Consultation Models
& SCA Frameworks
Your GPS for the consultation — because "just drive and hope for the best" hasn't worked as a strategy since 1976.
Consultation models are not rigid scripts — they are maps. They tell you where you are, where you are heading, and how to get there without losing the patient along the way. Master a model, then make it your own. This page covers everything: the major models explained, how they compare, how to use them in the SCA, and how they'll guide your real GP consultations for life.
📥 Downloads
Handouts, summaries, and teaching extras — ready when you are. Useful for self-study, tutorials, and last-minute SCA prep.
path: CONSULTATION MODELS
- communication skills for medical students - bristol - calgary cambridge.pdf
- consultation handbook by bill bevington.doc
- consultation models - types.ppt
- consultation models - an overview.ppt
- consultation models - especially tate.ppt
- consultation models - summary.doc
- consultation models - task vs process.ppt
- consultation models - with great slide notes.ppt
- consultation models and statistics.doc
- consultation models and the video man.pdf
- consultation models chapter.pdf
- consultation models exercise (TEACHING RESOURCE).pdf
- consultation models in a nutshell (with slide notes).ppt
- consultation models on 2 sides of A4.doc
- models of illness.ppt
- neighbour inner consultation checklist.docx
- pendleton 7 tasks in detail.doc
- pendletons 7 tasks.doc
path: SCA FRAMEWORKS
- sca - the hour glass approach.ppt
- sca consultation framework - dr ross.doc
- sca consultation framework - flannagan as a flow diagram.doc
- sca consultation framework - flannagan.doc
- sca consultation framework - rams 5+5 method.doc
- sca consultation framework - time efficiency in the CSA.pdf
- the gather guide helical sca framework.pdf
🌐 Web Resources
A hand-picked mix of official guidance and real-world GP training resources. Because sometimes the best pearls are not hiding in the official documents.
Core Consultation SkillsThe official resource supporting the Calgary-Cambridge model. Essential reference for the evidence base behind the model's structure.
A practical overview from a clinical perspective, updated 2024. Covers Pendleton, Neighbour, and Calgary-Cambridge with a focus on real GP use.
A comprehensive summary of all major models, with references to the original works. Useful for the AKT table revision.
NHS Health Education England teaching handout on all major consultation models. Clear, concise, authoritative.
The full web chapter on consultation models from the Essential Handbook for GP Training & Education. Deep and comprehensive.
The definitive source on the Simulated Consultation Assessment format, marking criteria, and what examiners assess.
How consultation models apply directly to the SCA domains. Practical and exam-focused.
A practical walkthrough of applying consultation models in the 12-minute SCA format. Good prep for structuring your approach.
A detailed exploration of narrative medicine in GP. Essential companion reading to this page.
A beautiful reflective piece on the value of listening. A must-read for any trainee who wants to understand why the narrative matters.
An academic paper proposing a new model for teaching consultation skills. Useful background for trainers and curious trainees.
Brief but authoritative entries on each major model. Useful for quick AKT fact-checking.
📋 If You Only Read One Section — Read This
The Map Analogy
Imagine driving from Sheffield to Sunderland without a sat nav. You could just drive and hope for the best — but you might take two hours longer, get lost twice, and arrive completely frazzled.
With a map, you get an overview. You know the route before you start. You can still enjoy the journey. And if you accidentally take a wrong turn, you pull over, check the map, and get back on track.
A consultation model is exactly that map. It doesn't force you down a rigid road — it shows you the overall route so the journey stays smooth, structured and — yes — actually enjoyable.
What a Consultation Model Actually Does
- Tells you where you are in the consultation right now
- Tells you where you're heading next
- Keeps the consultation comprehensive — nothing gets accidentally skipped
- Keeps the consultation structured for both you and the patient
- Gives you a recovery anchor when you get flustered — identify where you drifted, and step back in
- Makes the consultation time-efficient — structure prevents rambling
- Ensures you consult safely — fewer missed red flags, better safety-netting
🔄 Models Are Flexible — Not Protocols
A protocol says: "Do this, then this, then this — no exceptions." A consultation model says: "Here is the overall journey — follow it broadly, but follow the patient when they go somewhere interesting."
If a patient suddenly reveals something emotionally significant, follow that. When that natural line of enquiry completes, look back at your model, see where you are, and carry on. The model waits patiently for you.
🍊 Make It Your Own
Think about how to peel an orange. You could use your hands. A knife. A fancy gadget. The method varies, but the result — a successfully peeled orange — is what matters.
The model defines the content that needs to be achieved. How you achieve it is entirely up to you. Read several models, find the one that clicks with your personality, then adapt it until it feels natural.
Your consultation model should eventually feel like your own — not borrowed.
🔄 Why Are There So Many Models?
