Naturally Occurring
Evidence (NOE)
Because your ePortfolio deserves more than just forms and forgotten audits — and you've been doing brilliant things all along without realising it counts.
Handouts, templates, and teaching extras — ready when you are.
Templates for audits, presentations, post-reflections, and significant events — everything to get you started quickly.
path: NOE
Curated links — official and unofficial. Because the best pearls aren't always in the guidelines.
- RCGP — WPBA Overview
- RCGP — WPBA Mandatory Evidence Summary & Tracker (PDF)
- RCGP — 13 Capabilities Framework
- Bradford VTS — Quality Improvement (comprehensive guide)
- Bradford VTS — Audit
- Bradford VTS — Significant Event Analysis (SEA)
- Bradford VTS — Referrals
- Bradford VTS — Prescribing
- Bradford VTS — Complaints
- Bradford VTS — Case Studies & Presentations
⚡ Quick Summary — If You Only Read One Thing
And isn't that just earthquakes and tectonic plates? (No.)
NOE is one of those terms that sounds more complicated than it is. Once you understand it, you'll realise you've probably been generating it all along — you just didn't know it counted.
NOE refers to evidence that arises naturally during the course of your working life as a GP trainee — things you do as part of normal professional practice, not because someone asked you to fill in a form.
These are activities that demonstrate your commitment to improving the care you give patients, enhancing patient safety, and developing professionally.
Think of it as the portfolio space for the things you're most proud of that don't neatly fit elsewhere.
Quality Improvement Activity (QIA) is a specific subset of NOE. The GMC defines it as:
Any activity relevant to your work which includes an element of evaluation and action, and where possible, demonstrates an outcome or change. These activities should be robust and systematic.
QIA must be recorded in the 14Fish ePortfolio as a Quality Improvement Activity reflective learning log entry. It is intended to be smaller in scale than a formal QIP.
- Relevant to your work — not something academic for its own sake
- Personally involved — your work, not someone else's project
- Involves evaluation of current practice — not just description
- Results in an outcome or change — even a small one counts
NOE is particularly good at demonstrating the capabilities that are hard to capture through other WPBA tools.
The RCGP WPBA framework assesses 13 professional capabilities. NOE is not designed to cover all of them, but it provides particularly rich evidence for four specific areas — ones that formal assessments like COTs and CBDs often struggle to capture.
Organisation, Management & Leadership
Show how you initiated the activity, led others, managed the process, delegated appropriately, and organised data and results. Presentation of findings is particularly strong evidence here.
- How did you come up with this activity?
- How did you manage others involved?
- How did you gather, organise, and present findings?
- What delegation or empowerment was involved?
Working with Colleagues & in Teams
Show how you worked effectively with others, motivated colleagues, and persuaded people to change their approaches to improve patient care.
- How did you motivate people to engage?
- Who was involved and what did each person contribute?
- How did you work effectively with a team?
- What did you learn about teamwork from this?
Community Orientation
Most NOE activities involve moving beyond the individual patient in front of you to consider the health of the wider practice population — this is the essence of Community Orientation.
- What population group does this activity benefit?
- Was this sparked by an individual case that made you think bigger?
- How does this relate to the health of the practice population?
- What does this mean for patients who share a commonality?
Maintaining Performance, Learning & Teaching
Show that you can identify your own learning needs, evaluate your performance, complete a learning cycle, and describe how this activity has improved patient care.
- What have you learnt from the process?
- Describe the learning cycle you went through
- What would you do differently next time?
- How has this improved patient care?
When writing up any NOE activity, try to address all four of these capabilities in your reflection — even if one is more prominent than the others. A well-written NOE entry can tick all four boxes in a single piece of work. Your Educational Supervisor will notice.
You don't have to do everything. Pick what interests you. Pick what matters.
This is your menu of options — not a to-do list. The key is to choose activities that genuinely engage you and that will make a real difference, rather than ticking boxes for the sake of it. Grab one or two that spark something.
Clinical Audit
The Audit Cycle measures the quality of care provided to patients. Most trainees choose a clinical area — but think laterally. Creative audits stand out.
Examples: warfarin control, LFTs post-statin, antibiotic prescribing rates, cervical smear uptake, hypertension management, DMARD monitoring, minor surgery outcomes, end-of-life care quality, referral patterns.
ePortfolio: Record as a Quality Improvement Activity log entry.
Review of Clinical Outcomes
Reviewing data to understand patterns in outcomes — broader than a formal audit but equally valuable as a learning exercise.
