Detailed guidance for each CAT type

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

Preparation in advance

Trainee

• Undertake a Routine Day in Practice and provide details of the session in advance of the CAT

Supervisor guidance

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

Undertaking the CAT

• Review a selection of the patient contacts during the session - encourage the trainee to reflect:
  • Was the method of consultation appropriate e.g. telephone, face to face, visit?
  • oIs there evidence of appropriate data gathering, clinical examinations and procedural skills, clinical management and diagnosis and decisions?
  • Where any referrals made to other services, were they appropriate, what other options were available?
  • Review prescribing during the consultation
  • Comment on the quality of the trainee’s records.
• Discuss and encourage reflection on other activities undertaken during the day:
  • Prescription requests
  • Blood results
  • Review of hospital letters/other scanned documents
  • Practice meetings/other meetings
  • Informal discussion with colleagues
  • Contact with Secondary Care or other organisations.
• Discussion and reflection on time management

Capability areas suggested

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

See CAT question generator (PDF file, 668 KB) for suggested questions surrounding each capability area for discussing clinical cases

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

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

Organisation, management and leadership

• Uses the computer during consultations whilst maintaining rapport with the patient to produce records that are succinct, comprehensive, appropriately coded and understandable. 
• Is consistently well organised with due consideration for colleagues as well as patients. Demonstrates effective: time management, hand-over skills, prioritisation, delegation.

Managing medical complexity

• Simultaneously manages the patient’s health problems, both acute and chronic.
• Recognises the inevitable conflicts that arise when managing patients with multiple problems and takes steps to adjust care appropriately.
• Encourages the patient to participate in appropriate health promotion and disease prevention strategies.

Communication and consultation skills

• Consults in an organised and structured way, achieving the main tasks of the consultation in a timely manner. 
• Manages consultations effectively with patients who have different languages, cultures, beliefs and educational background

Other capabilities that could be covered include - 

Maintaining an ethical approach

• Reflects on how their values, attitudes and ethics might influence professional behaviour. 
• Values and appreciates different cultures and personal attributes, both in patients and colleagues. 
• Reflects on and discusses moral dilemmas encountered in the course of their work.

Data gathering and interpretation

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

Clinical examination and procedural skills

• Identifies and reflects on ethical issues with regard to examination and procedural skills.
• Shows awareness of the medico-legal background, informed consent, mental capacity and the best interests of the patient.

Making a diagnosis / decisions

• Addresses problems that present early and/or in an undifferentiated way by integrating all the available information to help generate a differential diagnosis.
• Has confidence in and takes ownership of own decisions whilst being aware of their own limitations.

Clinical management

Refers appropriately, taking into account all available resources.

Provides comprehensive continuity of care, taking into account all of the patient’s problems and their social situation.

Suggests a variety of follow-up arrangements that are safe and appropriate, whilst also enhancing patient autonomy

Working with colleagues and in teams

• Appreciates the increased efficacy in delivering patient care when teams work collaboratively rather than as individuals.
• Communicates proactively with team members so that patient care is enhanced using an appropriate mode of communication for the circumstances.

Give feedback on what they did well and agree what they should work on to improve or demonstrate in future learning events

Recording in the Portfolio

Supervisor guidance:

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

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

Preparation in advance

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

Undertaking the CAT

Supervisor’s Guidance:

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

Capability areas suggested

See CAT question generator (PDF file, 668 KB) for suggested questions surrounding each capability area for discussing clinical cases 

Clinical management

• Has any prescribing required been undertaken safely? Maps to: Maintains awareness of the legal framework for appropriate prescribing.  
• Have they applied any local and national guidelines including drug and non-drug therapies? Maps to: In addition to prescribing safely, is aware of and applies local and national guidelines including drug and non-drug therapies.
• Has any required follow-up in practice been arranged whilst also enhancing patient autonomy? Maps to: Takes active steps within the organisation to improve continuity of care for the patients. 
• Shown confidence in stopping or stepping down medication where this is appropriate. 

