skills used in the consultation are transferable to other areas of professional practice.  For example, your communication skills and approaches with patients are transferable to how you work with colleagues, in leadership and in teaching. Having highly developed communication skills is pivotal to all aspects of high quality patient care. 

'Consultation skills' and 'communication skills' are often used interchangeably, but these are only a subset of the interpersonal skills, knowledge and attitudes required to consult effectively.  

The following three areas have a strong influence on person-centred consulting: 

Attitudes, feelings and biases

  • Feelings and intuition strongly affect the consultation behaviour of both the doctor and the patient. These less transparent thinking processes bring benefits and risks to the consultation. For example, while they can help you to establish rapport, it is also important to be aware of the potential impact of conscious and unconscious biases on shared decision-making 
  • Many patients will attend the same GP repeatedly during the course of their lives: this longitudinal relationship can influence attitudes, feelings, biases and processes within consultations for both patients and doctors   
  • Patients' views and perspectives may change during the course of their lives and even during the course of an illness 
  • Health beliefs, preferences, ethnic and cultural differences have an impact on the way that patients present with illness, their willingness to engage with health services, and their management  
  • Adopting a curious and open-minded attitude can help you gain insights into patients' perspectives 
  • Some patients may wish to approach health and illness in a non-scientific way. The reality for most people is that they make their own health choices on the basis of their own values and not necessarily on the health system's values. Understanding and responding to this can improve both the patient experience and concordance with agreed care plans 
  • Patients may sometimes prefer to delegate their autonomy to you as their GP, rather than accept this responsibility themselves, particularly at times of illness or distress. While being willing to take on this responsibility when appropriate, it is important to support patients in maximising their capacity for decision-making and encourage self-care.  

The consultation process

  • Clinical effectiveness and optimising whatever time you have to spend with the patient depend on effective consulting skills. To have an effective consultation, you need to navigate with the patient through the usual phases of the consultation in an appropriate sequence and at an appropriate pace. A working understanding of consultation models can greatly assist this process. For example, if you do not spend sufficient time discovering the reason for the patient's attendance and their expectations for the consultation, then your agreed management plan is less likely to be appropriate, and patient safety as well as satisfaction may be compromised 
  • Close observation of and interest in the patient are essential  
  • Person-centred consulting includes the choice of responses, both verbal and non-verbal, that you and the patient make 
  • It is important to be aware of your practice in real time, always seeing the patient as an individual reacting to their own unique context and taking this into account when formulating your responses. This real-time monitoring is essential for detecting when a consultation is not going as well as hoped, enabling appropriate steps to be taken to address this  
  • Consultations are usually time-constrained, although longer consultations tend to be associated with better health outcomes, increased patient satisfaction and enablement scores.  Balanced against this are the competing demands of limited appointment numbers and reduced access to GPs 
  • Structured feedback on your consultation, with reference to evidence-based consultation and communication models, can help to improve your consulting skills. 

The wider context of the consultation

  • Consultations, along with episodes of illness, rarely impact on the patient alone 
  • It is important to understand the relationship between the interests of patients and the interests of their carers, in order to negotiate how relatives, friends and carers might become involved, while balancing the patient's rights to autonomy and confidentiality 
  • It is also important to identify and support people undertaking a caring role 
  • Consultations that work effectively from a patient's perspective require the doctor to understand that 'health' and 'illness' comprise more than the presence or absence of the signs and symptoms of disease 
  • Physical, psychological, socioeconomic, educational, cultural and community dimensions of health are reflected in every consultation  
  • It is important to understand the boundaries between professionals and other services with regard to clinical responsibility and confidentiality, particularly when working in teams and in care pathways that span organisations 
  • Each consultation provides a window to the local community. Cumulatively, these consultations can help you to understand the demography and diversity of your practice population, as well as provide powerful illustrations of unmet health needs and gaps in service provision. These experiences can be effectively combined with scientific data to inform the development of appropriate services for the community as a whole. It is also important to recognise the health needs of patients who are less able to consult.

Knowledge and skills guide

The main knowledge and skills required for effective consultation can be grouped into three broad areas: interpersonal skills, data-gathering (including history-taking, examination and investigations) and clinical management. The diagram illustrates these basic elements of a consultation. The order of these elements is not fixed and can sometimes change: 

Knowledge and skills diagram

(Diagram used with kind permission from Martin Block)

Interpersonal skills

This area is about communicating effectively with patients, using recognised consultation techniques, establishing effective patient partnerships, managing challenging consultations, consulting with third parties and using interpreters.  

In relation to these skills, a doctor demonstrating effective performance: 

  • Explores the patient's agenda, health beliefs and preferences 
  • Is alert to verbal and non-verbal cues 
  • Explores the impact of the illness on the patient's life 
  • Elicits psychological and social information to place the patient's problem in context 
  • Works in partnership with the patient and carers or relatives, finding common ground to develop a shared management plan 
  • Communicates risk effectively  
  • Shows responsiveness to the patient's preferences, feelings and expectations 
  • Enhances patient autonomy 
  • Provides explanations that are relevant and understandable to the patient 
  • Responds to needs and concerns with interest and understanding 
  • Has a positive attitude when dealing with problems, admits mistakes and shows commitment to improvement 
  • Backs their own judgement appropriately 
  • Demonstrates respect for others 
  • Does not allow their own views or values to inappropriately influence dialogue 
  • Shows commitment to equality of care for all 
  • Acts in an open, non-judgemental manner 
  • Is cooperative and inclusive in their approach
  • Conducts examinations with sensitivity for the patient's feelings, seeking consent where appropriate.  

Knowledge and skills required in this area include: 

  • Recognition that personal emotions, lifestyle and ill-health can affect both your consultation performance and the doctor-patient relationship 
  • Skills to respond flexibly to the needs and expectations of different individuals, including identifying and understanding the values that influence a patient's approach to healthcare and sharing information with patients in an honest, transparent and unbiased manner 
  • Skills to develop a shared understanding of a problem and its management with patients, so that they are empowered to make their own decisions and supported to look after their own health 
  • Skills to meet the needs of patients with communication problems, as well as those who have different languages, cultures, beliefs and expectations from your own 
  • Skills and techniques for consulting effectively in different contexts and settings, including:
    • with other participants present, such as interpreters, advocates, colleagues, parents, carers;
    • in different locations for example, patients' homes, residential or nursing care homes, urgent care centres and out of hours venues; and
    • when using different media for consulting remotely – for example, telephone, email, e-consulting, video consultations
  • Use of the computer in the consultation while maintaining rapport with your patient
  • Effective and safe telephone, email and online consultation, applying an awareness of their uses and limitations while mitigating risks
  • Approaches for optimising continuity of care and long-term relationships with your patient and their families
  • Approaches for assessing and enhancing a patient's decision-making capacity
  • Techniques to manage consultation time efficiently, including approaches for ending a consultation when appropriate
  • Approaches for optimising continuity of care with patients and their families 

Data-gathering, technical and assessment skills

This area includes gathering and interpreting the patient's information from their narrative, clinical record and biographical data. It also concerns the use of investigations and examination findings and requires proficiency in performing clinical examinations and procedures. 

In relation to these skills, a doctor demonstrating effective performance: 

  • Clarifies the problem and nature of decision required 
  • Uses an incremental approach, using time and accepting uncertainty 
  • Gathers information from history taking, examination and investigation in a systematic and efficient manner 
  • Is appropriately selective in the choice of enquiries, examinations and investigations 
  • Identifies abnormal findings or results and makes appropriate interpretations 
  • Uses instruments appropriately and fluently 
  • When using instruments or conducting physical examinations, performs actions in a rational sequence  

Knowledge and skills required in this area include: 

  • Focused history-taking, targeted questioning and examination to obtain sufficient relevant information to diagnose, manage and refer appropriately 
  • An appropriate and incremental approach to investigations 
  • Accurate, legible and contemporaneous clinical record-keeping 
  • Effective use of patient records and other written information during the consultation  
  • Recognition of 'red flag' elements in the patient narrative which may require urgent intervention to minimise risk 
  • Appropriate and timely physical examination and investigations.  

Clinical management skills

This area is about recognising and managing common and important medical conditions in primary care, demonstrating a structured and flexible approach to decision-making, and dealing with multiple problems and co-morbidity while promoting a positive approach to health.  

In relation to these skills, a doctor demonstrating effective performance: 

  • Recognises presentations of common physical, psychological and social problems 
  • Makes plans that reflect the natural history of common problems 
  • Offers appropriate and feasible management options 
  • Adopts clinical management approaches that reflect an appropriate assessment of risk 
  • Manages risk effectively in consultations, safety netting appropriately 
  • Makes appropriate prescribing decisions 
  • Refers appropriately and co-ordinates care with other healthcare professionals 
  • Simultaneously manages multiple health problems, both acute and chronic 
  • Encourages improvement, rehabilitation and recovery where appropriate 
  • Encourages the patient to participate in appropriate health promotion and disease prevention strategies. 

Knowledge and skills required in this area include: 

  • Techniques and approaches for:
    • managing uncertainty
    • exploring the probability of disease
    • reducing the possibility of harm; using time safely and appropriately –  watching and waiting when it is safe to do so; and 'safety netting' to manage and reduce risk
  • Approaches to inform and improve decision making about ethical dilemmas, including when and how to seek advice 
  • Formulation of appropriate differential and working diagnoses  
  • Maintenance of sufficient knowledge across the breadth of medical evidence in order to provide the best information for patients about their illness and treatment options 
  • Skills for reaching shared management decisions and plans based on the best available evidence and guidance, incorporating the patient's goals, values and unique circumstances 
  • Knowledge of evidence-based health and care choices so that an informed discussion can occur, taking into account the patient's values and priorities 
  • Approaches for communicating risks and benefits in a meaningful way to patients 
  • A comprehensive understanding of local services and patient pathways, to enable timely and appropriate referrals 
  • Knowledge of the self-management of acute and chronic disease as well as appropriate information sources to which patients can be directed 
  • Knowledge of lifestyle factors that affect health (for example, smoking, alcohol, diet, physical activity, sleep, stress) and evidence-based approaches to addressing these
  • Active health promotion within the consultation, including the shift from theory to clinical skills in behaviour change; the potential tension between this role and a patient's own agenda 
  • Skills to recognise and respond to a patient entering a terminal stage of illness
  • Skills to reconcile different and sometimes conflicting professional roles within the consultation, such as clinician, patient advocate, leader, gatekeeper and resource manager 
  • Skills required for working effectively with other professionals including:  
    • sharing information 
    • effective navigation to other professionals and services
    • use of team skill mix 
    • applying leadership and 
    • management and team-working skills 

How to learn this area of practice

Work-based learning

As a specialty trainee, primary care is the ideal place for you to learn about the GP consultation in practice. There will also be excellent opportunities in secondary care settings. Examples of how to make the most of your clinical experience include: 

  • Video analysis of consultations. This can be done using the Consultation Observation Tool (COT)  
  • GP trainers can sit in with specialty trainees to give formative feedback. This can be done using the COT  
  • Random case analysis of a selection of consultations. This can be done in a Case Discussion  
  • Reflection on secondary care consultations using the Clinical Evaluation Exercise (mini-CEX)  
  • Patients' feedback on consultations using validated satisfaction questionnaires or tools, for example the RCGP Patient Satisfaction Questionnaire (PSQ)  
  • Sitting in with GPs and other healthcare professionals in practice to observe different consulting styles 
  • Observation of consulting behaviour during outpatient clinics 
  • Using the telephone and other digital communication tools to consult in the practice as well as in 'Out of Hours' settings, initially under close supervision and later independently.  