Consultation models didn't arrive fully formed. They evolved across several decades, with each generation of GP educators building on what came before. The first formal consultation model emerged in the mid-1970s, and the models most widely used today — Neighbour, Pendleton, and Calgary-Cambridge — each represent a distinct moment in that ongoing conversation.
Because of this layered development, most models cover very similar territory. The core tasks of a good consultation — understanding the patient's agenda, reaching a shared diagnosis, agreeing a management plan — have remained remarkably consistent. What differs between models is emphasis and sequencing, not fundamental purpose.
🌟 Frameworks Are For Life — Not Just For Exams
Every qualified GP consults using some form of structure. Many aren't consciously aware of it — but watch any experienced GP consulting repeatedly and you will find a recognisable pattern. The structure is there; it has simply become automatic.
The moments when GPs drift from their usual structure — a rushed appointment, a distracted moment — are often exactly when things go wrong.
A real consultation:
A patient attended to discuss anxiolytics. The consultation felt positive, a prescription was written, and she seemed to agree with the plan. But she never took the medication.
When she saw a colleague, she explained: a close friend had become dependent on similar tablets, and she was frightened of the same happening. She also disliked pills in general.
The ICE had never been explored. Had it been, the whole management plan would have changed — perhaps an anxiety management programme, or mindfulness. Something tailored to what actually mattered to her.
The framework isn't a bureaucratic hurdle. It is the mechanism that prevents exactly this kind of gap.
⚙️ Becoming Automatic
Over time, a consultation framework internalises. Think of how you no longer have to consciously think through each step of taking a clinical history — as you once did as a medical student. The structure is still there, but it has become effortless.
That is exactly what happens with a consultation model. The framework disappears from view — and what remains is the space to genuinely connect with the patient in front of you. That is the real gift of a model used well.
The only difference between consulting in training and after qualification is that in real GP practice you get more than 12 minutes. What a luxury.
Nine major models have shaped how GPs consult. Each has something unique to offer. You don't need to memorise all of them for everyday practice — but you need to know them for the AKT, and understand the best ones for your SCA. Click each to explore.
Michael Balint was a Hungarian-British psychoanalyst working with GPs in London. His influential 1957 book The Doctor, His Patient and the Illness changed how we think about the doctor-patient relationship.
Key Concepts
- "The doctor as a drug" — the doctor themselves has a powerful therapeutic effect on the patient, independent of any treatment prescribed. How you make a patient feel matters as much as what you prescribe.
- "The apostolic function" — GPs unconsciously have a mission to convert patients to their own views of health and illness. Recognising this tendency helps doctors avoid imposing their agenda.
- Balint groups — small group reflective meetings where doctors discuss difficult or emotionally complex patient cases. Still widely used in GP training today.
Byrne and Long studied over 2,500 audio recordings of real GP consultations — the first systematic analysis of GP consultations ever conducted. Their key finding: most doctors consulted in a predominantly doctor-centred style, controlling the interaction through closed questions.
The 6 Phases
- Establishing the relationship with the patient
- Discovering the reason for attendance
- Verbal and/or physical examination
- Consideration of the patient's condition
- Detailing treatment or further investigation
- Terminating the consultation
Professor Nicholas Stott and RH Davis argued that every GP consultation has the potential to address four distinct areas — not just the presenting problem. Used together, they make every consultation far more valuable than it would be otherwise.
| Area | What it Means |
|---|---|
| A — Presenting problems | Manage what the patient came in with |
| B — Continuing problems | Address ongoing issues (e.g. diabetes, hypertension) |
| C — Help-seeking behaviour | Modify inappropriate illness behaviour |
| D — Health promotion | Opportunistic health education and prevention |
Cecil Helman was a medical anthropologist. He proposed that patients arrive at a consultation with a specific set of questions they want answered — often unspoken. Understanding these questions transforms how you approach the consultation.
Helman's 6 Questions Every Patient Wants Answered
- What has happened? — What is actually wrong?
- Why has it happened? — What caused this?
- Why has it happened to me? — Why am I affected?
- Why now? — Why is this happening at this time?
- What would happen if nothing were done? — Is it serious?
- What should I do / whom should I consult? — What should my next step be?
David Pendleton, Theo Schofield, Peter Tate and Patrick Havelock published The Consultation: An Approach to Learning and Teaching in 1984 — one of the most cited texts in GP education. This model introduced the revolutionary concept of ICE (Ideas, Concerns, Expectations) into GP training.
The 7 Tasks
- Define the reason for the patient's attendance (including ICE)
- Consider other problems the patient may have
- Choose an appropriate action for each problem
- Achieve a shared understanding with the patient
- Involve the patient in management (shared decision-making)
- Use time and resources appropriately
- Establish and maintain a therapeutic relationship
Roger Neighbour's The Inner Consultation (1987) is one of the most beloved consultation books in GP training. Written with warmth and humanity, it describes 5 checkpoints — a sequence of inner states rather than mechanical tasks.