Examples: QoF data, minor surgery outcomes, morbidity/mortality data, acute admission outcomes, quality of record keeping, telephone triage outcomes, commissioning information.
ePortfolio: Record as a Quality Improvement Activity log entry.
Significant Event Analysis / Learning Event Analysis (SEA / LEA)
Things go wrong in every clinical career — what matters is how you learn from them. Near-misses count too. Don't brush these off.
The aim: understand what happened, why it happened, and put measures in place to reduce recurrence. File serious events on Form R and inform your Educational Supervisor.
14Fish terminology: Logged as a Learning Event Analysis (LEA) in your ePortfolio. The form includes a "Threshold met?" tick-box — only tick Yes if the event has genuinely been referred to the GMC. For near-misses and everyday errors, always tick No.
ePortfolio: Record under Learning Event Analysis (LEA) in your 14Fish ePortfolio.
Case Study / Presentation
Engage your peers or MDT in review of an interesting or challenging case — clinical, medication-focused, or around care pathways and organisations.
Can be presented at HDR, to your hospital department, to your PHCT, or even to medical students. What matters is preparation: identify learning needs, set objectives, think about delivery.
ePortfolio: Record under Lecture/Seminar in your 14Fish ePortfolio.
Random Case Analysis (RCA)
Sit with a peer and look at a random selection of your own consultations. Explore what went well, what could have been better, and what you want to learn next.
Low effort, high learning value. Great for identifying blind spots you didn't know you had.
ePortfolio: Record as a learning log entry.
Referrals Analysis
Review your own referral patterns. Are you over- or under-referring? In which specialty? This is a surprisingly powerful piece of self-reflective learning.
You can focus on one specialty (e.g. musculoskeletal referrals) or look across the board. What does your referral rate tell you about your practice?
ePortfolio: Record as a Quality Improvement Activity log entry.
Investigations Analysis
Review your own investigation patterns. Do you over-investigate? Are there areas where you're not requesting enough? Focus on one area if you prefer — e.g. imaging requests.
Great for cost-consciousness and clinical appropriateness — two things ARCP panels love to see evidence of.
ePortfolio: Record as a Quality Improvement Activity log entry.
Prescribing Analysis
Review your own prescribing behaviour. Antibiotics, NSAIDs, antidepressants, PPIs — the list is genuinely endless and the learning is always valuable.
Compare against practice averages or local formulary guidance. What does your prescribing say about your clinical habits?
ePortfolio: Record as a Quality Improvement Activity log entry.
Discussion Paper
A structured written exploration of a topic — for instance, reviewing the most cost-effective method of managing a specific condition, or exploring a controversial clinical question in your practice.
Well-suited for trainees who enjoy reading and synthesising evidence — and a good way to prepare for tutorials.
ePortfolio: Record as a learning log or supporting documentation.
Literature Review
Formulate an evidence-based approach to managing a condition by reviewing the available literature — more rigorous than a discussion paper, but doesn't need to be publication-worthy.
Choose a topic relevant to your practice population. Links beautifully to your PDP.
ePortfolio: Record as supporting documentation or learning log.
Questionnaire / Survey
Doesn't need to be publishable. Simple patient or colleague surveys are completely valid. Patient experience surveys, staff feedback, or surveys about clinical decision-making all work well.
Examples: what patients think of GP locum quality, patient choice in contraception, staff experience of handover processes.
ePortfolio: Record as a Quality Improvement Activity log entry.
Research Study
If your practice is already involved in GP-based research, consider getting involved. Even a supporting role gives you valuable insight into primary care research methodology.
Check with your TPD — some deaneries have specific opportunities for trainees to join research activities.
ePortfolio: Record as supporting documentation.
New Service Development
Doesn't have to be a new clinic — it could be a new screening programme, a new patient pathway, an improved triage process, or a new referral protocol.
Examples: Vitamin D screening programme, social prescribing referral pathway, improved DMARD monitoring system.
ePortfolio: Record as a Quality Improvement Activity log entry.
Complaints Review
A thorough analysis of any complaints you have received, with genuine reflection and key learning points. Declaring an absence of complaints is also valid.
File serious complaints on Form R and inform your Educational Supervisor. Write a reflective piece — especially what you have learnt.
ePortfolio: File as an SEA or learning log; link to Fitness to Practise capability.
Safeguarding & PREVENT Training
Level 3 Safeguarding (children and adults) and PREVENT training are GMC mandatory requirements for all qualified GPs, including trainees. This is non-negotiable evidence.
Certificates may last 3 years, but an annual knowledge update is required every 12 months, even if LTFT. Don't forget to link the evidence in your compliance passport.
ePortfolio: Upload to Compliance Passport and link to mandatory training section.