You should have opportunities to discuss ethical and other values-related aspects of your practice with colleagues as these arise in your day-to-day work – for example. during contact with patients, their families and the wider community, and in relevant other contexts such as audit, significant event review meetings and developing practice policies (for example, on patient consent). It is particularly helpful if there is 'protected time' for reflection and shared learning. Presenting cases to your peer groups as part of the training programme will promote reflective practice and can be used to illustrate the diversity of values within a specific professional group.

It is also important for specialty trainees to understand that the practice of medicine has its own culture, values, morals and beliefs that may set doctors apart from patients. During your training you should be supported to gain a better understanding of the diverse nature of the society in which you will work. You should also learn to ask questions and look critically at your assumptions and attitudes about people who are different from yourself, as well as to reflect on these issues and, importantly, on your own feelings. The specialty trainee working in a hospital or in primary care should be training in an environment that embraces differences and similarities in culture, backgrounds and experience. This should be an environment free from racism, sexism and bullying where there are positive role models and processes in place that promote equality and value diversity in the workplace.

Self-directed learning

Role-played consultations, for example during teaching or courses, are valuable in exploring consultation behaviour in a safe environment, especially those using 'standardised patients' (played by actors or role-players who have been trained to react in a consistent or specific manner).

Peer-group meetings are an excellent forum for you to discuss, in confidence, video consultations recorded in your surgery or using commercially available teaching packages.

Book and web resources relevant to the GP consultation can be found in the curriculum section "Being a General Practitioner".

Balint groups

The Balint group1 is a highly developed and tested method of small-group consultation analysis that aims specifically to focus on the emotional content, not just of single consultations but of ongoing doctor–patient relationships. Many doctors who have had the experience of Balint training attest to the lifelong benefits that it can bring in terms of interest in patients' lives, self-knowledge, job satisfaction and prevention of 'burn out'.

Learning with other healthcare professionals

Consultations are a rich learning resource that can trigger multidisciplinary discussion about consulting skills, patient management, ethics, evidence-based practice, clinical guidelines, and many other things. This can be achieved by observing or being observed during a live consultation, using role-play, or watching recorded consultations. Emerging integrated care pathways and multi-professional team meetings offer valuable means of learning from the wider team, including social workers and secondary care consultants.

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT)

  • Understanding and use of decision aids  
  • Confidentiality and disclosure of medical records 
  • Advance care and decision-to-treat plans. 

Clinical Skills Assessment (CSA)

  • An older woman asks about options for euthanasia when her condition worsens. A hospital letter confirms her diagnosis of motor neurone disease 
  • A young person with diabetes has repeated admissions with ketoacidosis after ignoring instructions on managing her insulin  
  • Routine HRT check for 68-year-old woman with rheumatoid arthritis. 

Workplace Based Assessment (WPBA)

  • Tutorial on dealing with angry patients 
  • Significant event about a patient who complained that you missed their diagnosis of bowel cancer 
  • Audio COT on telephone consulting skills.  

References

1Balint M. The Doctor, the Patient and the illness Edinburgh; Churchill Livingstone (1986)


Equality, diversity and inclusion

This Topic Guide will help you understand important issues relating to equality, diversity and inclusion by describing the key learning points.

Summary

  • Supporting equality, diversity and inclusion involves recognising, respecting and valuing differences to create a cohesive community and working culture, for the benefit of organisations and individuals 
  • The Equality Act (2010) legally protects people from discrimination and aims to reduce socio-economic inequality, prohibit victimisation, eliminate discrimination and to increase equality of opportunity 
  • It is unlawful to discriminate against someone because of age, disability, gender reassignment, marital or civil partnership status, pregnancy and maternity, race, religion or belief, sex or sexual orientation 
  • We must be aware of our own judgements and reflect on how our practice could encourage or inadvertently discourage equality and diversity 
  • It is important to be able to raise issues and challenge colleagues should any behaviour lead to discrimination. 

Emerging issues

The National Health Service (NHS) is designed to improve, prevent, diagnose and treat both physical and mental health problems for every individual it serves with equal regard. This is irrespective of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity or marital or civil partnership status. The NHS also has a wider social duty to promote equality through the services it provides, especially to groups or sections of society where health and life expectancy could be improved.

The Equality Act (2010) legally protects people in the UK from discrimination in the workplace and in wider society. It aims to reduce socio-economic inequality, prohibit victimisation, eliminate discrimination and to increase equality of opportunity2. Diversity involves recognising, respecting and valuing individuals' differences. It aims to encourage those differences to create a cohesive community and working culture for the benefit of organisations and individuals. 

The GP's role in reducing discrimination and enhancing inclusion

Working in the NHS, we have authority and influence over fellow colleagues and patients and it is important to recognise the impact we have on those around us. This is especially important when considering our duty not to discriminate against our patients or colleagues and to encourage equality and diversity3.  

Discrimination can be defined as the practice of treating individuals less fairly than other people or groups. The Equality Act (2010) protects people from discrimination on the basis of nine 'protected characteristics': 

  • Age 
  • Disability; this includes physical and mental impairment 
  • Gender reassignment; this includes a person proposing to undergo, is undergoing or has undergone a process of changing their physiological or other attribute of sex 
  • Marriage and civil partnerships 
  • Pregnancy and maternity; this includes breastfeeding 
  • Race; this includes colour, nationality, ethnic or national origins 
  • Religion or belief; this includes a reference to a lack of religion or belief 
  • Sex; note some people may not identify with either gender group and this is referred to as non-binary gender or non-gender 
  • Sexual orientation; this includes lesbian, gay, bi-sexual and heterosexual people

Equality law affects all staff of a healthcare or social care organisation that provides services to the public. Services must not treat someone worse than another individual because of having one or more protected characteristics (this is direct discrimination and unlawful), for example it must not be made more difficult for someone with a protected characteristic to access their services. 

Other characteristics to consider (which are not of the nine protected characteristics) include any that increase the likelihood of difficulties for individuals or groups accessing care. These include: 

  • Socioeconomic reasons (for example, being homeless) 
  • Being a carer or dependent 
  • Having a diagnosis with a potentially stigmatising condition (for example, mental health or lifestyle related conditions such as obesity or those caused by smoking, alcohol or drug use).  

It is against the GMC's Good Medical Practice guidance to refuse or delay treatment because of our belief that a patient's actions or lifestyle have contributed to their condition.

Further aspects of Equality and Diversity can be considered from the following three areas: 

  1. The Practitioner 
  2. The Patient (or carer where appropriate) 
  3. As part of a team 

The Practitioner

Equality and Diversity is enabled through effective recognition of the communication needs of individual patients and colleagues. It is also important to be aware of our own judgements and to reflect on how our practice could encourage or inadvertently discourage equality and diversity (for example, ageism may result in conditions like dementia being underdiagnosed and underreported6). Furthermore, we may feel we have difficulty understanding or empathising with particular individuals or groups potentially resulting in discrimination (for example, those with a criminal history, sex workers or those with different political views). 

The GMC's Good Medical Practice states 'You must not unfairly discriminate against patients or colleagues by allowing your personal views to affect your professional relationships or the treatment you provide or arrange'. Should this occur, it is important to inform them about their right to see another doctor and to ensure they have enough information to exercise that right without implying or expressing disapproval of the patient's lifestyle, choices or beliefs.

It is also unacceptable to allow discrimination from a patient to go unchallenged, should they refuse treatment because of sex, race, religion, sexual orientation or any other protected characteristic. 

The Patient

Patients need care that is in keeping with their own beliefs and values, irrespective of the religion or beliefs of the healthcare professional.8 Patients must also receive care that meets their communication needs – both mental and physical; all organisations in England that provide NHS care are legally required to follow the Accessible Information Standard which aims to ensure people who have a disability are provided with information that they can easily read, understand and receive appropriate support to help them communicate.  

Organisations must consider in advance as well as respond to present needs of disabled patients so reasonable adjustments for the patient can be made. This could include: 

  • How people enter and find their way around 
  • What information and signs are provided  
  • How people communicate with staff
  • Adjustments to appointment times and length

The Team

Equality and diversity encourages the promotion of inclusion as well as protects employment rights. It is important to be able to raise issues and challenge colleagues should any behaviour lead to discrimination.  

Regarding the team, some areas to consider include our attitudes towards colleagues who are: 

  • At different positions in the health organisation (for example, junior doctor, salaried or partners) 
  • Working varying shifts (locum doctors, portfolio, limited sessions or taking career breaks)  
  • Proportionally underrepresented (for example, fewer doctors from lower socioeconomic backgrounds) 
  • From groups that have lower pass rates in examinations and assessments   

Employers must treat their staff fairly and with dignity and respect. Clear equality policies should be available and staff appropriately trained. Equality and diversity data on recruitment processes and workforce should be collected to inform working practices and to ensure transparency. 

How to learn this area of practice

Learning with other healthcare professionals

Primary care teams are highly sophisticated multi-professional groups. The opportunities for you to participate in shared learning with colleagues have expanded, particularly following the extension of non-medical prescribing and extensive collaborative working on long-term conditions and integrated care. 

In addition, you have many opportunities in primary care to discuss equality and diversity with nurses, allied health professionals and managers, all of whom should be engaged in the practice’s education and clinical governance programmes.  

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT) 

  • Disease patterns in different populations 
  • Awareness of protected characteristics of Equality legislation 
  • Genetic variation affecting response to drugs   

Clinical Skills Assessment (CSA)

  • Woman with raised BP in late pregnancy lives in a travelling community and cannot return to you for follow up as she is due to move on again.   
  • Muslim man with insulin dependent diabetes wishes to fast during Ramadan  
  • Young man who is a wheelchair user wants your written support in his claim of discrimination at work 

Workplace Based Assessment (WPBA)

  • Consultation Observation Tool (COT) on a patient with a learning disability who isn't turning up for her blood tests 
  • Learning log on the challenges using a sign language interpreter in a consultation with a patient with impaired hearing 
  • Case Based Discussion (CbD) about a patient who requested a termination, after the doctor she initially consulted refused to refer her. 

References

1 The NHS Constitution 27 July 2015 p3 
2 Equality Act 2010, p1  
3 The NHS Constitution 27 July 2015 p14 
4 Good Medical Practice, General Medical Council, 2013, p19 
5 Equality and diversity strategy 2014-17, General Medical Council, p9 
6 Good Medical Practice, General Medical Council, 2013, p17-20 
7 Equality and diversity strategy 2014-17, General Medical Council, p9 


Evidence based practice

This Topic Guide will help you understand important issues relating to evidence-based practice, research and sharing knowledge by describing the key learning points.

