MRCGP & GP Training

Naturally Occuring Evidence (NOE)

Naturally Occuring what? Isn't that earthquakes and stuff?

No… that’s naturally occurring phenomena.

  • Naturally Occurring Evidence (NOE) NOE is a term for things which occur ‘naturally’ during the course of a GP’s professional working life which demonstrate your commitment to improving the care one gives to patients and enhancing their safety.  A subset of Naturally Occurring Evidence is Quality Improvement Activity.   
  • Quality Improvement Activity (QIA) The GMC definition of Quality Improvement Activity is any activity that is relevant to your work which includes an element of evaluation and action, and where possible, a demonstration of an outcome or change.  These activities should be robust and systematic.
There are things that you will do during your time as a GP Trainee which provides additional evidence for the Professional Capabilties that unfortunately does not fit in neatly into one of the other Work-Place Based Assessement components.   Things which occur “naturally” as you progress through your GP post.   Things which show that you care of the quality of care you are providing your patients.   Things which you are proud of and are an achievement in themselves.    The provision for an area called NOE (Naturally Occuring Evidence) within your ePortfolio provides a space for you to put all of this.  

Which Professional Capabilties does NOE provide evidence for?

  • ORGANISATION, MANAGEMENT & LEADERSHIP (OML)
    You can show your leadership skills – how you came about the NOE activity and decide to lead on it.    And then you can talk about your management and organisational skills – especially if several people were involved.  How did you manage them?  Your delegation skills.   Your empowering skills. How did you gather your data?  How did you organise your results.   Did you present anything?
  • WORKING WITH COLLEAGUES AND IN TEAMS (WWC)
     Looking for ways to persuade people to change their traditional approaches and improve care.  How did you motivate people?  Who did what?  How did you work effectively together?  What did you learn about teamwork?
  • COMMUNITY ORIENTATION (CO)
    Most NOE activities involve moving away from caring for the individual patient immediately in front of the GP and looking at “the management of the health and social care of the practice population…” This is a core part of the definition of Community Orientation.   Again, think about what led you to this particular NOE activity?   Was it an encounter with a single patient which then made you think about patients who share a commonality with that patient?   How does your NOE activity benefit the a population group?
  • MAINTAINING PERFORMANCE, LEARNING, TEACHING (PLT)
    What have you learnt from the process?   Describe any learning cycles.   What might you consider doing next time to make NOE activities easier?  How has what you have done improved patient care?

What sorts of things can I do as NOE?

You don’t have to do everything on this list.  Pick a few that generate an interest.  This is an opportunity for you to play with them with some support from your trainer.  Grab the opportunity!  Whatever activity you choose to do, it must…

  • Be relevant to your work
  • Show personal involvement (not the work of others)
  • Involves evaluation of current practice
  • Results in an outcome or some sort of change.

and try and pick something that

  • interests you rather than what the practice wants you to do.  Pick something that ‘lights your fire’.
  • has relevance and applicabiltiy.  In other words, something worthwhile doing because it will make a difference, rather than something  that is merely interesting.

 The Audit Cycle measures the quality of care we provide to our patients.  Most trainees go for an audit of some sort of clinical area.  For instance, the control or warfarin, LFTs being checked post stating, or exercise instead of NSAIDs for tennis elbow.  But it needn’t be.  For instance, you could do an audit of ‘the doctor’s bag’ or the comprehensiveness of patient details on blood result forms etc.  Think laterally and be creative.  (By the way, other common examples of audit relate to minor surgery, cervical smears, monitoring of DMARDs, end of life care, cancer diagnosis, referrals and admissions, hypertension management, leg ulcer care, investigations and imaging).

Most Audits and Projects provide easy evidence for the following competencies:

  • Organisation, Management & Leadership
    Which is “about the appropriate use of primary care administration systems effective record keeping and information technology for the benefit of patient care’. So getting data out and using this to improve care through audit is clearly part of this competency domain.
  • Working with colleagues and in teams
    Audit is not just about collecting the data and analysing this all by yourself.   You may well have involved several other members of the team.  Perhaps you had to persuade colleagues to change their traditional approaches and improve care … or “working effectively with other professionals to ensure patient care…”
  • Community Orientation
    Audit involves moving away from caring for the patient immediately in front of the GP and looking at “the management of the health and social care of the practice population…” This is a core part of the definition of Community Orientation.
  • Maintaining performance, learning and teaching
    There are several parts of the word pictures used to describe this competence which particularly address the audit/ project… “investigates personal performance”… and “evaluates the process of learning so as to make future learning cycles more effective.”
  • Bradford VTS pages on Audit

This could include a review of QoF data, commissioning information, minor surgery data, morbidity/mortality data, review of outcomes of acute admissions, quality of record keeping, review of telephone triage outcomes.