Organisation management and leadership

• Have the correct codes been identified to be added to the patient records? Maps to: Uses and modifies organisational and IM&T systems to facilitate clinical care to individuals and communities.  Uses the primary care organisational systems routinely and appropriately in patient care, this includes the use of computerised information management and technology.

Community orientation  

• Has the information from the letters taken into consideration local prescribing policies?   If appropriate have wider teams or local resources been used? Maps to: Reflects on the requirement to balance the needs of individual patients, the health needs of the local community and the available resources.  Demonstrates understanding of how the characteristics of the local population shapes the provision of care in the setting in which the doctor is working.   Considers local and national protocols. 

Working with colleagues and teams

• Has appropriate follow-up with correct primary care team been arranged if required? Maps to:  Appreciates the increased efficacy in delivering patient care when teams work collaboratively rather than individuals.  Communicates proactively with team members so that patient care is enhanced using an appropriate mode of communication for the circumstances. 

Recording in the Portfolio

Supervisor guidance:

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

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

Preparation in advance

Trainee

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

Supervisor guidance

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

Undertaking the CAT

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

Capability areas suggested

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

See CAT question generator (PDF file, 668 KB) for suggested questions surrounding each capability area for discussing clinical cases

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

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

Organisation, management and leadership

• Is consistently well organised with due consideration for colleagues as well as patients. Demonstrates effective: time management, hand-over skills, prioritisation, delegation 
• Uses the primary care organisational systems routinely and appropriately in patient care for acute problems    
• Responds positively when services are under pressure in a responsible and considered way.             

Working with colleagues and in teams

• Appreciates the increased efficacy in delivering patient care when teams work collaboratively rather than as individuals. 
• Communicates proactively with team members so that patient care is enhanced using an appropriate mode of communication for the circumstances.

Clinical management

• Suggests a variety of follow-up arrangements that are safe and appropriate, whilst also enhancing patient autonomy. 
• Responds rapidly and skilfully to emergencies, with appropriate follow-up for the patient and their family. Ensures that care is co-ordinated both within the practice team and with other services.

Other capabilities that could be covered include: 

Maintaining an ethical approach

• Reflects on how their values, attitudes and ethics might influence professional behaviour.
• Demonstrates equality, fairness and respect in their day-to-day practice.
• Reflects on and discusses moral dilemmas encountered in the course of their work      

Communication and consultation skills

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

Data gathering and interpretation

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

Clinical examination and procedural skills 

• Chooses examinations appropriately targeted to the patient’s problem(s)
• Identifies and reflects on ethical issues with regard to examination and procedural skills.

Making a diagnosis / decisions  

• Has confidence in and takes ownership of own decisions whilst being aware of their own limitations.
• Give feedback on what they did well and agree what they should work on to improve or demonstrate in future learning events.

Recording in the Portfolio

Supervisor guidance

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

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

Preparation in advance

Trainee

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

Supervisor guidance

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

Undertaking the CAT

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

Supervisor guidance

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

• Select the Capability areas the trainee has demonstrated during this discussion. (Please see list below for suggestions of what is likely to be covered by the Online/digital/electronic Consultation CAT).
• Give feedback on what they did well and what they should work on to improve or demonstrate in future learning events.

Capability areas suggested

See CAT question generator (PDF file, 668 KB) for suggested questions surrounding each capability area for discussing clinical cases

Clinical management

• Has the trainee appropriately triaged the Online/digital/electronic consultation and dealt with the patient appropriately e.g., bringing the patient in for a face-to-face assessment where needed or providing appropriate safety netting if dealing with patient over the phone or via text.

Managing medical complexity

• Where multiple problems are presented in an Online/digital/electronic consultation has the trainee managed these appropriately? For example, taking into account co-morbidities and allergies etc. Have they recognised the inevitable conflicts that arise when managing patients with multiple problems and taken steps to address these?