Summary

  • Evidence-based healthcare involves using scientific rigour to appraise evidence from a wide range of sources to best benefit the patient or the service. Primary care research can enhance understanding about the causation, prevention and treatment of disease, which can in turn guide effective and relevant health policies and practice.
  • As a GP, you should be able to understand and communicate the results of relevant population-level research, and to decide whether the findings are applicable to your own patients. In particular, you should be able to effectively communicate risk 
  • Whilst being able to adopt a non-judgmental, evidence-based approach, it is essential to adopt a collaborative approach to care. This requires taking into account the patient’s values, priorities and circumstances, the community, and the healthcare setting 
  • Be aware of individual bias (including unconscious bias) in interpreting data, and follow the GMC's Good Medical Practice guidance in respecting culture, disability, religion, gender, sexuality, social and economic status 
  • As learners and teachers, every GP should be equipped to share knowledge with others through, for example, teaching, mentoring and supervision. 

Knowledge and skills guide

As a GP, you are expected to understand the principles, strengths and limitations of evidence-based practice. The process of evidence-based practice was defined in the Sicily statement, 20031. It involves five steps: 

  1. Translation of uncertainty into answerable questions 
  2. Systematic retrieval of the best evidence available 
  3. Critical appraisal for validity, clinical relevance and applicability 
  4. Application of results in practice 
  5. Evaluation of performance (at an individual or organisational level)   

This topic overlaps with others and, in particular, should be considered in conjunction with the following RCGP Topic Guides: 

  • Consulting in General Practice 
  • Improving Quality, Safety and Prescribing 
  • Population Health 

Transferrable research and academic skills

As a GP, you will need to acquire the research and academic skills that are necessary to keep up-to-date with progress in your field and to aid your decision-making. These skills may be applied in many areas of practice, including: 

  • the clinical management of patients, including treatment, referral, and acute care;  
  • dealing with uncertainty (through the use of best available evidence);  
  • challenging established practice and abandoning ineffective practices; 
  • prescribing; 
  • enabling safer working systems; 
  • improving the quality of health promotion and preventive medicine in your practice; 
  • audit and quality improvement within your practice or organisation; 
  • lifelong learning; 
  • improving population health, through engagement in activities ranging from local healthcare commissioning and public health policy to global climate change and sustainability; and
  • primary care research, management, medical education or specialist roles. 

A GP is expected to understand basic research methodology (for example, the difference between qualitative and quantitative data, and studies using social science methods as well as bioscience) and how different types of research activity may contribute to patient care. This includes: 

  • Qualitative and quantitative research:
    • differences in forms of research and when each is appropriate; 
    • patient factors requiring both quantitative and qualitative analysis (for example, concordance with treatment); and 
    • techniques such as pilot studies, questionnaire design, field observations, interviews, focus groups and analysis of transcripts of narrative material; ethnography and observation, action research, case study; consensus methods such as Delphi or nominal groups 
  • Study designs and their advantages and disadvantages including: 
    •  systematic reviews and meta-analysis;
    •  experimental: randomised controlled double blind; 
    •  quasi-experimental: non-randomised control group; and 
    •  observational: cohort (prospective, retrospective), case-control, cross-sectional. 
  • The most appropriate research design to examine a hypothesis: 
    • knowledge of the 'hierarchy of evidence' ranging from case reports, through case-control and cohort studies, to randomised controlled trials, systematic reviews and meta-analyses; 
    • strengths and limitations of research methodologies; and 
    • multi-morbidity research and its limitations 
  • Differences between research, clinical audit and quality improvement

Epidemiology concepts (see also Topic Guides on Population Health and Infectious Disease and Travel Health) 

As a GP, you share responsibility for the health of your local population and should understand fundamental concepts in epidemiology. These include: 

  • The main reasons for patients consulting in UK primary care  
  • Population statistics including incidence, prevalence, mortality ratios, death rates  
  • Differences between population and individual risk 
  • Risk of disease in population groups, including your own practice population 
  • Qualitative measurements of health and approaches to qualitative research such as focus groups, Delphi analysis, ethnography 
  • Decisions or interventions made in the interests of a community or population of patients (for example, immunisation) 
  • Psychosocial, cultural, political, economic and other social determinants affecting evidence-based practice 
  • Inequalities in healthcare access and delivery. 

Statistical concepts and terminology

As a GP, you are expected to know some basic statistical terminology, including the terms listed in the table below, and be able to conduct simple calculations for evidence-based practice. 

 

  • Absolute risk (AR)   
  • Meta-analysis                     
  • Absolute risk increase (ARI) or reduction (ARR)
  •  Mode 
  • Association
  •  Negative predictive value (NPV) 
  • Bayesian probability 
  •  Null hypothesis 
  • Bias 
  •  Number needed to harm (NNH) 
  • Blinding 
  •  Number needed to treat (NNT)  
  • Case control 
  •  Odds & Odds Ratio 
  • Case fatality 
  •  Positive predictive value (PPV)  
  • Cohort
  •  Prevalence 
  • Confidence intervals 
  •  Probability 
  • Confounding 
  •  p-values  
  • Correlation
  •  QALY (quality adjusted life year) 
  • Crossover
  •  Randomised controlled trial (RCT) 
  • Cross-sectional 
  •  Range 
  • DALY (disability adjusted life year) 
  •  Regression to the mean 
  • Data types (categorical, ordinal, continuous) 
  •  Relative risk (RR) 
  • Discrimination 
  •  Relative risk reduction (RRR) 
  • Distributions (normal and non-parametric) 
  •  Reliability 
  • Event rate
  •  Risk ratio 
  • Generalisability 
  •  Sampling 
  • Hazard Ratio 
  •  Sensitivity 
  • Incidence 
  •  Specificity 
  • Inclusion/exclusion criteria 
  •  Standard deviation (SD) 
  • Likelihood ratios 
  •  Standardised mortality rates and ratios 
  • Mean 
  •  Systematic review 
  • Median  
  •  Trends  
 
  •  Triangulation 
 
  •  Type 1 and 2 errors 
 
  •  Validity (internal and external) 

Critical appraisal

Your understanding of research design, epidemiology, and statistical concepts will help you to critically appraise written or graphical information such as trial results or abstracts, clinical governance data (audit, benchmarking, performance indicators) and data presented in medical journals. Further knowledge in this area includes: 

  • Clinical interpretation of results from common statistical tests, for example: 
    • analysis of variance, multiple regression, t-tests and non-parametric data (for example, chi squared, Mann-Whitney U); and 
    • simple (symmetrical, skewed) distributions, scatter diagrams, box plots, forest plots, funnel plots, statistical process control charts, Cates diagrams, decision aids 
  • Difference between causation and correlation 
  • Types of bias, reliability, validity, and generalisability 
  • Influence of individual bias and social factors on interpretation of research results 
  • Evaluation of guidelines to determine how suitable they are for clinical practice (including methodology, evidence-base, validity, applicability, authorship and sponsorship) 
  • Strengths and limitations of surveys and local healthcare reviews. 

Evidence in practice

As a GP you should be aware of the skills needed to improve population, as well as individual, health. You should apply your understanding of evidence to your own practice and set your own learning objectives based on your clinical experience.  

Further knowledge and skills in this area include: 

  • Applicability of population-level studies to individuals and certain groups (for example, groups commonly excluded from clinical trials, disadvantaged groups) 
  • Applicability of research results/conclusions to clinical practice 
  • Effective communication about evidence-based interventions to help patients make decisions about their health, including methods of calculating, demonstrating and explaining risk to patients  
  • How to search for and retrieve valid information (including using online and other resources to help your own learning) 
  • Influence of health economics studies on healthcare resource allocation and guidelines  
  • Pharmaceutical marketing 
  • Potential tensions between evidence-based practice and patient values/choices 
  • Predictive personalised care (for example, drug treatment)  
  • Reasons for lack of evidence about certain interventions (for example, rare conditions, conditions that have low morbidity or low pharmacological input) 
  • Recognising that poverty is a common cause of ill health and consider this when interpreting research. For example, a health outcome attributed to a certain characteristic (for example, ethnicity) may be due to an underlying environment of disadvantage 
  • Role of large GP records databases (for example, QResearch, the Clinical Practice Research Datalink etc.) and how to contribute patient data to these 
  • Use of decision aids and information technology in clinical and professional practice. 

Screening (see also RCGP Topic Guide on Population Health)

  • Information available to patients to aid decision making with regard to screening 
  • Population-based prevention strategies including immunisation, health screening and population screening 
  • Principles of screening (for example, Wilson’s criteria) and the concepts of primary, secondary and tertiary prevention; their application to screening programmes and recall systems 
  • Risks and benefits of screening programmes. 

Sharing knowledge

As a GP you have a role in sharing knowledge with others. This may include formal or informal teaching, mentoring, supervising colleagues and peers, and education in the wider community. Underpinning this is the need for better patient care. Important principles include: 

  • Understanding that teaching other people involves more than imparting information 
  • The difference between clinical and educational supervision and the different competences required in the two roles 
  • Being prepared, as a doctor, to act as an educator and learner within your local community 
  • Approaches to effectively teach and mentor others within a team  
  • How to engage those you are teaching in a dialogue about their values and goals 
  • Techniques to adjust your own teaching style to suit the individual as well the subject, being aware that not every individual will learn in the same way 
  • How to give and receive effective feedback from individuals or groups, following the principles described in the General Medical Council's Good Medical Practice 
  • Understanding of information governance, intellectual property, legal, privacy and security issues when sharing knowledge (including via online and social media channels), particularly when this involves other people’s work or identifiable information about individuals. 

Ethics and governance in education and research

As a GP you are likely to participate directly or indirectly in research and educational activity which may have ethical and clinical governance implications. For example, you may be an educational supervisor or academic GP, your practice may be part of a research network, or you may be asked to assist in recruiting patients to clinical trials. Also, you may see patients who are involved in clinical trials or be asked for your professional or expert opinion on a piece of research. It is important, therefore, to understand the ethical and governance principles that underpin such activities, and have an awareness of your own attitudes, values, professional capabilities and ethics in this context. 

While promoting the benefits, you should assure patients that participation in research and education is voluntary and that declining to participate will not negatively impact on their care. 