The 5 Checkpoints Explained
- 1. Connecting — Establish genuine rapport. Pick up verbal and non-verbal cues ("minimal cues"). Make the patient feel safe to speak.
- 2. Summarising — Confirm you have understood the patient's problem well enough to proceed. Check back with them. Patient must feel truly heard.
- 3. Handing Over — Transition to management collaboratively. The patient is involved and empowered — not just told what to do.
- 4. Safety Netting — Plan for uncertainty. What if the management plan doesn't work? What would trigger a return visit? Protect the patient (and yourself).
- 5. Housekeeping — Before the next patient enters — check in with yourself. Are you carrying emotional baggage from this consultation? Deal with it, or it contaminates the next one.
RC Fraser (1987) described areas of clinical competence that GPs should demonstrate. His work was influential in shaping the competency-based approach to GP assessment. Less commonly tested in the AKT than Pendleton, Neighbour, or Calgary-Cambridge, but worth knowing exists.
Peter Tate's The Doctor's Communication Handbook (1st ed. 1994) is a practical, readable guide to patient-centred consulting. Tate was one of the core architects of the old MRCGP video assessment, and his model formed the backbone of the COT (Clinical Observation Tool) criteria.
Tate's approach emphasises the shared understanding — not just gathering information, but ensuring the patient genuinely understands their situation and is empowered to participate in their own care.
Developed by Suzanne Kurtz and Jonathan Silverman at the Universities of Calgary (Canada) and Cambridge (UK), first published in 1996. Updated with Draper in 2003. Used in 56% of UK medical schools (as of 2009 survey). The most evidence-based consultation framework available.
The 5 Stages
- Initiating the Session — Establish rapport, identify reasons for attendance, set the agenda collaboratively
- Gathering Information — Patient's story (biomedical + psychosocial + ICE), open and closed questions
- Physical Examination — Conduct and explain examination; invite the patient's interpretation
- Explanation and Planning — Provide clear information in digestible chunks; check understanding; shared decision-making
- Closing the Session — Summarise and clarify the agreed plan; safety-net; final check
The 2 Threads (Run Throughout)
📖 The Four Books Worth Reading
You don't need to read all four at once. Pick one that fits where you are in training and start there.
Best for ST1s. Warm, readable, almost narrative in style. Changes how you think about consulting.
The definitive reference for Calgary-Cambridge. Evidence-based and comprehensive. A cornerstone text.
Practical, readable, widely referenced. Particularly useful for understanding COT and SCA criteria.
Light-hearted but wise. Covers tricky consultation scenarios that other books avoid. Trainees love it.
The first minute of any encounter sets the tone for everything that follows. In GP, this is not just a nice idea — it is evidence-based. Research shows that the patient's uninterrupted opening monologue typically lasts 30 to 90 seconds. That window is priceless.
Most doctors interrupt their patient within an average of 18 seconds. Once interrupted, the patient's opening monologue is lost. And with it, often the most important clue to the real problem.
How to Get the Golden Minute Right
- Be quiet. Genuinely, attentively quiet.
- Be yourself. Warmth doesn't require words — use your body language, posture, and eye contact.
- Show you want to help. A genuine expression of welcome goes further than any carefully scripted opener.
- Do not rush. If you look rushed, the patient will condense their narrative into the shortest possible version — and the important things get cut.
- Listen actively. Nod. Lean slightly forward. Allow silences. Brief acknowledgements like "mm-hmm" or "I see" signal that you are tracking what they say.
- When they pause, explore. Ask open questions: "Tell me more about that." Follow the story, not your checklist.
🧠 The Garden Maze Analogy
Imagine standing at the entrance of a large garden maze, facing dozens of possible paths. You have no map. Which way do you turn? Now imagine there's a small arrow on the ground pointing you in a general direction. Suddenly, the first steps are obvious.
That's what the patient's opening monologue gives you. Without it, you're guessing blindly. With it, you have a starting direction — not the whole journey, but enough to begin with confidence.
In a doctor-centred consultation, the doctor asks the questions and the patient responds. The consultation becomes a series of one-piece jigsaw hand-offs — one question, one answer, one question, one answer. A picture emerges eventually, but it takes a long time, and it's often incomplete.
In a patient-centred consultation, the patient is invited to tell their story — their narrative. The narrative hands the doctor multiple jigsaw pieces at once, in context. The picture comes together faster, and in more detail.
The narrative also frequently reveals something unexpected that changes the entire diagnostic and management approach — something the doctor would never have thought to ask about directly.