Significant events area certainty in all of our working lives.  Things will occasionally go wrong.  It’s important not to brush these off but to study them and learn from them.  These don’t need to be serious events – but even near misses that could have potentially had a really adverse outcome.  We need to put measures into place to stop their likelihood of recurrence.   Professional Capabilities demonstrated through SEA work include…

  • Working with colleagues and in teams
    SEAs provide an opportunity to work with your colleagues to make things better.  Talking together to improve systems for instance.  Working out together the multiple factors that led to the SEA.  Events that relate to teamworking.
  • Maintaining performance, learning and teaching
    SEA is particularly good evidence for this domain, because it allows trainees to show reflection on performance and subsequent improvement, which is the heart of what this domain is about.
  • Fitness to practice
    If the SEA includes discussion about the performance of those involved in the event, including the trainee
  • Maintaining an ethical approach
    The SEA discussion provides an opportunity for the feelings of those involved to be aired. For example, the values, beliefs, prejudices and ethical approaches of those involved might be discussed and reflection on this (anonymised) can provide evidence for this domain.
  • Bradford VTS pages on SEA

This is where you engage your peers/multidisciplinary team in a review of an interesting or challenging case – usually to understand a topic more generally.  You might focus on a clinical area – like an unusual presentation of chest pain (reminding us all about being ‘broad minded’) or it might focus on medication (e.g. patient who was tried on several migraine treatments – to help illustrate perhaps a structured management approach) or you might focus on something totally different (like care pathways or organisations).

  • Please file your case study or presentation under Lecture/Seminar in your ePortfolio.
  • The case study/presentation mainly covers Professional Capability domail Performance, Learning and teaching.  It is important to ensure that the GMC expectation that doctors are involved in teaching is included and completion of all the word pictures in this competency domain requires demonstration of teaching and learning from that teaching. (“identifies learning objectives and uses teaching methods appropriate to these” and “assists in making assessments of learners” ).  So the process of reflecting and writing up the case study/presentation is evidence for primarily competency domain 10… though the content of the presentation may also address other competencies.
  • Question from a recent Trainer: Does the presentation have to be at Half-Day Release to peers?  Can it be to members of our PHCT?  Can it even be a presentation to our medical students?   Answer: To answer this question, one has to think about the purpose of the presentation. The purpose behind the presentation is to help the trainee acquire some teaching and planning skills.   Therefore, a presentation to any of these groups (including medical students) is simply fine.  But the GP trainee should have given some thought to it rather than a quick and dirty presentation. In other words: a) identifying the audience’s learning needs b) setting some aims and objectives c) thinking about the method of delivery/presentation and if they’re super duper trainees d) evaluating the session.
  • Bradford VTS pages on Case Studies

Engaging in a dialogue with one of your peers – looking at one of your surgeries, and picking some patients at random – to explore what you have done well, what could have been better and determine future learning needs.  

  • Bradford VT pages on RCA 

It is a GMC mandatory requirement for qualified GPs to engage in level 3 training every 3 years.   This includes trainees too

Some GPs over-refer, others under-refer.  Where do you lie on this scale?  You can even pick one area to look at – like musculoskeletal medicine referrals.

Some GPs over-investigate, others under-investigate.  Where do you lie on this scale?  Again, you can even pick one area to look at –xrays or CT scans for instance.

It is good to review your own prescribing behaviour – for instance, how often you resort to antibiotics or NSAIDS … the list is endless.

For instance, reviewing the most cost-efficient method of managing a condition.

To formulate and evidence-based approach to managing a condition based on a review of the literature out there.

  • Bradford VTS pages on Literature Reviews

This needn’t be something worthy of publication (unless you want to).  It’s okay to keep things simple – for instance, a questionnaire to see what patients think of the GP locums the practice employs or something more clinical like patient choice in contraception.

If your practice is already involved in the GP based research – then think about getting involved.

This doesn’t have to be a new clinic.  For example, it could be a new screening programme (eg for vit D deficiency).

A write up of your complaints, a thorough analysis of them, and key learning points.

  • Please detail serious in the Form R and inform your Educational Supervisor.   You should also write a reflective piece about it in your learning log – in particular, what have you learnt.
  • Declaring the absence or demonstrating an appropriate response to complaints is a professional expectation (and so relates to domain 12 – Fitness to practice).
  • Complaints are significant events and as such also relate to domain 10 – Maintaining performance, learning and teaching.
  • Which other competencies are involved will depend on the nature of the complaint made.  Statistically complaints are likely to relate to Communication (domain 1), Practicing holistically (domain 2) and to domain 8 (Working with colleagues and in teams) but there may well be elements of Clinical management (5) and of course the Data gathering (3) element is often
  • Bradford VTS on Complaints
  • central to establishing what happened… were the notes adequately detailed?

To show what you have learnt, highlight remaining (and new) needs and thus help with your continuing personal & professional development plan.

  • Please file your entry for this under Courses & Certificates.
  • The trainee should look at the important issue of self-care and work-life balance (Competency domain 12- Fitness to practice).
  • The core of the reflection on post will provide significant evidence around Competence domain 10 (Maintaining performance, learning and teaching) by encouraging the GPSTR to look at what has been learnt, and what remains to be learnt from the post that is finishing and starting to plan for learning in the next post. (thus encouraging appropriate PDP entries)
  • The reflection should look at the hospital posts and reflect on the learning that is relevant to GP… which will include a Community Orientation aspect (competency domain 9) by detailing how the resources encountered in the post can be accessed/used by GPs.
  • See DOWNLOADS section above for some reflection templates.

Is it mandatory?

NOE is NOT mandatory!!!   After all, it is NATURALLY OCCURING.   See it as an opportunity for you to show case some of the wonderful things that you have done that are difficult to provide elsewhere.

So, do whatever interests you!   Yorkshire & Humber Deanery suggest the following  (note the operative word suggest):

  • A Significant Event every 6 months.
  • One QIA project throughout your training period.   This I believe is now a national requirement preferably during ST1
  • A Reflection On Your Post every  6 months.
  • A Case Presentation or any Presentation every 6 months – either to the scheme, your hospital department or your training practice.

Got any suggestions or advice?

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