Important areas of knowledge in this area include: 

  • Autonomy and patient choice 
  • Confidentiality and information governance (including relevant legislation) 
  • Conflicts of interest (for example, incentives for certain interventions) 
  • Consent  
  • Ethical approval and role of ethics committees 
  • Impact on patients and staff of GP research 
  • Patient safety  
  • Research fraud

How to learn this area of practice

Portfolio-based learning (for example, the RCGP e-Portfolio) is a useful approach to manage your professional education, serving as a continually updated repository to enable your knowledge, reflections and learning to be recorded and reviewed. Learning entries may arise from a wide range of activities. These include:

  • Compliments and complaints 
  • Critical and significant event analyses 
  • Discussions with peers, mentors and teams 
  • Feedback from teaching sessions 
  • Guidelines (for example, NICE, SIGN) 
  • Learning events – such as attendance at lectures, courses and workshops 
  • Online learning and e-Learning activities 
  • Patient feedback surveys and engagement meetings 
  • Practice-based learning events or learning with a group of peers 
  • Quality Improvement Projects (including audits) 
  • Reading journals and electronic materials 
  • Reflection on a patient’s unmet needs (PUNs) or the doctor’s educational needs (DENs) 
  • Structured feedback from supervisors, colleagues and teams

To become an effective and efficient professional learner, it is important to develop the habit of embedding your learning and continuing professional development (CPD) into your daily practice (in all your roles), adapting your approaches to your personal development aims and the context in which you work. 

Discussions with supervisors, appraisers and mentors will enable you to recognise not only your preferred learning style but also the best learning opportunities for specific needs. For instance, new NHS guidelines can be learnt through reading documents or attendance at a lecture, but the development of a new system of care within a practice may best be achieved by learning and working with your practice team. 

A good understanding of how you and your colleagues learn will not only help you in your own CPD but also enable you to help develop the whole team through group learning activities. 

Work-based learning

Learning from contact with patients (including direct observation of clinical contact) is a prerequisite for good practice. It may not always be easy, however, for you to apply evidence in daily clinical practice – for example, when working with a patient who has views or values that diverge from your own. However, patients and carers will often place their trust in your advice, which is why it is important that you build a sound evidence-base to inform your decisions, gained from understanding research papers, reviews and clinical guidelines.  

Many learners find it more engaging to practice critical appraisal skills within a team context (for example, appraising and debating a guideline or research paper within a journal club). Similarly, many of your best learning opportunities may come from team discussions relating to significant event audits, audits performed in the practice or from audit data collected around the locality and used as a benchmarking tool to compare practice performance.  

Additionally, working with research networks allows you to get a sense of research governance and the principles of good research practice.   

Self-directed learning

Self-directed learning, reading books, journals, abstracts, reviews, and editorials, amongst other sources, will give you an excellent opportunity to engage in topics you choose yourself, guided by your own educational needs. e-Learning modules, such as the RCGP Essential Knowledge Updates, provide opportunities to learn new clinical information. Local audit group meetings may provide opportunities to learn about audit. You can find an e-Learning module(s) relevant to this topic guide at e-Learning for Healthcare

Multi-disciplinary learning

You can obtain useful knowledge and skills from a wide range of different professionals. This could be through direct clinical contact with other professionals providing services to your patients – for example, in clinics with midwives, practice nurses, and health visitors. Opportunities also exist through carefully reading correspondence from other professionals. Other sources include in-house or locality-based educational programmes. Multi-disciplinary team working offers the opportunity for many different staff to work together and understand each other’s perspectives.  

Structured learning

There are many opportunities for more formal (structured) learning, such as courses on evidence-based practice. These include research and clinical update study days, which could be offered through RCGP or other hosts, such as university departments. Your local training programme will offer updates and workshops tailored for trainees.  

Academic work in general practice

Many GPs develop academic careers, in addition to their clinical work. This can be done through specific academic training posts, developed jointly by postgraduate/workforce deaneries and universities, or through becoming tutors in undergraduate medicine and developing academic research skills related to that. There are pathways for entering academic practice after getting your Certificate of Completion of Training (CCT), and you can get more information on this through the RCGP.

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT)

  • Interpretation of prescribing data audit and prioritising changes 
  • Calculating and explaining common terms used in risk communication such as ARR, RRR, NNT and NNH 
  • Interpretation of graphical and tabular data 

Clinical Skills Assessment (CSA)

  • Discussion with a patient who is unsure about whether they should start on a statin, after they have been identified to have a 10-year cardiovascular risk of 15%  
  • Phone call: a father wants to know why an antibiotic was not prescribed during an earlier consultation for his child, whom now has acute otitis media 
  • An elderly woman with well-controlled hypertension has been identified by a practice audit as having atrial fibrillation – but she is not taking anticoagulation therapy. 

Workplace Based Assessment (WPBA)

  • Log entry reflecting on the visit of a pharmaceutical company representative promoting a specific drug 
  • Audit of your antibiotic prescribing against current national guidance and evidence  
  • Consultation Observation Tool (COT) discussion about the risks and benefits of Hormone Replacement Therapy (HRT) for a perimenopausal woman.

References

1 Dawes M, Summerskill W, Glaziou P et al. Sicily Statement on evidence-based practice BMC Medical Education 2005: 5; 1 


Improving quality safety and prescribing

This Topic Guide will help you to understand important issues relating to improving quality, safety and prescribing by describing the key learning points. 

Summary

  • It is an essential part of your professionalism as a doctor to regularly review the standards of practice and care that you and your team provide. Improving patient safety and quality are fundamental to reducing the risk of preventable injury, suffering, disability and death and are necessary to enhance the experience and outcomes of care.
  • The working environments, systems and behaviours of those working in health can all influence patient safety. Working in partnership with patients and carers and promoting an organisational culture that allows everyone to be honest (and raise concerns openly) is an essential part of sustaining a safe working environment.
  • Clinical Governance is the system through which organisations are accountable for continuously improving the quality of care and maintaining high standards. Understanding how to apply tools and metrics to monitor this is key to improving the quality of care.
  • Quality improvement skills are now regarded as essential for every doctor. These involve the application of a systematic approach that uses specific, evidence-based techniques to improve and maintain quality.
  • Safe, effective prescribing and monitoring of medications (and other healthcare interventions) is essential to ensure high-quality, safe care. Patients are vulnerable to mistakes being made in any one of the many steps involved in ordering, dispensing and administering medication and other healthcare products.

Knowledge and skills guide

Patient Safety

The duties of every doctor registered with the General Medical Council begin with making the care of the patient your first concern10. Patient safety includes the prevention of errors and adverse effects to patients associated with health care2. A patient safety incident is any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS care. Patient safety is fundamental to reduce risks of preventable injury, suffering, disability and death. Patient safety integrates into all areas of health care and is key to improving quality.  

Quality in general practice can be considered in terms of the following six areas: 

  1. Safety: avoiding injuries to patients from the care that is intended to help them 
  2. Timeliness: reducing waits and sometimes harmful delays for both those who receive and those who give care 
  3. Effectiveness: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit 
  4. Efficiency: avoiding waste, including equipment, supplies, ideas and energy 
  5. Equality: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status  
  6. Person-centredness: providing care that is respectful of and responsive to individual patient preferences, needs, and values3

One of the greatest challenges in healthcare is delivering safer care in complex, pressurised environments where adverse events, including unintentional but serious harm, can occur4. There is, on average, a 1 in 300 chance of a patient being significantly harmed by their healthcare5 and adverse events may result from problems in practice, products, procedures or systems. Safety studies show that worldwide about 20-40% of all health spending is wasted due to poor-quality care resulting in additional hospitalisation, litigation costs, infections acquired in hospitals, disability, lost productivity and medical expenses6.  

It is important to be aware of each individual’s own capabilities, values, ethics and accountability. There may be ethical tensions inherent in governance processes and resource allocation. Personal health and well-being must be maintained (for example, being immunised against common or serious communicable disease where appropriate). It is important to protect patients and colleagues by managing risk while adhering to GMC fitness to practise guidance. 

The working environment, systems in place (including IT, the quality of data entry and communication between professionals) and behaviours of those working in health can all influence patient safety. It is important to review and reflect on the standards of practice and the care that is provided. The diversity of practices and the variation in patient demographics means a variety of measures is important for a broad, balanced view.

Clinical governance

Clinical Governance is the system through which organisations are accountable for continuously improving the quality of services and standards of care. This involves recognising and responding to practice variation, understanding Quality Improvement (see further below) and applying key tools such as clinical audit, significant event analyses and improvement methodology. Patient safety incidents, near misses and complaints are part of a jigsaw of information that can be used to share and learn lessons. Understanding how to monitor and when to apply tools and metrics to improve the quality of care is a key skill that should be learnt and developed, this is essential for personal and collective professional development.  

Working with patients and carers and promoting an organisational culture that allows them and all staff to be honest and raise concerns openly is essential. Some patient groups may be more at risk due to characteristics such as language, literacy, culture and health beliefs. 

When risks to safety happen, immediate action must be taken (for example, an error in patient diagnosis, inadequate resources or a colleague who is not fit to practice and is putting patients at risk). Where appropriate:  

  • Record or report the concern or incident 
  • Offer help in emergencies 
  • Admit when an error has occurred 
  • Communicate openly to those involved 
  • Apologise and explain fully to those affected 
  • Advise on how patients can raise issues or complain 
  • Personally reflect and share any learning

Quality and safety within the NHS in England, Scotland, Wales and Northern Ireland is managed by devolved regulatory organisations. The Care Quality Commission (CQC) oversees the quality of healthcare in England. In Scotland the role of the CQC is fulfilled by the Care Inspectorate and in Wales by the Care Standards Inspectorate for Wales. In Northern Ireland, the role is carried out by the Regulation and Quality Improvement Authority (RQIA), which includes registration of providers including GP practices.  

Other organisations such as The National Institute for Health and Care Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN) play an important role in the safety and quality of clinical interventions and patient pathways. 

Prescribing

The term 'prescribing', as used in the RCGP curriculum, describes many clinical activities closely related to safety and quality, including prescribing medicines, devices, dressings and other products, as well as advising patients on the purchase of over the counter medicines and other remedies. Prescribing may also be used to describe written information provided for patients (information prescriptions) or advice given7. This topic guide will mainly focus on illustrating the general principles around the prescribing of prescription-only medicines – please refer to other topic guides for condition-specific treatments. 

Prescribing and monitoring of medications and other products needs to be understood, developed and explored to ensure high-quality, safe care. Unsafe prescribing practices and prescribing errors are a leading cause of patient safety incidents across the world8. This includes adverse reactions to medications which can be defined as any response that is noxious, unintended and occurs at doses used for prophylaxis, diagnosis or therapy9

Patients are vulnerable to mistakes being made in any one of the many steps involved in ordering, dispensing and administering medication and other products.  