- Reveals the real concern — often different from the stated reason for attendance
- Identifies the patient's beliefs, fears, and expectations before you have to ask
- Prevents premature diagnostic closure
- Creates shared understanding faster than Q&A
- Produces management plans the patient will actually follow
- Reduces clinical error — you can't miss what the patient is telling you if you're genuinely listening
🌟 A Clinical Pearl — The Migraine Consultation
A patient presented with classic migraine. The initial impulse was to prescribe acute treatment and prophylaxis — clinically reasonable, efficiently achieved.
But something prompted a pause. "What's your life like at the moment — are you busy?"
She opened up: long hours, disrupted sleep, missed meals, high stress. She hadn't realised these were linked to her migraines. And when asked what she thought would help — her eyes widened. She hadn't thought about tablets at all. She wanted two weeks off to reset her routine.
The result? A jointly agreed plan that addressed the root cause — and that she was far more likely to act on than a prescription she didn't want. That management plan emerged entirely from the narrative. It could never have been second-guessed from a symptom checklist alone.
Can you see how a few extra moments listening to the patient's narrative — genuinely listening — produced a better plan than three times as many closed questions would have done?
👥 Doctor-Centred vs Patient-Centred — The Chest Pain Example
The same patient. Two very different consultations. Notice how much more information emerges — and how much faster — in the patient-centred approach.
🧩 The Jigsaw Puzzle — Why Narrative Works Faster
Think of the patient's full story as a large jigsaw puzzle. In a doctor-centred consultation, each question-and-answer exchange hands you one piece at a time. The picture builds, slowly, with effort, and with you deciding which piece to ask for next.
The narrative approach works differently. When you open the space and invite the patient to tell their story, they hand you several pieces at once — in context, in their own words, and in the order that makes sense to them. The picture forms faster. And crucially, the patient often hands you pieces you would never have thought to ask for.
⚖️ When to Follow the Framework — and When to Follow the Patient
Using a consultation framework well doesn't mean using it rigidly. The skill lies in knowing when structure should guide the consultation, and when it should step aside.
🕊️ The Distressed or Grieving Patient
When a patient has just lost someone, is in tears, or has disclosed something deeply personal — follow them. Let the framework wait in the background. Forcing structure onto a human moment will close the patient down entirely, and the chance to reach the real concern will be lost.
When the emotional exchange reaches a natural pause, calmly return to the framework, identify where you are, and continue. The model waited. It always does.
🌊 The Rambling or Tangential Patient
With a patient who talks at length but doesn't connect their thoughts into anything clinically useful — use the framework with more deliberate structure. Without it, twelve minutes will pass and you will have gathered warmth but little clinical information.
Gently but clearly guide the consultation: "That's helpful — I want to make sure I cover the most important things for you today. Can I ask you about..." The framework gives you permission to redirect without dismissing the patient.
🧭 The Consultation Mindset
Follow the patient when they lead somewhere relevant. Return to the framework when they are done. The framework holds — because you have practised it enough that it no longer needs your full attention. What remains belongs to the patient.
The following insights are drawn from UK GP training schemes, RCGP examiner accounts, deanery guidance, and trainee experience reports — aggregated across deaneries including North West, Bristol, Severn, and from trainees who have sat and passed (and sometimes initially not passed) the SCA. None of this conflicts with RCGP or GP educator guidance — it adds practical texture to the official framework.
📊 What Actually Gets Weighted in the SCA — The Domain Reality
Many trainees enter the SCA not realising that Clinical Management carries the most weight. Understanding this changes how you allocate your 12 minutes.
🟢🟡🔴 The RAG Self-Assessment System — How Trainees Measure Progress
The RCGP-endorsed North West Consultation Toolkit (Hawkridge & Molyneux) uses a Red-Amber-Green rating system across 29 consultation competencies. Successful trainees use this to identify their weakest areas — not just to practise, but to practise the right things.
The following themes emerged consistently across multiple UK deaneries, trainee accounts, and examiner feedback reports. Each cluster represents something a significant number of trainees either got right — or got wrong — and wished they'd addressed earlier.
Multiple trainee accounts report the same strategy: keep a small notebook (physical or digital) throughout ST2 and ST3 in which you write down phrases that worked — phrases you heard a colleague use, a phrase your trainer gave you, or a phrase that came out of your own mouth and you thought "yes, that sounded natural and landed well."
Over months, this notebook becomes a personal phrase bank — one that fits your personality, not someone else's script. By the time the SCA arrives, the phrases are yours. You've said them to real patients. They feel natural under pressure.
What to Capture in Your Phrase Notebook
- Natural-sounding ways to ask about home and work life that don't sound like a tick-box exercise
- Ways to ask about ICE that feel conversational in different clinical contexts (not the same phrasing every time)
- Your best transitional phrases — how you move from history-taking to management naturally
- Your best safety-netting phrases — specific and clear, not generic
- Phrases for difficult moments — anger, distress, unreasonable requests — that you've tested in real consultations
- Anything your trainer said during a joint surgery that you thought: "I wish I'd said that"
One of the most widely shared preparation strategies from successful SCA candidates: request 15-minute appointments in the run-up to the exam, and apply SCA-style consulting to every patient — but only allow yourself 12 minutes of actual consultation time, using the remaining 3 minutes for documentation.
