Trainees often struggle with this capability. Trainees think that if a condition is complicated, it is complex – BUT IT IS NOT! For example, the CKD management pathway is rather complicated, but when you slow down, it’s quite straight-forward to follow. It is not complex. Complicated and Complex mean different things. Complicated is something that might have lots of parts to it but everything follows a logical order and is therefore quite easy to follow or fix. An non-functioning electrical device might look COMPLICATED by having loads of components, but because everything has a logical placement, it should be easy for most technicians to fix. The weather is an example of something that is COMPLEX – where one little change can have a massive and sometimes unpredictable effect elsewhere. Do you see the difference between complex and complicated?  Trainees think that if they manage 2 or 3 problems together – it demonstrated Managing Medical Complexity – but IT DOES NOT! If they are four simple things (let’s say sticky eye, sore throat, a mole and a fungal toenail infection – yes having four things COMPLICATES matters but does not make the consultation COMPLEX. Yet someone who has both hypertension and CKD – is complex because drug management of the BP might have an adverse effect on the renal function.

I see that the RCGP have include Health Promotion in this capability, but there is a separate capability for this! So, if you want to focus on this, I suggest writing it within that capability. However, if the health promotion is part of a bigger picture of medical complexity, then you may wish to write about it here. You decide.

Think medical complexity when…

• 2 or more COMPLEX medical problems to juggle (acute or chronic) – how did you do it?
• where you’re stepping in to improve health care co-ordination (e.g. too many specialists involved and the patient is confused)
• where you’re stepping in because of Collusion of Anonymity (look it up – coined by Balint) 
• there is uncertainty – describe methods to handle uncertainty.  (One example is by safety-netting)
• explaining risk – because is a very special skill, it’s a hard thing to do right.  How did you explain risk of something: e.g. risk of getting pregnant on contraception, QRISK explanation

How you work with others. Remember, this is not about you being the “superhero” but how you work other others in a team. Remember: “there is no I in teams”. If you want to write about a team which you felt you led well (perhaps on a crash call in hospital or say
a project in GP), then write this under the Leadership capability in OML(Organisation, Management & Leadership).

Examples of Working With Teams

• Seeking a 2nd opinion or advice from a colleague
• Involving other health professionals in the management  – not just hospitals e.g. community matrons, referrals, virtual ward, HVs, Midwives, DNs, Crisis teams, Mental Health, The Labs – microbiology, haematology etc.  Why did you involve them?  For advice or help with patient care?  Team-based approach to patient care?
• Coordinating existing specialist involvement in a more team-based approach to enhance patient care, rather than silo working or preventing a Collusion of Anonymity.
• Acute admissions – liaising with on-call team, handing over, information in the letter.
• Passing on information to relevant colleagues – updating them about a patient
• Reading and complying with what others have written e.g. management plan
• Team dynamics – e.g. in meetings, in general, the ethos of the practice.
• Working on a project with others – QoF/DES/LES/Audit work
• Teaching colleagues – perhaps a workshop or teaching event you ran

Teamwork Principles You Can Write About…

1. Understand how teams work (Tuckman & Group Dynamics)
2. Facilitation skills (including how to encourage participation & managing conflict)
3. Defining clear Goals
4. Being Organised – Clear Roles & Tasks (read about Belbin’s Teams Roles), Delegation
5. Communicating well (SBAR, handover, referral letters, discharge letters)
6. Listening well (including allowing people to express feelings)
7. Making good decisions together
8. Mutual Trust, Respect
9. Being Flexible
10. Providing Skills training & Support
11. Enjoying the process & Celebrating Success
12. Communities of Practice (Wenger)- look it up.

Remember to be specific when you write about what you have or are planning to learn. For example, when writing about your learning needs, don’t just write “I will read up more about facet joint arthritis”. Be specific to show us that you have thought about it and are definately planning to do it. For example, you might write “I plan to read more about facet joint arthritis – great health professional article on patient.info”. Likewise, instead of “a course on Motivational Interviewing”, write “a course on Motivational Interviewing – one in Manchester run by xxx in Dec 21”.  Oh and don’t cut and paste things from online learning material. That will not help you learn and it also does NOT show us that you are learning. We are more  interested in what exactly is new for you and is going to change the way you do things in the future. What are the key take-home messages for you.

Also, when writing about teaching you have delivered, don’t just write about what you did (i.e. don’t just be descriptive). Tell us did it that particular way and try and relate it to (i) educational theory and (ii) faciliation theory – plenty of www.bradfordvts.co.uk (click on TEACHING). In other words, tell us “the intelligence behind your doing”. Don’t forget to evaluate your teaching – it’s the only way to get insight & improve!

• Teaching others
• What things have you looked up?   Care – don’t put too much “reading” stuff down.
• What modules and courses have you done?  Detail what you learned that you are going to put in practice.  Tonnes of learning detail is not necessary.  We are interested in the most important points for YOU.  
• Have you been involved in teaching others?   What did you do?  Why did you do it that way?  What teaching/facilitation methods did you use?  Relate what you did to the educational theory.