The causes of medication errors include a wide range of factors including:  

  1. inadequate knowledge of patients and their clinical conditions 
  2. inadequate knowledge of the medications 
  3. calculation errors 
  4. illegible handwriting on the prescriptions 
  5. confusion regarding the name of the medication 
  6. poor history taking10 

When prescribing, it is essential to follow the law and GMC guidance11 and to take account of licensing and local prescribing guidance as well as other relevant regulations. This includes clinical guidelines published by: 

  • NICE (England) and SIGN (Scotland) 
  • Scottish Medicines Consortium and Health Improvement Scotland (Scotland) 
  • Department for Health, Social Services and Public Safety (Northern Ireland) 
  • All-Wales Medicines Strategy Group (Wales) 
  • Medical royal colleges and other authoritative sources of specialty specific clinical guidelines  
  • The British National Formulary (BNF) and the BNF for Children

The process of prescribing requires:

  • A targeted assessment of the patient and other information sources (for example, the medical record and carers) to elicit sufficient knowledge of the patient and their conditions, and all medication they are taking (including over the counter treatments)  
  • An appropriately detailed understanding of the patient's history, including any previous adverse reactions to medicines and recent use of other medicines (including over-the-counter and herbal medicines, illegal drugs and medicines purchased online) 
  • Wherever possible, an agreement with the patient and their carers on the treatment proposed, appropriately explaining:
    • expected benefits and risks, including serious and common side effects;
    • what to do in the event of a side effect or recurrence of the condition;
    • how and when to take the medicine and how to adjust the dose if necessary (or how to use a medical device);
    • duration of treatment; and
    • arrangements for monitoring, follow-up and review, including further consultation, blood tests or other investigations, processes for adjusting the type or dose of medicine, and for issuing repeat prescriptions if appropriate (for example, DMARDS, warfarin, lithium)
  • That the prescription is in the patient's best interests (including potentially dependent medications, for example, opioids, benzodiazepines and z-drugs)
  • The right patient is issued with the correct prescription
  • The correct dose is prescribed (particularly if the dose has previously varied for example, in children)
  • The prescription is clear and legible in accordance to statutory requirements
  • Accurate and timely documentation on the patient's record
  • Preparation of the prescription for authorisation by staff who are competent to do so
  • Reviews by a suitable healthcare professional at an appropriate time, including monitoring of the patient's condition and confirming that the medicines are being taken as directed and are still needed – as well as being effective and well-tolerated. 

Further points about prescribing can be considered in relation to the following three areas: 

  • The Prescriber 
  • The Patient (and/or carer where appropriate) 
  • As part of a team and the wider system 

The Prescriber

As a prescriber, your role is to:

  • Recognise and work within the limits of your competence 
  • Maintain and develop your knowledge and skills in pharmacology, therapeutics and medicines management relevant to your role and prescribing practice 
  • Be responsible for all prescriptions signed and for decisions and actions when prescribing, including if prescribing at the recommendation of another healthcare professional 
  • Avoid prescribing for yourself or anyone with whom you have a close personal relationship wherever possible 
  • Be aware of your own prescribing practice (using local data where appropriate) and the potential influence and expectation from peer, patient and commercial pressures 
  • Consider the benefits, impacts and risks of prescribing in the following situations: 
    • via telephone, video-link or online; 
    • signing prescriptions generated by others; 
    • generating repeat prescriptions; 
    • when prescribing unlicensed medication; and 
    • your own previous experience of medications. 

The Patient

Safe and effective prescribing always involves consideration of the patient and their unique circumstances, for example: 

  • Take into account prescribing in special conditions such as with patients who are pregnant, breast feeding, have renal or hepatic impairment or palliative care needs 
  • Provide patients with information in patient information leaflets (PILs) and other reliable sources of information (for example, NHS Choices and resources bearing The Information Standard quality mark) where appropriate 
  • When prescribing, consider whether requests for repeat prescriptions received earlier or later than expected may imply poor adherence which could lead to inadequate treatment or adverse effects 
  • It is important to apply effective strategies for communicating about and reducing the risk of dependency or addiction to medicines where this may occur (for example, opioids, benzodiazepines, GABA drugs) as well as supporting and managing patients who have become dependent on medications, seeking specialist advice and intervention when appropriate 
  • If you consider that a requested prescription would not be of overall benefit, you should explore the reasons for the request with the patient or carer. If you still consider the prescription would not be of overall benefit, or is likely to be harmful, you should not prescribe it and should explain the reasons for your decision. You should also explain what other options are available (including the option for the patient to seek another opinion) 
  • Where patients do not take a medicine as prescribed, a discussion to understand the reasons for this should take place and any further information or reassurance provided where appropriate. The aim should be to reach a shared understanding and an agreed course of treatment the patient is able and willing to adhere to.  
  • Consider the impact of polypharmacy and, where appropriate, consider support structures such as carers, district nurses or the use of dosette boxes 
  • Under current rules, the NHS only accepts responsibility for supplying ongoing medication for temporary periods abroad of up to three months. If a patient will be abroad for longer, then the patient should be given a sufficient supply of their regular medication to enable them to get to their destination and find an alternative supply  
  • If prescribing for patients who going abroad or who are overseas, consider how the patient's condition will be monitored. Also consider whether there is a need for additional indemnity cover or registration with a regulatory body in the country in which the prescribed medicines are to be dispensed.  
  • Advise patients on exemptions from prescription charges where appropriate (a full list of exempted conditions is available on the NHS Business Services Authority website) 
  • Acknowledge the benefits of drug switching but also the potential confusion that may be experienced if the colour and shape of medicines are changed and the impact repeated switching may have on trust and compliance. 

The Team and Wider System

Safe and effective prescribing also requires an understanding of the organisational systems in place for medication prescribing, issuing, monitoring and review: 

  • Ensure drugs are received, stored and disposed safely and appropriately 
  • Make use of electronic and other systems that can improve the safety of prescribing (for example, by highlighting interactions, allergies and by ensuring consistency and compatibility of medicines prescribed) 
  • Work with pharmacists and consider their role in delivering medication, conducting medicines reviews, explaining how to take medicines and offering advice on interactions and side effects 
  • If unsure about interactions or other aspects of prescribing, seek advice from experienced colleagues including pharmacists, prescribing advisers and clinical pharmacologists 
  • Information about medicines should accompany patients (or quickly follow) when patients are transferring between care settings (for example hospital, nursing or residential placement) 
  • Ensure any changes to medications (for example, following hospital treatment or due to blood or microbiology results) are reviewed and quickly incorporated into the patient's record 
  • Inform the Medicines and Healthcare products Regulatory Agency (MHRA)12 about suspected adverse reactions and incidents using the Yellow Card Scheme13. Where appropriate, inform the patient's GP and the pharmacy that supplied the medicine  
  • Inform the patient's general practitioner if prescribing for a patient but you are not their general practitioner 
  • Drug switching may be externally recommended (for example, by specialists or Clinical Commissioning Groups) for quality reasons such as efficacy or efficiency. Consider the impact of drug switching in the patient's best interest and the impact of cost saving on the wider system 
  • Consider the impact antibiotic prescribing has on the wider system with regards to drug resistance 

Quality Improvement

"In order to practise medicine in the 21st century, a core understanding of quality improvement is as important as our understanding of anatomy, physiology and biochemistry"
Stephen Powis, Medical Director, Royal Free London NHS Foundation Trust, 2015

Quality Improvement requires continuous improvement through critical thinking and understanding of the complex healthcare environment, application of a systematic approach to design, and testing and implementation of changes whilst measuring and reviewing outcomes. The aim is to understand and make a positive difference to patients by improving healthcare processes and services including safety, effectiveness and experience of care. 

This requires a working knowledge of: 

  • the principles of Quality Improvement; 
  • how quality improvement benefits patients, staff and organisation; 
  • the importance of context and organisational culture and how this impacts quality improvement work; 
  • the importance of safety, team work and human factors;  
  • the importance of involving patients and carers in quality improvement work – and how to do this effectively; 
  • the role of data to both assess improvement needs and measure improvements; 
  • the effectiveness of small cycles of change; 
  • the role of critical incident reporting and significant even analysis; and 
  • the common barriers that prevent teams from introducing a clinical quality improvement and ways to identify and address these.  

All GP trainees are required to complete a Quality Improvement Project (QIP) during their GP specialty training, as part of Workplace Based Assessment for the MRCGP.  

As a GP, and in order to successfully complete Quality Improvement activity, the following knowledge and skills are required: 

  • The role of systems in healthcare and understanding variation 
  • The likely differences in impact and sustainability between changing systems and changing within systems 
  • Management theory and change concept models used to improve system and process reliability 
  • The effects of equipment, environment and human factors including teamwork, culture and organisation when designing or evaluating system safety or reliability 
  • Application of root cause and systems analysis methods 
  • Systems design principles that make it easy for healthcare workers to do the right thing or to make errors 
  • Definition of processes, process mapping and assessment of process value 
  • Outcome theories relevant to quality improvement in healthcare  
  • Improvement models including Plan Do Study Act (PDSA) cycle and its application to healthcare 
  • Setting a specific improvement aim statement including how much by when 
  • Understanding of statistics and application of tools (for example, run charts, process mapping, tally charts, Pareto charts, statistical process control charts, driver diagrams) 
  • Clinical audit cycles, their role as quality improvement tools and their limitations 
  • Methods for defining outcomes and linking how improving outcomes are linked to improving processes 
  • Rationale for predicting outcomes before the test 
  • Methods and practices for implementing a change, spreading, evaluating and sustaining improvement  
  • Understanding stakeholders and the features of effective team communication and ways to influence others (i.e. adopting an approach that is safe, inclusive, open, seeking common goals and consensus seeking).

How to learn this area of practice

Work-based learning

It is essential that GP trainees gain a good understanding of quality improvement, prescribing and patient safety before completing training. Primary care settings, both inside and outside the practice, are ideal environments to learn and apply the key principles.

All GP trainees should complete a quality improvement project relating to patients in their training practice and actively contribute to the practice's significant event audit meetings. Recognising this as an opportunity for reflection as well as possible celebration of good care is a particular feature of primary care teams.

As a GP specialty trainee you should take the opportunity to visit your local primary care commissioning organisation or health board, in order to understand the role of clinical governance leads. Observing a governance committee would help you in understanding their associated processes. This may change over time with the impact of practices working together as federations and, in England, with the formation of Sustainability and Transformation Plans (STPs) and changes to Clinical Commissioning Groups.

Observing the systems developed by a practice to manage repeat prescribing and exploring the team's decisions about to manage risk in this process can provide valuable insights. It is also worthwhile considering the variation in impact and uptake of NICE guidance. Likewise, the processes that occur during a consultation when a decision to refer is made, as well as the practical systems in place to achieve the referral, are ideally explored within the primary care setting. Reflecting on cases that illustrate a delay in diagnosis using tools such as Significant Event Analysis (SEA) can help in understanding the complex process of diagnosis, within both the primary and the secondary care setting.

Learning about the differences between primary and secondary care will help the specialty trainee gain a broader understanding of the principles and practice of clinical governance and how to maximise benefit for patients. There should be opportunities to undertake clinical audits and critical event analysis with hospital colleagues.

Root Cause Analysis (RCA) is the standard risk tool used in secondary care and familiarity with its application can be best observed in this setting. Specialty trainees should be able to describe the particular role of risk managers in acute trusts and this is best appreciated while in this environment.

The primary/secondary care interface is especially vulnerable to patient safety incidents. Observing and understanding how different systems and processes manage this and other key transitions of care (for example, between health and social care) can often reveal areas for quality improvement.