Why 15 rather than 12? Because in the real SCA, you don't have to wait for patients to arrive, take their coats off, or chase a referral. Those 3 minutes of buffer represent the real-world time those tasks absorb. Consulting in 15-minute slots with a 12-minute internal limit builds exam-realistic stamina without artificial difficulty.
What This Builds (That Mock Cases Alone Don't)
- Real-patient variability — real consultations don't follow a script. Unexpected information, emotional responses, and agenda-shifting are things actors can replicate only so well.
- Clinical confidence — knowing the clinical content well enough to manage it in 12 minutes, not just know it academically
- Consultation automaticity — the model becomes background process, freeing attention for the patient
- Natural empathy — which sounds rehearsed in mock sessions and genuine after thousands of real interactions
Across multiple UK deaneries, the majority of trainees who passed the SCA report that peer study groups were key to their preparation. But not all study groups are created equal.
The most effective format consistently reported is groups of 3–5, with each session rotating roles: doctor, patient, and examiner/observer. Every participant should be actively involved in every case — either consulting, simulating, or observing and giving structured feedback.
The Three-Way Role Rotation
| Role | What You're Practising |
|---|---|
| Doctor | Consultation structure, time management, phrase naturalness, management quality |
| Patient (actor) | Understanding how actors are trained to respond — what cues they give, what behaviours they display |
| Observer | Spotting what gets missed from the outside — the most powerful learning role |
Almost universally reported as uncomfortable but valuable — and almost universally described as transformative once done. Watching your own consultation recordings forces you to confront things that are invisible from inside the consultation.
The trainee account that resonates most: "Initially I felt those sample videos were perfect examples — but when I re-watched them after practising more, I noticed some cases could have been done better. I assume this is where I started to improve my consultations."
- Verbal cues you missed — things the patient said that you didn't respond to or follow up
- Habitual fidgeting, looking at the screen, or body language that signals disengagement
- ICE asked formulaically or rushed through at a single point
- Transitions that felt smooth to you but looked abrupt on screen
- A safety net that you thought was clear but was actually a single vague sentence
- Management that got less time than you thought — it felt like 5 minutes, the timer says 3
This is one of the most important and consistently underused insights from trainees who struggled in early SCA attempts: if the examiner cannot see or hear something, it cannot be marked.
The SCA examiner watches a video recording of your consultation. They have no access to your inner monologue. If your working diagnosis, your clinical reasoning, your safety-netting thought, or your management rationale stays inside your head — it scores zero.
🔕 Silent ≠ Marked
- "I'm thinking this could be X or Y" — say it
- "Based on what you've told me, my working diagnosis is..." — say it
- "I want to make sure I'm not missing anything serious, so I'd like to check..." — say it
- "If things don't improve, here's specifically what I want you to watch for..." — say it explicitly
- "I'm recommending X because it fits with current guidance for this..." — say it
This theme appears repeatedly across trainee accounts from International Medical Graduates — not as a criticism of other healthcare systems, but as an honest reflection of what takes extra adjustment in UK GP consulting.
The shift required is cultural, not clinical: from a directive, expert-led model (common in many international systems) to a partnership model where the patient's preferences, values, and decisions are genuinely central to the management plan.
- Deciding and advising without involving the patient in the decision
- Prescribing or referring without explaining the rationale or checking the patient's response
- Missing or not following up on expressed patient concerns
- Safety-netting that is generic rather than personalised to this patient's situation
- Closing before checking the patient's understanding and agreement
The Shared Decision-Making Shift
A directive consultation sounds like: "I'd recommend starting metformin for your diabetes."
A shared decision consultation sounds like: "Based on your results, medication would be the next step for most people in your situation. Metformin is usually the starting point — but I'd like to hear your thoughts. Are there any concerns about starting a new medication? And what matters most to you in how we manage this?"
Both might lead to the same prescription. But only the second demonstrates the partnership the SCA is assessing.
In a 12-case exam, at least one case will not go as planned. This is normal — and not necessarily a problem. The SCA does not have a per-station pass requirement. The mark is cumulative across all 12 consultations. A poor case followed by a recovery can still produce a pass.
What does cause failure is carrying the anxiety from case 5 into cases 6 through 12. This is the Neighbour "Housekeeping" principle in action — and it applies with extra force in the exam setting.
The 3-Minute Reset Protocol
- In the 3-minute prep window between cases: do not replay the last case
- Take one slow breath. Deliberately close the mental file on the previous case
- Say to yourself (silently or aloud): "I have been good at consulting. I am good at consulting. I will be good at consulting."