Reflection on Your Post / Job
A structured reflection on what you have learnt from a post, what learning needs remain, and how you are planning your development — especially useful at the end of each rotation.
Should address self-care and work-life balance (Fitness to Practise). For hospital posts, include reflection on how resources encountered can be accessed and used in GP practice — this covers Community Orientation.
ePortfolio: File under Courses & Certificates. See downloads above for templates.
From "I'm not sure what to do" to "I've written it up beautifully."
Notice something that bothers you (or excites you)
The best NOE activities start with curiosity or frustration. A patient encounter that made you think. A process that seems inefficient. Something you wonder about in your own practice. Start there.
Check it meets the 4 criteria
Relevant, personally led, evaluative, results in change. If it doesn't meet all four, adjust the framing before you begin — not after you've done all the work.
Choose the right activity type from the menu
Match your idea to the most appropriate activity type (audit, SEA, prescribing analysis, etc.). Some ideas work as multiple formats — pick the one you'll find most engaging.
Do it, involve others where appropriate, document as you go
Don't wait until it's complete before making notes. Teams, data sources, what you found — record it in real time. This makes the write-up ten times easier.
Write your reflection covering all four capabilities
Use the four RCGP capabilities as a loose structure. Show leadership, teamwork, population thinking, and personal learning. One well-written reflection can tick all four at once.
Upload to the correct section of your 14Fish ePortfolio
Different activity types go under different sections (QIA log, Lecture/Seminar, Courses & Certificates, SEA). Check where each one goes before uploading — getting this wrong is a common and easily avoidable mistake.
Discuss with your Educational Supervisor at your next ESR
NOE is reviewed as part of your six-monthly Educational Supervisor Review. Flag it, discuss what you learnt, and link it to your PDP for the next period.
Step-by-step guides for the activities people find hardest to write up well.
Knowing what to do is only half the challenge. The other half is knowing how to write it up in a way that your Educational Supervisor can map to capabilities, and that an ARCP panel can read without having to guess at your learning. These frameworks turn good activities into good evidence.
🔄 The Reflection Frameworks — Gibbs and ISCE
Best used for: emotionally charged events, complex situations, SEAs. Iterative — designed to improve performance on repeated experiences.
Best used for: most everyday log entries. Simpler and more practical than Gibbs. Directly maps onto the 14Fish learning log structure.
🪞 How to Write a Strong Reflection on Post
File under Courses & Certificates in 14Fish. Aim for something meaningful — this is one of the most evidence-rich entries you can write, but most trainees do it in 10 minutes and regret it.
1. What I came in knowing (and not knowing)
Set the baseline. What were your learning needs at the start of this post? What did you think you'd find difficult? This is important for showing progression.
2. What I actually learnt — clinical and non-clinical
Go beyond clinical knowledge. What did you learn about teamwork, systems, communication, uncertainty, or yourself as a doctor?
3. How this connects to GP practice
Especially important for hospital posts. This directly covers Community Orientation. "When I encounter a patient who has been in cardiology, I will now know that... and I will think to ask about..."
4. What still needs developing
Honest self-assessment. Link to your PDP for the next post. Shows insight and forward-planning.
5. Self-care and work-life balance
RCGP explicitly requires Fitness to Practice (domain 12) to be addressed here. Brief but genuine: what did this post teach you about managing your wellbeing? What boundaries are you setting?
6. Two or three specific things I'll do differently
Concrete, named actions. "I will now always ask about... before referring to..." These are your personal quality improvements — they close the learning loop and link to your PDP.
Things that catch people out — and how to avoid them.
The things people wish someone had told them at the beginning.
⚖️ The Bawa-Garba Concern — What You Need to Know
A recurring concern in GP training communities: the Bawa-Garba case, in which a doctor's reflective professional notes were used in GMC proceedings. This has led some trainees to avoid writing LEAs/SEAs about near-misses and errors, or to write them vaguely.
The consensus from GP educators, deaneries, and academic reflection guidance is clear:
- Reflection is an essential professional skill and its value is well established in GP training and revalidation
- Anonymised, thoughtful reflection on near-misses and errors is expected and encouraged
- The purpose of the LEA/SEA is learning, not evidence-gathering for disciplinary proceedings
- The educational value outweighs the very small risk for trainees reflecting normally on common near-misses
Practical writing guidance — a professional tone that emphasises learning and system improvement:
- "Debriefed with my trainer, which led to useful learning about..."
- "This case raised the importance of recognising my limitations and seeking advice early..."