Learning with other healthcare professionals

Primary care teams are highly sophisticated multi-professional groups. The opportunities for you to participate in shared learning with colleagues have expanded, particularly following the extension of non-medical prescribing and extensive collaborative working on long-term conditions and integrated care.

In addition, you have many opportunities in primary care to discuss clinical governance with nurses, allied health professionals and managers, all of whom should be engaged in the practice's education and clinical governance programmes.

Unscheduled care in the community, both in hours and out of hours, is provided by a variety of different contractors utilising the skills of practitioners such as paramedics, emergency care practitioners, urgent care centres, crisis mental health teams and walk-in centres. These are ideal places for you to see and understand the use of skill-mix in healthcare and to compare and contrast the benefits and disadvantages of each option, including the usage of telephone calls triage and calls using clinical pathways (such as the 111 service)

Examples of how topics may be tested in the three parts of the MRCGP

Applied Knowledge Test (AKT)

  • Drug monitoring requirements 
  • Safe prescribing in multimorbidty 
  • Controlled Drug regulations

Clinical Skills Assessment (CSA)

  • Your practice nurse sustains a needlestick injury while taking blood from an intravenous drug user 
  • An elderly woman whose INR is within the therapeutic window for only 40% of the time attends for review 
  • A middle-aged man who has recently registered attends for a review of his repeat medication which lists nine different medications

Workplace Based Assessment (WPBA)

  • Log entry about a significant event in which you have been directly involved  
  • Case discussion on the workflow of blood results for patients taking DMARDs to minimise the risk of harm 
  • Completing a Quality Improvement Project (QIP) on a locally-identified need, identifying intended outcomes, implementing the changes, measuring their impact and disseminating your learning. 

References

www.gmc-uk.org/guidance/good_medical_practice/duties_of_a_doctor.asp  
https://www.who.int/patientsafety/en/  
3 Crossing the Quality Chasm: A New Health System for the 21st Century, The Institute of Medicine, 2001 
4 WHO Patient Safety Curriculum Guide: Multi-professional Edition, 2011, WHO Library Cataloguing-in-Publication Data, Printed in Malta, p.8 
5 10 facts on patient safety - fact file version (World Health Organization)
6 www.gmc-uk.org/guidance  
7 www.who.int/patientsafety/en  
8 World Health Organization. International drug monitoring-the role of the hospital. A WHO report. Drug Intelligence and Clinical Pharmacy, 1970, 4:101-110 
Smite J. Building a safer NHS for patients: improving medication safety. London, Department of Health, 2004 
10 www.gmc-uk.org/Prescribing_guidance.pdf_59055247.pdf  
11 www.gov.uk/government/organisations/medicines-and-healthcare-products-regulatory-agency  
12 https://yellowcard.mhra.gov.uk/  


Leadership and management

This Topic Guide will help you understand important issues relating to leadership and management by describing the key learning points.

Leadership and Management is a continuously developing area of high importance and there are other helpful resources available. This Topic Guide does not replace them and will be regularly updated in view of the continuous developments.

Summary

  • The fundamental purpose of clinical leadership is to improve health outcomes and quality of care for your patients, so it is an essential part of being a doctor.
  • Your own personal characteristics and skills determine your ability as a leader and team manager and has a direct influence on the care your patients receive.
  • Leading and managing improvement in healthcare systems is just as important as, and complementary to, acting on behalf of an individual patient.  
  • Leadership is everyone’s responsibility and there is a wealth of evidence to show that a well-led organisation is a safer place to work and to receive care.
  • GPs play a growing range of leadership and management roles in the NHS, from running a practice through to leading GP federations, commissioning groups and integrated care organisations.

Effective primary care requires the co-ordination and commitment of a multi-professional team working in partnership with patients  Leadership is everyone's responsibility and there is a wealth of evidence to show that a well-led organisation is a safer place to work and to receive care. GPs play a growing range of leadership and management roles in the NHS, from running a practice through to leading GP federations, commissioning groups and integrated care organisations.

The role of the GP as a leader and manager in healthcare

In the 'Tomorrow's Doctors' (2009) the GMC stated that "It is not enough for a clinician to act as a practitioner in their own discipline. They must act as partners to their colleagues, accepting shared accountability for the service provided to their patients. They are also expected to offer leadership and to work with others to change systems when it is necessary for the benefit of patients."  

Good leadership practice has a direct impact on safe and effective patient care. The culture established by the leaders of a healthcare organisation is essential to enable a team that is able to work together in order to achieve the best outcomes for all patient populations. Being able to share knowledge within teams and the wider community (education, mentoring or change management) is a central principle of shared leadership. 

The GMC Generic Capabilities Framework (2017) included the domain of 'Capabilities in Leadership and Team working'. This requires doctors in training to demonstrate that they can lead and work effectively in teams by:  

  • demonstrating an understanding of why leadership and team working is important in their role as a clinician  
  • showing awareness of their leadership responsibilities as a clinician and why effective clinical leadership is central to safe and effective care  
  • demonstrating an understanding of a range of leadership principles, approaches and techniques  
  • demonstrating an ability to moderate their leadership behaviour to improve engagement and outcomes  
  • appreciating their leadership style and their impact on others  
  • thinking critically about decision making, reflecting on decision-making processes and explaining those decisions to others in an honest and transparent way  
  • supervising, challenging, influencing, appraising and mentoring colleagues and peers to enhance performance and to support development  
  • challenging and critically appraising performance of colleagues, peers and systems  
  • promoting and effectively participating in multidisciplinary, interprofessional team working  
  • understanding and appreciating the roles of all members of the multidisciplinary team 
  • promoting a just and fair, open and transparent culture 
  • promoting a learning culture 

Emerging issues

The UK population is changing and there are new and an ever-increasing ability to treat and manage illnesses that previously caused great disability or death. At the same time, people are living longer with increasing levels of long term conditions and limited resources within the NHS. Therefore, in order for a health service to provide comprehensive healthcare to such a population, a health service needs to change. GPs must keep up-to-date with and shape the future plans for the NHS, understanding how each part of the health service is working to deliver the planned outcomes.

As a clinician at the frontline of health services, you will need to understand not only how to work within systems of healthcare but also how to work with those systems for the benefit of your patients. This will require an understanding of the context, structures and processes in and by which care is delivered. This goes beyond that of your specific clinical role.

As a GP you have a wider social responsibility to use healthcare resources economically and sustainably. In addition to their business and employer responsibilities in local practices, GPs also perform a growing range of leadership and management roles in other NHS organisations.

Patients and staff will look to GPs to influence and help determine the future direction of services; in leading and managing change there is a need for you as a GP to understand yourself, how you can work effectively with your teams and others, and how to take people with you. This means contributing to the well-being of yourself, your colleagues and your patients through good management of all involved in the provision of care, and the design of robust systems that encourage good care and effective, sustainable and environmentally sensitive use of resources.

Leadership frameworks

The Medical Leadership Competency Framework: Enhancing Engagement in Medical Leadership (2010) was jointly developed by the Academy of Medical Royal Colleges and the NHS Institute for innovation and Improvement. It describes the leadership competences that doctors need to become more actively involved in the planning, delivery and transformation of health services.

The Healthcare Leadership Framework is built around delivering a service to the patient and founded on the concept of 'shared leadership'. There are targeted development programmes named after well-known leaders – Edward Jenner, Mary Seacole, Elizabeth Garrett Anderson, Nye Bevan – supporting all levels of experience and challenge.

In 'Developing People - Improving Care' the National Improvement and Leadership Development Board (2016) provided a national framework for action on improvement and leadership development in NHS-funded services.  It identifies 'Five Conditions' for improving care:  

  1. Leaders equipped to develop high quality local health and care systems in partnership 
  2. Compassionate, inclusive and effective leaders at all levels 
  3. Knowledge of improvement methods and how to use them at all levels 
  4. Support systems for learning at local, regional and national levels 
  5. Enabling, supportive and aligned regulation and oversight 

Knowledge and skills guide

Many GPs take on the additional challenge and responsibility of running their own practice, acting as the employer of a team of administrative and clinical staff and taking on financial responsibility for their business. This requires GPs to develop a wider range of business and management capabilities than doctors in most other medical specialties. 

Ethical Principles of leadership and management

This includes the knowledge and application of principles such as beneficence, non-maleficence, justice, autonomy to everyday leadership decisions.  

Common leadership and management issues arising in general practice

There should be a working knowledge of following topics. Although this is not an exhaustive list, it includes:  

  • Equality and diversity including disability registration, rights and access, discrimination law including race, gender, disability, age, sexual orientation 
  • Probity for example, gifts, conflicts of interest, financial probity, effect of payment by results such as referral management and other targets 
  • NHS Complaints procedure and principles, litigation and medical negligence and raising and acting on concerns about patient safety, whistleblowing.  
  • Poor performance (NCAS, LMC, Deanery, GMC, primary care organisation, Occupational Health) 
  • Welfare of practitioners such as health, conduct issues. 

National regulations, contractual and legal frameworks

  • Medical indemnity applied to primary and secondary care including medical negligence
  • Other Acts and regulations relevant to medical practice including (but not limited to): 
    • Access to Medical Records – children, deceased, compensation, research, what to withhold
    • Children's Act
    • Controlled drug regulations including register, prescribing, storing, destruction 
    • Data protection – Caldicott principles, GDPR, record-keeping, legal basis and consent models for information sharing, lost records, privacy and fair processing notices, sharing electronic records, storing and destroying medical records
    • Driving regulations – duties in relation to advising patients on fitness to drive and DVLA regulations
    • Health and Safety at work regulations relevant to general practice including infection control, vaccine storage, decontamination/spillage (COSSH regulations), safe practice and methods in the working environment relating to biological, chemical, physical or psychological hazards, which conform to health and safety legislation
    • Mental Health Act
    • Misuse of Drugs
    • NHS Prescription regulations
    • Performers List/Health Care Board regulations
    • Removing patients from a List. 

Administration

  • Death and cremation certificates including regulations on completing certificates, when to refer to the Coroner/Procurator Fiscal 
  • Insurance certificates including for life insurance, critical illness insurance (Personal Medical Attendant's reports), travel insurance 
  • Notification of infectious diseases (see RCGP Topic Guide Infectious Disease and Travel Health) 
  • Private certificates/medicals – principles such as disclosure of information for example, firearms, insurance cancellation, probation, adoption, critical Illness cover, fitness to fly/travel 
  • Registration including visual impairment, disability 
  • Relevant benefits and allowances (for example, DS1500, maternity benefits /MAT B1 forms) 
  • Relevant regulations for Mental Capacity and Mental Health Acts 
  • Statements of Fitness to Work certificates and related sickness regulations such as Statutory Sick Pay, Employment Support Allowance, principles of returning to work. 