Organisation, management and leadership

• Has the trainee produced clearly documented notes and saved all relevant text messages if appropriate? Have they sought advice from seniors where there is any uncertainty and clearly documented these? Have they delegated appropriately e.g. by booking patient with the in house physiotherapist or clinical pharmacist where indicated? Did they manage time appropriately?

Community orientation

• Has the trainee demonstrated how they have adapted their own clinical practice to consider their local resources, for example referring patients to in house physiotherapist or to the social prescriber where relevant? Are they aware of all the resources available in house and in the wider PCN?

Fitness to practice

• Has the trainee reflected on and learnt from performance issues (e.g., failing to bring a patient in when necessary, instead of dealing with on the phone) in order to improve patient care?

Recording in the Portfolio

Supervisor guidance

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

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

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

Preparation in advance

Trainee

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

Supervisor / trainer

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

Undertaking the CAT

Supervisor guidance

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

Capability areas suggested

See CAT question generator (PDF file, 668 KB) for suggested questions surrounding each capability area for discussing clinical cases

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

Maintaining an ethical approach

• Demonstrates the application of “Good Medical Practice” in their own clinical practice.
• Demonstrates equality, fairness. 
• Reflects on and discusses moral dilemmas encountered in the course of their work.

Data gathering and interpretation

• Chooses examinations and targets investigations appropriately and efficiently
• Understands the significance and implications of findings and results, and takes appropriate action

Making a diagnosis/decisions

• Makes diagnoses in a structured way using a problem-solving method 
• Uses an understanding of probability based on prevalence, incidence and natural history of illness to aid decision-making 
• Revises hypotheses in the light of additional information

Clinical management

• Responds rapidly and skilfully to emergencies, with appropriate follow-up for the patient and their family. Ensures that care is co-ordinated both within the practice team and with other services.

Managing medical complexity

• Simultaneously manages the patient’s health problems, both acute and chronic
• Recognises the inevitable conflicts that arise when managing patients with multiple problems and takes steps to adjust care appropriately

Working with colleagues and in teams

• Understands the context within which different team members are working
• Is an effective team member, working flexibly with the various teams involved in day-to-day primary care
• Appreciates the increased efficacy in delivering patient care when teams work collaboratively rather than as individuals
• Communicates proactively with team members so that patient care is enhanced using an appropriate mode of communication for the circumstances

Organisation, management and leadership

• Is consistently well organised with due consideration for colleagues as well as patients. Demonstrates effective: time management, hand-over skills, prioritisation, delegation
• Responds positively when services are under pressure in a responsible and considered way - helping someone else by covering work
• Uses the primary care organisational systems routinely and appropriately in patient care, includes the use of computerised information management and technology (IM&T)

Practicing holistically, promoting health and safeguarding

• Demonstrates understanding of the patient in relation to their socio-economic and cultural background
• Utilises appropriate support agencies (including primary health care team members) targeted to the needs of the patient and/or their family and carers

Community orientation

• Demonstrates how they have adapted their own clinical practice to take into account the local resources, for example in referrals, cost-effective prescribing and following local protocols

Recording in the Portfolio

Supervisor guidance

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

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

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

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

Preparation in advance

Trainee

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

OR

• Undertake a further leadership activity or other leadership development

AND

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

Supervisor guidance:

Review the learning log entry on the portfolio

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

Undertaking the CAT

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

Capability areas suggested

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

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

See CAT question generator (PDF file, 668 KB) for suggested questions surrounding each capability area for discussing clinical cases

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

Organisation, management and leadership

• Is consistently well organised with due consideration for colleagues as well as patients. Demonstrates effective: time management, hand-over skills, prioritisation, delegation 
• Helps to support change in the organisation. This may include making constructive suggestions.
• Actively facilitates change in the organisation. This will include the evaluation of the effectiveness of any changes implemented.
• Uses and modifies organisational and IM&T systems to facilitate: Clinical care to individuals and communities, Clinical governance Practice administration
• Other capability areas can be demonstrated during the CAT, in particular

Working with colleagues and in teams

• Appreciates the increased efficacy in delivering patient care when teams work collaboratively rather than as individuals. 
• Shows awareness of the strengths and weaknesses of each team member and considers how this can be used to improve the effectiveness of a team
• Shows some understanding of how group dynamics work and the theoretical work underpinning this. Has demonstrated this in a practical way, for example in chairing a meeting.
• Helps to coordinate a team-based approach to enhance patient care, with a positive and creative approach to team development.