- Open the next case notes — fresh, with full attention
This is not feel-good nonsense. Evidence from educational psychology consistently shows that positive self-talk genuinely improves performance under test conditions.
High-Scoring Behaviours — Drawn From Examiner Accounts
- Efficient, focused history — not exhaustive, but covering what matters
- Explicitly managing uncertainty: "I'm not entirely certain yet, so I'd like to..."
- Using the patient's own words and reflecting them back
- Noticing and responding to what the patient doesn't say as much as what they do
- Generating and testing a working hypothesis — not just gathering data
- Producing an evidence-based or clinically reasonable plan — not just a vague "I'll refer you"
- Avoiding over-investigation and over-prescription — using resources appropriately
- Making a working diagnosis explicit: "Based on what you've told me, I think this is most likely..."
- Acknowledging comorbidity and its impact on the management plan
- A specific, named safety net — not just "come back if you're worried"
- Responding to the patient's emotional cues — not just moving to the next question
- Empathy that is genuine and well-timed — not scripted or out of place
- Checking patient understanding in a way that doesn't feel patronising
- Genuine shared decision-making — not offering choices as a formality
- Adapting communication style to this specific patient — not a one-size-fits-all approach
- "Lecturing the patient" — explaining the full NICE guidance in clinic-speak without checking they're following
- Refusing to make a diagnosis because "we'd need to do more tests" when a working diagnosis is clearly supportable
- Risk-averse referrals for everything — appropriate management in primary care is what's being tested
- A safety net so vague it doesn't actually protect the patient
- An agenda that belongs to the doctor, not the patient
Trainee accounts from those who failed an initial attempt and then passed reveal consistent themes about what changed. These are not theoretical — they come from real trainees who went through the process.
- Going into data gathering without a plan — just asking questions without knowing what they were building toward
- Allowing emotional cases to derail the clinical structure entirely
- Knowing what shared decision-making was but not genuinely practising it — instead, explaining a plan and then saying "does that sound okay?"
- Safety-netting as an afterthought — one vague sentence delivered while mentally finishing the consultation
- Not using the 3-minute reading time strategically — beginning each case reactive rather than prepared
- Using the reading time to sketch an expected consultation structure — not rigidly, but as an anchor
- Practising ICE exploration as part of the opening narrative — not as a discrete block of questions
- Consciously building in a transition at the 6-minute mark: "So I think I have a good picture now — let me share my thinking with you..."
- Safety-netting with specifics: "If the rash spreads beyond the area it's in now, or you develop a fever over 38°, I want you to call 111 the same day"
- Practising breaking bad news, handling angry patients, and managing inappropriate requests — the cases that trip people up disproportionately
The SCA uses a remote video format (9 video consultations, 3 telephone). Consultation models were largely developed for face-to-face encounters — so how do they adapt?
The short answer: the core tasks remain identical. The tools for achieving them change slightly. And some new challenges emerge that models don't directly address.
What's Different About Video / Audio
- Non-verbal cues are harder to read — pick up on voice tone, pacing, hesitation, and silence with extra attention
- Your own non-verbal matters — lean toward the camera, maintain eye contact with the lens (not the screen image), nod visibly. Body language still communicates — but it has to work through a screen
- Rapport requires more effort — the natural warmth of physical presence doesn't translate automatically. Your voice, pacing, and word choices carry more weight
- Signposting is more important — transitions that might feel natural face-to-face can feel abrupt over video. Signpost before changing direction
- Audio-only cases require explicit confirmation — at the start of a telephone case, briefly confirm who you're speaking to and introduce yourself clearly
Based on what trainees who passed consistently report — and on examiner guidance from multiple UK deaneries — here is a practical preparation roadmap. Start in ST2, not the month before the exam.
🔡 CONNECT to Remember Neighbour's 5 Checkpoints
Modified mnemonic — remember the first checkpoint and chain the rest:
Connecting → Summarising → Handing Over → Safety Netting → Housekeeping
Think: "Can Some Humans Stop Hurrying?" — or create your own that sticks.
📅 The Chronological Chain
Models in order — useful for AKT timeline questions:
⚡ The "Unique Contribution" Cheat Sheet
AKT questions often test what was unique about each model. Memorise these one-liners:
"Doctor as drug" + apostolic function
First to record + analyse consultations
4 areas, especially opportunistic health promotion
6 questions — anthropological patient illness beliefs
Introduced ICE — the biggest unique contribution in this group
Housekeeping = emotional self-care for the doctor
5 stages + 2 threads — the most evidence-based model
Time management for SCA — protect the management phase
Common Trainee Blind Spots
- Not knowing the consultation is unstructured until they watch it back on video
- Confusing "asking ICE questions" with "patient-centred care" — the questions are tools, not the goal
- Difficulty transitioning from data gathering to management — the infamous "stuck in history-taking" pattern
- Over-using closed questions from medical school habit
- Not recognising when a patient has already volunteered their ICE in the opening
- Treating safety-netting as an afterthought rather than an integral part of the plan
- No housekeeping awareness — emotionally exhausted by difficult cases with no recovery strategy
Tutorial Ideas & Discussion Prompts
Tutorial 1 — The Video Review
Ask the trainee to map their own COT video against the Calgary-Cambridge model or Neighbour's checkpoints. Which stage are they strongest in? Which checkpoint was missing?