Practice management and business matters

You should have a working knowledge of: 

  • Contract requirements such as clinical outcome frameworks and enhanced services. 
  • External assessment and inspections (for example, CQC, training inspections, Care Inspectorate) 
  • Federations and GP networks 
  • Financial aspects of a medical practice (for example, interpreting simple profit and loss accounts, a balance sheet, sources of income and expenditure) 
  • Freedom of Information and information governance including Caldicott guardians, management of data, confidentiality 
  • Information technology to facilitate clinical and business practice (for example, chronic disease surveillance, audit, financial management) 
  • Key issues of being self-employed, including partnerships and locum work  
  • Key issues of employing or being employed (fo example, as salaried doctor, or doctor in training)  
  • Legal and contractual frameworks for provision of primary care services in all four nations 
  • Patient Participation Groups 
  • Patient registration and eligibility for NHS care  
  • Pensions 
  • Practice development plans and strategy 
  • Premises management (for example, leases, insurance, fire regulation) 
  • Principles of commissioning, including roles of GPs as commissioner and provider 
  • Principles of employment regulation including appointment, discrimination, redundancy, dismissal. Occupational health for staff including immunisation, ill health, infectious disease 
  • Principles of partnership agreements  
  • Provision of additional services (for example, dispensing medication, travel clinics) 
  • Record keeping - clear, accurate, legible and contemporaneous record keeping, amending records 
  • Staff development, training and appraisal 
  • UK health priorities and regional and local variations 
  • Workload issues and Major incident planning and the role of the GP

How to learn this area of practice

Work-based learning

Undertaking a leadership activity provides an opportunity for trainees to provide evidence linking to leadership and teamwork. This will provide a deeper level of integration within the organisation, benefits for the practice, for example system changes leading to greater efficiency, and benefits for patients, relating to improvements in patient safety.  

Doctors will enter GP training with a range of experience in leadership and it is important for them to consider, in conjunction with their clinical and educational supervisor, how to develop these skills over the course of their GP training and beyond. It is important that an environment is created to encourage leadership activities, facilitating the process and providing opportunities and support, with an openness to feedback. 

Suggested activities might include:

  • Chairing meetings 
  • Running and educational session 
  • Designing clinical protocols or pathways of care 
  • Producing information and resources for patients for example, Webpages or leaflets 

Quality Improvement Projects

The GMC expects all doctors to take part in systems of quality improvement. Quality improvement projects should be led by trainees, supported by their educational supervisor and include working as a team with other members of the practice to create a sustainable change.  

The topic for a 'Mini-QIP' could be a process or system, clinical care issue, or educational initiative that ultimately has an impact on the safety of patients. 

It can be harder to carry out quality improvements in secondary care in a short timescale due to the larger scale and complexity of the organisation – but it is possible to become involved with how changes are introduced. If you have the opportunity to speak to or shadow someone introducing a project you can learn from observing how service changes can be carried out even in a large organisation. 

Self-directed learning and formal learning

You can find an e-Learning module(s) relevant to this topic guide at e-Learning for Healthcare   

Learning with other health care professionals

Leadership and Quality Improvement is always best learnt with others from as wide a clinical background as possible. It is essential to get used to seeing how others (patients, clinical and managerial colleagues) see the problem at hand in order to be able to find a solution. Obtaining feedback as you learn is essential as is the ability to give supportive and constructive feedback to others.  

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT)

  • Ethical principles working within the NHS with scarce resources 
  • Statutory legislation such as information governance and confidentiality 
  • Completing insurance claim forms from medical records

Clinical Skills Assessment (CSA)

  • Patient who is a receptionist in the practice requests sick leave because she is being bullied by the practice manager 
  • A man, newly diagnosed with essential hypertension, asks why the drug he has been prescribed is not recommended as the first line choice in the current guidelines 
  • New district nurse asks advice on the management of an uncomplicated sore throat in a housebound patient with a previous stroke. 

Workplace-based Assessment (WPBA)

  • A Quality Improvement Project (QIP) on looking at the number of salbutamol inhalers prescribed to adults and reviewing patients who may need additional treatment 
  • Learning log on leading the afternoon session on the VTS course 
  • Attending a course on leadership skills for the future GP. 

Urgent and unscheduled care

This Topic Guide will help you understand important issues relating to understand the care of people presenting in the urgent and unscheduled care context by illustrating the key learning points with a case scenario and questions.

The role of the GP in urgent and unscheduled care

As a GP, your role is to: 

  • Make the patient's safety a priority. Recognise patients with urgent needs and act promptly and effectively to ensure correct and timely treatment and reduce the risk of death or morbidity 
  • Meet the additional challenge of gathering information and communicating effectively, professionally and sensitively with patients, carers and family members in urgent and unscheduled care contexts. This includes accurately assessing a patient who may be acutely ill through phone, email and face-to-face consultations 
  • Co-ordinate care with other services and professionals (for example, ambulance service, community nurses and secondary care) and follow agreed protocols where appropriate, ensuring appropriate referral or follow up where necessary 
  • Maintain patients' autonomy in urgent situations where you may need to make decisions in their best interests. Consider the appropriateness of interventions according to the patient’s wishes, the severity of the illness, any co-morbid diseases and best evidence, while managing any differences of opinion with and between relatives and carers 
  • Offer patients and carers tailored advice on self-management and when and who to call for help if their problem worsens or does not follow the expected course of recovery (‘safety-netting’). 

Emerging issues in urgent and unscheduled care

The provision of urgent and unscheduled care is becoming increasingly diverse across the four UK nations and services in one area may differ substantially from another. It is therefore important that the experience attained during training is sufficient to enable the development of capabilities necessary to work in a variety of urgent and unscheduled care contexts.  

The models for delivering unscheduled care (including urgent care) in different communities and regions are changing, and it is important to stay up to date with your local arrangements. Within urgent and unscheduled care, there is increasing focus on the delivery of integrated multi-professional care delivered in the most appropriate setting, with more care being provided ‘closer to home’ or in the home itself. This requires a more flexible and team-based approach. 

Reviews of the Urgent and Emergency care (UEC) system 1 and subsequent reports have outlined five key elements to be developed in relation to urgent and unscheduled care:  

  1. Provide better support to self-care  
  2. Help people to get the right advice or treatment in the right place, first time 
  3. Provide a highly responsive urgent care service outside of hospital 
  4. Ensure that those people with more serious or life-threatening emergency needs receive treatment in centres with the right facilities and expertise 
  5. Connect the whole UEC system together through networks. 

Specifically, national priorities for Urgent and Emergency Care include focus on simplifying access for the public, improved mental health care, development of 111 / triage services and increasing patient access to primary care through online tools and Apps. Skills and capabilities required through training will increasingly need to be applied to these new contexts and may include calculation and interpretation of clinical prediction tools for severe illness (for example, early warning scores). 

Knowledge and skills guide

For each problem or disease, consider the following areas within the general context of primary care: 

  • The natural history of the untreated condition including whether acute or chronic 
  • The prevalence and incidence across all ages and any changes over time  
  • Typical and atypical presentations 
  • Recognition of normal variations throughout life 
  • Risk factors, including lifestyle, socio-economic and cultural factors 
  • Diagnostic features and differential diagnosis 
  • Recognition of deterioration, 'alarm' or 'red flag' features 
  • Appropriate and relevant investigations 
  • Interpretation of test results 
  • Management including self-care, initial, emergency and continuing care, chronic disease monitoring 
  • Patient information and education including self-care and 'safety-netting' (when and who to call for help if their problem worsens or does not follow the expected course of recovery) 
  • Prognosis 

Symptoms and signs

  • Symptoms and signs of acute illness in adults including patients with intellectual disabilities, dementia, communication problems 
  • Symptoms and signs of the acutely ill child (see RCGP Topic Guide on Children and Young People) 
  • Symptoms of acute illnesses that may indicate an acute exacerbation of a chronic disease 
  • Chronic or co-morbid diseases, risk factors and treatments that can influence the incidence and presentation of acute illnesses 
  • Important symptoms and signs that may indicate severe illness but which may be produced by other, less severe illnesses and strategies to avoid missing those severe illnesses when not obvious at initial presentation (for example, viral symptoms in a child should not exclude the recognition of sepsis) 
  • Factors that may alter the presentation of symptoms and signs of severe illness, particularly when there are limitations to immune competency (including those who are pregnant, very young or very elderly, on immunosuppressive drugs or who have other health conditions) 
  • Features of mental health emergencies including delusional states and self-neglect 
  • Factors suggestive of a high risk of harm to self or others 
  • Features of severe or life-threatening injuries 
  • Features of serious illnesses that require an immediate response. Examples include: 
    • Cardiovascular: chest pain, abnormal pulses (arrhythmias, bradycardia, tachycardia), hypertension, dyspnoea, oedema, hypotension, dizziness, syncope, vascular compromise haemorrhage 
    • Central nervous system: reduced conscious level, seizures, dizziness, confusion, loss of sensation or function, cerebellar and vestibular dysfunction, weakness, spasticity, paraesthesia, speech and language deficits, headache, visual problems including reduced acuity, diplopia, pupillary abnormalities, visual field defects, ophthalmoplegia 
    • Digestive: abdominal pain, dysphagia, melaena, bloody diarrhoea, haematemesis 
    • Endocrine: lethargy, polyuria, polydipsia, pain 
    • Kidney: dehydration, anuria / oliguria 
    • Respiratory: wheeze, dyspnoea, stridor, drooling, choking, respiratory distress and respiratory failure, cyanosis, hypoxia, tachypnoea, low oxygen saturations, low peak flow, chest pain, haemoptysis, swelling of face or tongue 
    • Sepsis: tachypnoea, hypotension, and altered mentation, fever, rashes and meningism

When providing urgent and unscheduled care, it is especially important to consider how acute illness and distress, and the emotional effect this has on patients, carers and healthcare professionals, can affect communication. 

Common and important conditions

  • 'Dangerous diagnoses' – these are conditions that always require urgent action if they are suspected. Some important examples include:
    • Acute psychosis/mania
    • Aneurysms
    • Appendicitis
    • Cancer (for example, hypercalcaemia, neutropenic sepsis, spinal cord compression, superior vena cava obstruction)
    • Intestinal obstruction or perforation
    • Limb ischaemia
    • Meningitis
    • Mental health including crisis
    • Myocardial infarction
    • Pregnancy related issues including ectopic
    • Pulmonary embolus
    • Sepsis
    • Stroke / CVA
    • Subarachnoid haemorrhage
  • Emergency conditions where the underlying diagnosis may not be known (for example, anaphylaxis, choking, loss of consciousness, cardio-respiratory arrest)
  • Emergencies that may occur in relation to certain healthcare activities (for example, anaphylaxis or allergic reaction after immunisation, local anaesthetic toxicity, vasovagal episodes)
  • Emergencies arising in patients receiving palliative or end-of-life care (see RCGP Topic Guide on People at the End-of-Life) 
  • Multi-factorial problems associated with patients who live alone and / or with multiple co-morbidities, particularly older adults, with an acute presentation may be frail and have both social and medical care needs 
  • Conditions associated with social, cultural and lifestyle factors that influence the incidence, severity and presentation of acute illnesses (for example, delayed presentation and increased mental distress in cultures in relation to certain illnesses that may be considered stigmatising; or acute illness relating to omitting medication during periods of religious fasting)
  • Death (both expected and unexpected) including the assessment, confirmation and the legal requirements.  