Maintaining performance, learning and teaching

• Shows a commitment to professional development through reflection on performance and the identification of personal learning needs.
• Addresses learning needs and demonstrates the application of these in future practice. 
• Personally, participates in audits and quality improvement activities and uses these to evaluate and suggest improvements in personal and practice performance.

Fitness to practice

• Demonstrates the accepted codes of practice in order to promote patient safety and effective team-working.
• Actively seeks to anticipate and rectify where systems and practice may require improvement in order to improve patient care.
• Encourages an organisational culture in which the health of its members is valued and supported.

Maintaining an ethical approach

Awareness of current legislation as it applies to clinical work and practice management.

Recording in the Portfolio

Supervisor guidance

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

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

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

Preparation in advance

Trainee

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

Undertaking the CAT

Supervisor guidance

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

Capability areas suggested

See CAT question generator (PDF file, 668 KB) for suggested questions surrounding each capability area for discussing clinical cases

Clinical management 

• Has the trainee prescribed safely?
• Are they aware of and are they applying local and national guidelines including drug and non-drug therapies?
• Are they aware of legal frameworks for appropriate prescribing?

Managing medical complexity

• Has the trainee simultaneously managed patients’ health problems, both acute and chronic (e.g. by taking into account comorbidities, existing medication and allergies)?
• Communicated risk effectively to patients (from documentation in the clinical records)?
• Recognised the inevitable conflicts that arise when managing patients with multiple problems and taken steps to address these?

Organisation, management and leadership 

• Has the trainee produced records that are succinct, comprehensive, appropriately coded and understandable?

Community orientation

• Has the trainee demonstrated how they have adapted their own clinical practice to take into account their local resources, for example colleagues with GPSPI experience; or in cost-effective prescribing by following local protocols?

Maintaining performance Learning and teaching 

• Has the trainee shown a commitment to professional development through reflection on performance and the identification of personal learning needs?

Fitness to practice

• Has the trainee reflected on and learnt from performance issues (e.g. drug errors) in order to improve patient care?

Recording in the Portfolio

Supervisor guidance

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

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

Preparation in advance 

Trainee

• None

Supervisor guidance

• None

Undertaking the CAT 

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

Capability areas suggested

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

See CAT question generator (PDF file, 668 KB) for suggested questions surrounding each capability area for discussing clinical cases.

Some examples:

• Review how long the consultation took, as well as their recording of the consultation itself. These can be used to assess organisation, management and leadership
• Review the trainee’s recording, using READ/ SNOMED codes as appropriate, observations recorded, history and other data gathering as well as clinical management, diagnosis and decisions and follow-up.
• Involvement of other doctors or team members may also be reviewed which can give information for the Capability of working with colleagues and teams.
• How much health promotion was undertaken? Holistic care and managing medical complexity.

It is recommended that one of the chosen capabilities is ‘organisation management and leadership’, with specific comment on the trainees time management and clinical notes included coding. 

Recording in the Portfolio

Supervisor guidance

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

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

Preparation in advance 

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

Undertaking the CAT 

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

Capability areas suggested

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

See CAT question generator (PDF file, 668 KB) for suggested questions surrounding each capability area for discussing clinical cases 

It is recommended that two of the chosen capabilities are:

• Community orientation, discussing the appropriateness and effectiveness of the referral (considering the different options available).
• Organisation, management and leadership, discussing the quality of the trainees’ clinical record keeping included coding. 

Recording in the Portfolio

Supervisor guidance:

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

Characteristics of a good GP referral letter

Introduction

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

Referral rates vary enormously and for a variety of reasons. 

It can be important to consider:

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

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

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