Tutorial 2 — The Model Match
Present a scenario and ask: which model fits best? Then: how would you adapt your favourite model to this specific type of consultation?
Tutorial 3 — Housekeeping Reflection
"Tell me about a consultation that stayed with you today. What did you do with that feeling before the next patient came in?" Introduce Neighbour's housekeeping concept through the trainee's own experience.
Reflective Questions to Use With Trainees
- "If you were that patient, would you feel heard after that consultation?"
- "At what point did you transition from data gathering to management — was that the right moment?"
- "Did you explore what the patient was actually worried about? When did you find out?"
- "Did the patient leave knowing what to do if things got worse?"
- "How did you feel after that consultation — and did you carry any of that into the next one?"
| Model | Developers | Year | No. of Components | Key Components | Unique Contribution |
|---|---|---|---|---|---|
| Balint | Michael Balint | 1957 | Concepts (not numbered steps) | Doctor as drug; apostolic function; Balint groups | First to describe the therapeutic relationship itself as a treatment. Introduced Balint groups for reflective practice. |
| Byrne & Long | Byrne & Long | 1976 | 6 phases | 1) Relating 2) Discovering 3) Examination 4) Consideration 5) Treatment plan 6) Termination | First systematic analysis of GP consultations. Studied 2,500+ recordings. Identified doctor-centred vs patient-centred spectrum. |
| Stott & Davis | Stott & Davis | 1979 | 4 areas | A) Presenting problem B) Continuing problems C) Help-seeking behaviour D) Health promotion | Showed every consultation can address 4 areas, not just the presenting problem. Foundation for opportunistic health promotion. |
| Helman | Cecil Helman | 1981 | 6 questions | What happened? Why? Why me? Why now? What if nothing done? What should I do? | Anthropological insight into patients' illness beliefs. These 6 questions are the deep structure beneath ICE. |
| Pendleton et al ★★ High AKT | Pendleton, Schofield, Tate, Havelock | 1984 | 7 tasks | 1) Define reason for attendance (ICE) 2) Other problems 3) Appropriate action 4) Shared understanding 5) Patient involvement 6) Use time/resources 7) Therapeutic relationship | Introduced ICE (Ideas, Concerns, Expectations) into GP consultation teaching. Also introduced "Pendleton's Rules" for feedback. |
| Fraser | RC Fraser | 1987 | Competence domains | Areas of clinical method; GP competencies framework | Competency-based framework influencing GP assessment design. |
| Neighbour ★★ High AKT | Roger Neighbour | 1987 | 5 checkpoints | 1) Connecting 2) Summarising 3) Handing Over 4) Safety Netting 5) Housekeeping | Introduced Housekeeping (doctor's emotional self-care). Describes Organiser & Responder internal voices. Warm, patient-centred approach. |
| Tate | Peter Tate | 1994 | Communication domains | Patient-centred communication; doctor-patient relationship; explanation & planning | Shaped MRCGP video assessment criteria. Practical and clinical in focus. |
| Calgary-Cambridge ★★ High AKT | Kurtz & Silverman (updated with Draper 2003) | 1996 | 5 stages + 2 threads | Stages: Initiating · Gathering · Examination · Explanation & Planning · Closing. Threads: Building the Relationship + Providing Structure | Most widely used evidence-based model. Used in 56% of UK medical schools. Integrates process and content skills. The 2 threads are a key AKT trap. |
| Ramesh's 6+6 | Dr Ramesh Mehay (Bradford VTS) | 2000s | 2 phases | First 6 min: Data Gathering (presenting complaint, history, ICE, psychosocial, examination). Last 6 min: Explanation, Planning & Closure | Practical time management framework for the SCA (12-min consultations). Prevents trainees running out of time mid-consultation. |
🔥 The Facts That Will Gain You Marks
Consultation models questions in the AKT are usually factual recall — who, when, how many. These are the facts to own before exam day.
- Pendleton (1984) introduced ICE — not Neighbour, not Calgary-Cambridge. This is the most common AKT trap on this topic.
- Neighbour (1987) introduced "Housekeeping" — this means the doctor's emotional self-care between consultations, NOT admin tasks.
- Calgary-Cambridge (1996) has 5 stages + 2 threads. The two threads are "Building the Relationship" and "Providing Structure." Answering "5 components" alone is incomplete.