Examinations and procedures

  • Basic Life Support skills including performing cardio-pulmonary resuscitation (CPR), using Automated External Defibrillators and giving emergency drugs 
  • Examination of the relevant system or body part as appropriate 
  • Mental state examinations and risk assessments to ensure the safety of others 
  • Giving emergency or urgent medications in primary care, including oxygen, adrenaline, GTN, intramuscular or subcutaneous injections, inhalers and nebulisers

Investigations

  • ECG interpretation 
  • Recognise and differentiate between patients who require urgent investigation, patients who can wait longer for a routine investigation and those where time should be used as a diagnostic tool 
  • Near patient blood testing (for example, glucose, haemoglobin, CRP, d-dimer) 
  • Peak flow measurement and interpretation 
  • Urinalysis tests including pregnancy test 
  • Vital signs measurement including respiratory rate, blood pressure and oxygen saturation

Service issues

  • Knowledge of how to access the key services, organisations and professionals, both in the community and in secondary care, who provide unscheduled care for patients in- and out-of- hours, in order to organise effective care in the most appropriate location for the patient 
  • Familiarity with available prescribing options, medicines and equipment in the workplace, and car / bag and maintenance of appropriate equipment and drugs 
  • Local and national protocols and decision support systems for urgent care (for example, NICE / CKS and SIGN guidance) 
  • Options available to enable timely review of acutely ill patients to monitor their condition and determine changes to initial management plans 
  • Options available to maintain continuity of care for a patient undergoing an episode of acute illness, including appropriate communication between team members. This includes access to the patient's medical records and other relevant information about them 
  • The importance of providing appropriate documentation and records for each patient contact, which must be communicated to the next professional involved with that patient 
  • Appropriate use of emergency services, including the logistics of communicating with an ambulance/paramedic crew and the response time required 
  • Strategies for ensuring effective and appropriate communication and escalation of concern regarding deteriorating patients to ambulance services, the ED and acute service colleagues 
  • Clinical, administrative and pastoral support that a GP needs to provide at times of crisis or bereavement (including certification of illness or death) 
  • Approaches for managing patients who may make inappropriate or frequent demands on the health service (for example, because of a disorganised lifestyle or mental health disorder) 
  • The role of the GP in commissioning urgent and unscheduled care in your community  
  • The administrative and operating processes for the urgent care organisations you may be working in. These include: 
    • Information technology (IT) systems, including electronic patient records 
    • The process for recording and transmitting information about patients and the outcomes of any contact with them 
    • The communication systems used by the organisation, particularly regarding an urgent or deteriorating patient

Additional important content

  • Knowledge of how to access and use the processes and procedures in place to ensure patient safety in the urgent care setting (for example, clinical governance, quality control and health and safety) 
  • The medico-legal issues and indemnity requirements for the urgent and unscheduled care you provide 
  • The importance of positive, caring and respectful attitudes to the patients, carers and colleagues with whom you work in urgent care context, many of whom you may not have met before 
  • Processes for reporting and analysing significant and untoward events relating to acutely ill patients 
  • Procedures for giving effective feedback to the urgent care organisations and colleagues with whom you have worked and trained

Case discussion

You are working in an urgent care clinic. You take a phone call from a father who is worried about his 4-year-old daughter, Jana who has 'tummy pain'. He tells you they have recently moved to the UK from Russia and that he has already consulted another GP colleague earlier today who diagnosed an upper respiratory tract infection with mesenteric adenitis.  

The father has a thermometer at home and reports that Jana's temperature is now 39.6°C. He is worried because Jana has not recovered since her appointment earlier and he asks you to prescribe some antibiotics for him to collect from a nearby pharmacy, as he has no car and feels Jana is too unwell to bring down to the clinic in a taxi or on the bus.  

Questions

These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case discussion with your Educational Supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.

                         Core Competence                 
                           Questions                     
Fitness to practise
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients. 
Would my approach to the management of this child differ at different times of the day (for example, if the call was at lunchtime/midnight, or at the start of my shift/at the end of my shift)? Why and how might this affect my behaviour? 

If Jana's parent was a regular patient I knew well, how might my management be different? 

Would my approach to the management of this child differ if I had a previous experience of a significant event or complaint from a similar case? 
Maintaining an ethical approach
This addresses the importance of practising ethically, with integrity and a respect for diversity. 
Do I think that a doctor who is a parent would manage this situation differently from a doctor who has no children? What are my attitudes towards parents and families of a different social class or general educational achievement to my own? 

What experiences have I had of patients from a different ethnic background? How might my practice change as a result of this? 
Communication and consultation
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters.

What skills do I need to consult effectively on the telephone? How might this change with a potential language barrier? 

What questions would be reasonable to ask the parent to establish Jana's clinical condition? 

How might my consultation be different if there was very high parental anxiety or, alternatively, a lack of sufficient parental concern? 

How do I manage situations where the patient or their family are used to a healthcare system or culture that operates different to the NHS? 

Data gathering and interpretation  
This is about interpreting the patient's narrative, clinical record and biographical data including investigations
What other factors do I need to know about the child? What other information about the family would be useful? 

How do I assess the severity of this child's condition? 

What guidelines might help? 
Clinical Examination and Procedural Skills 
This is about the adoption of an appropriate and proficient approach to clinical examination and procedural skills. 
How do I accurately assess possible signs of sepsis in children? 

Are there circumstances where I might need to be able to obtain venous access and administer IV fluids or medication? If so, am I able to proficiently do this? 
Making decisions 
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice. 

What is my strategy for ensuring Jana's safety? 

How much should the anxiety of Jana's parent influence this? 

If I establish this is not urgent and does not require examining, how would I safety net? 

Clinical management
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches. 
What are the differential diagnoses? 

What would make me suggest bringing Jana in to examine as opposed to going straight to hospital? 

What advice would I give Jana's parent if I establish Jana needs immediate ambulance assistance? 
Managing medical complexity
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation. 
If I feel I need to examine the child but the parent is reluctant to bring Jana to see me, how would I deal with this? 

How would my management differ if Jana had a complex medical history? 

If this was a non-urgent case in-hours, what services are available that could offer support? 
Working with colleagues and in teams
This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development. 

If I was concerned there was a safeguarding issue in this case, how would I manage this? Who else might be able to help me?  

What processes are important for continuity of care in the urgent care and out of hours setting? 

What documentation would be particularly helpful for Jana's GP? How might this differ if Jana needed referral to hospital? 

What conditions are notifiable and how would I do this? 

Improving performance, learning and teaching  
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, quality improvement and research activity. 
What do I know about the incidence of specific infections illnesses in the community? What are the routes and sources for getting that information for my locality and nationally? 

What is the evidence relating to temperature control in febrile illnesses? 

What areas could be explored further for potential improvement for colleagues managing similar cases? 
Organisational management and leadership
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills. 
What are the challenges with working with different care records in different parts of the health care system? 

What can my practice do to improve patient access to urgent appointments? 

If I had difficulties or if I noticed areas for organisational improvement, how would I feedback to the organisation? 
Practising holistically, safeguarding and promoting health 
This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers. 
How would I explore the health beliefs of the parent? What do I need to know about this family? 

How could I support Jana's parent with self-management? 

How might I react if I find out a parent refuses to have their child immunised against measles, mumps and rubella? 
Community orientation 
This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare. 
How do I include the parents in the management of this situation? What questions would I ask?  

What negative influences or barriers might exist in the community that could exacerbate problems for Jana and her family? 

What community services might be available to help Jana and her family?  

How to learn this area of practice

Work-based learning

As a GP specialty trainee, you must gain experience of managing patients presenting with urgent and unscheduled healthcare needs, which is an important feature of both 'in-hours' and 'out-of-hours' GP care. Because there are particular features of unscheduled care that require a specific educational focus, such as the increased risk of working in isolation, the 'high-stakes' nature of clinical decisions, the relative lack of supporting services and the frequent need to promote self-care, it is important that you spend sufficient time in these environments.

There are a number of organisations involved in the delivery of urgent and unscheduled primary care including, pharmacies, dentists, 111, GP Practices, Urgent Care Centres, Out-of-Hours providers, 7-day access services and Emergency Departments (EDs or A&Es). The model of service provided increasingly varies, but there will be a need for partnership and collaboration between all agencies at the local level. As part of your training programme, you need exposure to a variety of community-based emergency and out-of-hours models.

The hospital environment can be an ideal setting for you to see concentrated groups of acutely ill children and adults. All doctors entering general practice training programmes are expected to have acquired the competences in acute care set out in the Foundation Programme Curriculum. Many doctors will have acquired additional competences during their hospital training, before entering GP specialty training. Some GP training programmes will contain placements of varying length in acute medicine and Emergency Departments that are ideal environments for learning about acutely ill people and their management. While you will have learnt cardiopulmonary resuscitation skills in the Foundation Programme (or equivalent), it is important to maintain these skills once in practice through regular updates and practical training sessions. Hospital resuscitation departments usually have excellent learning resources for you to keep up to date with these skills.

All GP trainees and GPs should have access to BLS/cardiopulmonary resuscitation courses and learning resources during their primary care placements, to help them address their learning needs.

Learning with other healthcare professionals

Teamwork is essential for the effective management of acutely ill patients in primary and secondary care. It is vital that all members of the primary healthcare team (including receptionists) understand their roles in managing acutely ill patients and contribute to the development of practice guidelines.

Acute events are an important source of material for significant event analyses and team members should be encouraged to participate in these and learn from them at both the individual and team level. Working in the acute and urgent environment will help you team members to gain valuable experience of working and learning in multi-professional settings, which will include GPs, nurses, paramedics, Emergency Department staff, etc. Examples include observing nurse practitioners or emergency care practitioners triaging patients and attending home visits with paramedics.

Formal structured learning opportunities can include organisation induction programmes (for example, when starting to train or work in an out-of-hours GP centre), telephone consulting skills courses and e-Learning opportunities. You can find an e-Learning module(s) relevant to this topic guide at e-Learning for Healthcare

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT)

  • Recognition of less common presentations of CVA 
  • Symptoms and signs of sepsis 
  • Management of an epileptic seizure 

Clinical Skills Assessment (CSA)

  • Phone call: Paramedic asks for a routine visit to a middle-aged man who has a 4-hour history of paraesthesia in his arm. His provisional diagnosis is nerve entrapment 
  • House call: Young man with acute headache and vomiting. An examination is expected 
  • Young woman feels unwell and is sweating, lightheaded and has a rapid pulse. An examination is expected

Workplace-based Assessment (WPBA)

  • Take a history with a parent about their febrile child 
  • Case discussion about an elderly patient with pneumonia who has capacity and is refusing admission to hospital  
  • Clinical examination of an acute abdomen for possible appendicitis.

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