- "We reviewed the process as a team and agreed the following change..."
Trainees who avoid reflection entirely leave large gaps in PLT and Fitness to Practice evidence — gaps far more likely to cause ARCP problems than a well-written near-miss reflection.
Something to make it stick when you're trying to explain it to someone else at 8am.
| Term | What It Means | Mandatory? |
|---|---|---|
| NOE | All naturally occurring portfolio evidence — the big category | No (as a category) |
| QIA | Quality Improvement Activity — a subset of NOE | Yes — every year |
| QIP | Quality Improvement Project — formal, assessed version | Yes — once in ST1/2 GP post |
- Audit, prescribing analysis, referrals analysis, QIA, new service: Quality Improvement Activity log entry
- Case study / presentation: Lecture/Seminar section
- Learning Event Analysis (LEA) / SEA: Learning Event Analysis section — not a regular log entry
- Reflection on post: Courses & Certificates section
- Safeguarding certificates: Compliance Passport → link to mandatory training
- Safeguarding annual entries (adult + child): Learning log — one entry per domain per year
- Discussion paper / literature review: Supporting Documentation or learning log
- Complaints: LEA/SEA section or learning log, link to Fitness to Practise
- HDR / teaching sessions attended: Supporting Documentation
📅 What to Do in Each Training Year — NOE Summary
| Year | QI Requirement | Other NOE Priorities |
|---|---|---|
| ST1 | 1 × QIA (hospital posts work fine) — or start your QIP if in a GP post | LEA from any near-miss; reflection on post every 6 months; start building capability coverage early; safeguarding entries (adult + child) |
| ST2 | 1 × QIA or QIP in GP post (QIP is strongly preferred for your CV) | QIP in GP post is the sweet spot; safeguarding entries both years; case presentation to any group counts |
| ST3 | 1 × QIA (if no QIP this year) + Leadership Activity | QIP if not done in ST2; reflection on final post; case presentation; Leadership MSF in second half of ST3 |
💡 The QIP on your CV is more impactful when completed in a GP post — it demonstrates primary care QI, which future employers value. ST2 GP post is the sweet spot: past ST1 nerves, before ST3 exam pressure.
The Personal Development Plan is how you show you're planning ahead, not just reacting.
The Personal Development Plan (PDP) in your 14Fish ePortfolio is not just a box to fill — it is the mechanism by which your NOE activities connect to your ongoing learning. A well-maintained PDP shows ARCP panels that you are an active, self-directed learner — not just someone completing the minimum requirements.
PDP entries should be SMART:
- Specific — "Improve my antibiotic prescribing for URTI" not "Improve prescribing generally"
- Measurable — "Review 10 of my prescriptions and compare against guidelines" not "Do better"
- Achievable — Realistic within the timeframe and post
- Relevant — Links to a genuine learning need identified from a case, feedback, or log entry
- Time-bound — "By the end of this 6-month post"
Aim for 3–5 PDP entries per post. The 14Fish ePortfolio has a "Send to PDP" button within log entries — use it whenever you identify a learning need.
Helping trainees understand what NOE is and why it matters — before they accidentally skip it.
- Confusion between "NOE is not mandatory" and "QIA is not mandatory" — these are not the same thing. Trainees frequently get this wrong.
- Over-reliance on formal WPBA tools (COTs, CBDs) while neglecting NOE — leaving huge capability gaps in OML and Community Orientation.
- Treating the ePortfolio as a tick-box exercise — uploading activity without substantive reflection.
- Filing under the wrong section — especially presentations (should be Lecture/Seminar, not supporting documentation).
- Forgetting to link NOE to specific capabilities in the ESR discussion.
- "Walk me through something you've noticed in your practice that you'd want to investigate further."
- "If you were going to do an audit tomorrow, what would you audit and why?"
- "Have you had any near-misses since we last met? Tell me about one."
- "What's something about your prescribing or referral behaviour you're curious about?"
- "How would you explain NOE to a medical student joining your practice next week?"
- "What did you learn from your last rotation that you're going to do differently in GP?"
- RICE criteria met: Is it relevant, personally led, evaluative, and outcome-focused?
- Reflection depth: Does the trainee show genuine learning, not just description?
- Capability coverage: Does the reflection address OML, WWC, CO, and PLT — or just one?
- Evidence of change: Has something actually changed as a result? Even a small, specific change counts.
- Patient benefit: Is there a clear line from the activity to improved patient care?
- Discuss one potential NOE activity at each tutorial, proactively — don't wait for the trainee to bring it up.
- Help trainees see that things they've already done might qualify — retrospective recognition is powerful motivation.