- Byrne & Long studied over 2,500 audio-recorded consultations — the first systematic analysis of GP consulting.
- Helman (1981) described 6 questions patients want answered — NOT 5. "Why now?" is the one most often forgotten.
- Stott & Davis (1979) described 4 areas — presenting problem, continuing problems, modification of help-seeking behaviour, and opportunistic health promotion. Area C (help-seeking) is commonly missed.
- Balint coined "doctor as drug" and described the "apostolic function" — the doctor's unconscious mission to convert patients to their own view of illness.
- Neighbour described the Organiser (task-focused) and Responder (empathic) as the two internal voices a doctor must balance.
- Pendleton's Rules for feedback: learner reflects first (positive then developmental), then observer follows the same structure.
- Calgary-Cambridge was developed at Universities of Calgary (Canada) and Cambridge (UK) — hence the name.
- Mead & Bower (2000) described 5 dimensions of patient-centredness if asked about a more recent model.
- Saying Neighbour introduced ICE (wrong — it was Pendleton)
- Saying Calgary-Cambridge has only 5 stages (wrong — it has 5 stages + 2 threads)
- Saying Helman described 5 questions (wrong — it's 6)
- Saying Stott & Davis described 3 areas (wrong — it's 4)
- Saying Housekeeping means paperwork (wrong — it means emotional self-care)
Pendleton = 7 tasks
Neighbour = 5 checkpoints
Calgary-Cambridge = 5 + 2
Helman = 6 questions
Stott & Davis = 4 areas
Byrne & Long = 6 phases
Why This Works for the SCA
The SCA consultation lasts 12 minutes. The 6+6 framework fits perfectly — 6 minutes each half, totalling the full 12 minutes.
The key insight is this: by the 6-minute mark, you should be thinking about transitioning. Not necessarily there yet — but thinking about it. If you are still in history-taking territory at minute 8, you are in trouble.
Both Phases Earn Marks in All Domains
A common misconception is that the first half is "for Data Gathering marks" and the second half is "for Clinical Management marks." This is wrong.
First 6 minutes earns marks in:
- ✅ Data Gathering (history, examination)
- ✅ Interpersonal Skills (how you ask, listen, empathise)
- ✅ Clinical Management (flag raised during examination)
Last 6 minutes earns marks in:
- ✅ Clinical Management (the plan you explain)
- ✅ Interpersonal Skills (how you explain and share decisions)
- ✅ Data Gathering (anything you realised you missed earlier)
📋 The Generic SCA Consultation Framework
Most SCA consultation frameworks — including Ramesh's 6+6 — share the same underlying ten-step structure. This is what the 6+6 time split maps onto in practice. The steps don't have to be followed rigidly or in exact sequence, but all should be covered by the end of the twelve minutes.
🎯 What Examiners Are Looking For — Consultation Skills in the SCA
The SCA assesses three domains: Data Gathering, Clinical Management, and Interpersonal Skills. Consultation models underpin all three. These are the behaviours that score well — and the omissions that cost marks.
- Opening — allow the patient to speak. A confident opener followed by attentive silence. Do not rush into closed questions.
- ICE must sound natural. Not "Can I ask you what your ideas about this are?" — but "What do you think might be going on?" or simply following where the patient leads.
- Empathy must be genuine and timed well. An empathic statement that interrupts a patient mid-sentence scores nothing. Pause. Acknowledge. Then move forward.
- Summarise before moving to management. "So what I'm hearing is... — is that right?" signals a transition and ensures shared understanding. Examiners love it.
- Never skip safety-netting. Even a one-line safety net is worth marks. No safety-net is patient-unsafe — and examiners will note the absence.
- Your model should be invisible. The best SCA consultations don't feel like a model being applied — they feel like a real conversation. The model is running quietly in the background, not visibly on the screen.
- Handle the difficult moment explicitly. If the patient is upset, angry, or asking for something inappropriate — acknowledge it directly. Don't move past it as if it didn't happen. Examiners specifically watch how you handle these moments.
- Interrogation-style opening (rapid closed questions)
- ICE asked formulaically at the same point every time
- Spending 10+ minutes on history with nothing left for management
- Safety-netting omitted due to time pressure
- Empathy scripted, flat, or timed poorly
- Name the patient and use their name
- Signpost before transitions: "I'd like to move on now to..."
- Check understanding: "Does that make sense?"
- Invite agenda-setting: "Is there anything else today?"
- Make the safety net explicit and specific — not vague
- "What matters most to you in how we manage this?"
- "Let me make sure I've understood you correctly..."
- "I want to be honest with you about what I'm thinking"
- "If things don't improve, here's what I'd want you to do..."
- "What are your thoughts on that option?"
All phrases below are designed to sound natural, calm, and human — not scripted. Read them once. Practise saying them aloud. Then use them tomorrow.