- Model reflective practice yourself: "I did a prescribing analysis last year that showed me…"
- For hospital-based trainees: prompt them to look for NOE opportunities in every post — even in specialties that seem unrelated to GP.
- Remind LTFT trainees they need proportionally more QIA entries across their extended training.
The questions trainees actually ask — with straight answers.
If NOE is not mandatory, can I just skip it entirely?▾
Not quite. While "NOE" as a broad category is not mandatory, certain elements within it are. A QIA is required every training year (GMC requirement), and a QIP must be completed once in a primary care placement in ST1 or ST2. You also need safeguarding training.
Beyond those requirements, skipping NOE entirely would mean leaving large gaps in your evidence for OML, Community Orientation, and Working with Colleagues — capabilities that formal WPBA tools (COTs, CBDs) struggle to capture. An ARCP panel will notice.
Does my presentation have to be at HDR? Can it be to my PHCT or medical students?▾
The purpose of the presentation activity is to help you acquire teaching and planning skills — so presentation to any group is completely valid: your VTS scheme at HDR, your hospital department, your PHCT, your practice team, or even a group of medical students.
What matters is the preparation: a) identify your audience's learning needs, b) set aims and objectives, c) think about the method of delivery, and if you're particularly keen, d) evaluate the session afterwards. A quick and dirty slide deck with no preparation does not count.
I'm in a hospital post right now. Can I still do a QIA?▾
Yes. A QIA can be done in any post — hospital or GP. However, the QIP (the more formal project, required once) must be in a GP primary care placement. So if you're in a hospital year, a QIA is fine, but don't try to complete your QIP here — save that for your GP post.
Good QIA ideas for hospital posts include: prescribing analysis, referrals analysis, SEA, a presentation to your department, or a reflection on your post linking hospital learning to GP practice.
What actually counts as an "outcome or change"?▾
It doesn't need to be dramatic. The "change" can be: a change in your own clinical behaviour, a change in practice policy, a change in a system or process, a decision to investigate further, or even the establishment of a plan that will be revisited. What matters is that the activity didn't just generate data — it resulted in some kind of action.
Example: "I found I was over-prescribing antibiotics for URTI. I discussed this with my trainer and agreed to change my management approach. I'll review my prescribing again in 3 months." That's a valid outcome, and it's a realistic one.
I'm training less than full time (LTFT). Does that change anything?▾
LTFT trainees complete the same number of WPBA assessments per training year, but because their training year is longer in calendar terms, they will complete more QIAs over the whole of their training. The requirement is per training year, not per calendar year — so if you're on 50% LTFT, your "training year" is two calendar years, and you'll need a QIA per training year (i.e. one every two calendar years at 50%).
This also applies to safeguarding: the annual knowledge update is required every 12 months even if LTFT. Don't assume your calendar year and training year are the same.
What's the difference between an SEA and a complaints write-up?▾
A Significant Event Analysis (SEA) covers any event where something went wrong or nearly went wrong — including events that had no complaint attached to them. SEAs can involve near-misses, process failures, or critical incidents you identified yourself.
A complaints review is specifically about formal complaints made about your care. Complaints should be declared on Form R and your Educational Supervisor should be informed. Complaints are significant events and should also be written up as SEAs, but they have an additional administrative requirement that general SEAs do not.
My ARCP panel said my QIA "does not meet RCGP criteria." What do I do?▾
Don't panic — this is a common and fixable problem. The panel can ask you to rewrite or add further information. Revisit your entry using the RICE framework: Relevant, personally Involved, results in Change, involves Evaluation. The most common reasons for rejection are: not enough personal engagement described, no clear outcome or change demonstrated, or the activity reads as descriptive rather than evaluative.
Rewrite the reflection to be more explicit — show what you did, what you found, what you changed, and what you learnt. Then resubmit and inform your Educational Supervisor that you've updated it.
What do IMGs find most confusing about NOE?▾
Several things tend to catch international medical graduates off guard:
- The expectation that individual clinicians drive quality improvement — in many healthcare systems this is seen as a management function, not a clinical one.
- The reflective writing style — first-person, candid, and evaluative reflections can feel uncomfortable if you've trained in a culture where acknowledging difficulty or error is not normal in professional writing.
- The idea that there is no single "right answer" for what to do as a NOE activity — the flexibility can feel confusing when you're used to more structured systems.
The UK training system genuinely values your perspective as someone who has worked in a different healthcare environment. Use that in your Community Orientation reflections — what did you notice about how primary care works differently here, and what did that teach you about UK GP practice?