This capability actually covers lots of things! So best to think in terms of the 3 things – (1) Organisation (2) Management (3) Leadership

ORGANISATION:

• Understanding primary & secondary care organisational systems.
• Computerised medical records – how you use them to facilitate patient care; your medical notes – organised, comprehensive, logical?  
• Using other medical/non-medical IT systems – to manage the patient, to keep clinically up to date, other uses

MANAGEMENT:

• This is about managing yourself and/or others.
• Methods to help you keep on top of things – your blood results, letters and other admin work amongst the daily duties of a GP.
• Methods to help make you/organisation be more productive
• Time management
• Please detail what you are doing rather than being vague with words like “I am being more productive and efficient”. We want to know how. If you can’t tell us how, then it’s likely you don’t know what you are doing. So please tell us how. Again, it is about “the intelligence behind the doing”. 

LEADERSHIP:

• Don’t think of leadership as that top person in an organisation that leads the others below.  That’s a leader, not leadership. Leadership is broader than that. 
• Chairing a meeting
• Helping to manage staff or team-building activities
• You may have led a team or project or a change in the way of working in the practice you are working in.
• You can even show leadership qualities when managing a complex patient – let’s say where lots of specialists are involved but doing their own thing (silo working) – and you step in to coordinate the care in order to provide optimal patient care.
• If you are going to talk about leadership, you should relate what you are doing (the description) to the theory (i.e. “the intelligence”).

Leadership theory/principles include:

1. believing in the purpose/committing to the project/taking responsibility – developing a vision
2. (developing or enhancing skills that you may need for the job,
3. making sound & timely decisions,
4. communicating well,
5. leading by example (& showing humility),
6. knowing your people, valuing them & looking out for their welfare (& being forgiving)
7. skills – delegation, motivation, prioritisation, facilitation, influencing others,negotiation, empathy
8. learning agility – learning to be curious – being innovative,
9. showing self-awareness,
10. O-HIT core values – Openness, Honesty, Integrity & Trust.

There are 3 parts of this capability. You can write about any one of them.

PRACTISING HOLISTICALLY

• Looking at the problem in a wider context rather than just a medical one.  Why do we encourage this? Because the management of the problem in many instances needs more than just the quick “plaster” fix of a drug. So – write about these additional measures you have put in place to help – e.g. daycare, nursing support, referral to counselling.
• How is it affecting the patient’s life, their family’s, their work, their mental sanity.
• Explore ICE (Ideas, Concerns, Expectations) – how did this change your management?   Did you challenge any unhelpful health beliefs?
• Explore the PSO (Psycho, Social, Occupational) aspects of the problem on a patient’s life (or on his or her family) – how did this change your management?   Did you advise on any workplace adjustments?
• Understanding the problem in relation to the patients cultural and socio-economic background.

PROMOTING HEALTH

Please don’t try and squeeze in health promotion just for trying to impress us. Health Promotion has to be appropriate and realistic. Of course, if someone smokes you want to explore if they are open to smoking cessation, but give it the time and space it deserves and only do it when appropriate to do so. So, if a patient comes in with depression and you spend a good time on their low mood and suicidal ideation, talking about smoking cessation is not the right thing to do here – best left for another day, when the patient is in a happier part of their life (and more likely of success too).

• What tools you used if any, to promote health (e.g. Cates’ plots, decision-aids, health promo leaflets, SWOT analysis).
• What skills did you use to engage in positive health?   Motivational Interviewing skills for example.  Risk explaining skills.    Challenging unhelpful health beliefs.

SAFEGUARDING

A patient may come in with a problem that actually necessitates an enquiry into safeguarding, even though that might not have been part of their agenda. But doctors have to make doctoring decisions and if someone is at risk of harm – that has to become part of the agenda. So, if a lady comes in and reveals Domestic Violence, and this occurs in the presence of young children, safeguarding has to be part of the discussion and management plan.

So detail…

• what you did,
• why you did it,
• show that you have an understanding of safeguarding systems and
• detail how you did it to try and minimise an angry response.

Another capability trainees struggle with and what they write about often fails to “hit the mark”. So please re-read this capability to get the true definition of what it means firmly grounded into your head. Many trainees think referring a patient to a service in the community is a demonstration of this capability. IT IS NOT. This capability is about THE COMMUNITY rather than individuals, hence the term COMMUNITY orientation. It’s about populations rather than individual patients. It’s about population medicine and health rather than individual medicine and health.

In dealing with an individual patient many of us come across issues that apply more widely to other patients who share a similar characteristic. For example, you may have a poorly controlled diabetic in front of you and you realise he know nothing about diabetes or dietary management because all of your leaflets are in English and not in Punjabi – his mother tongue. You then realise you have a significant Punjabi community and thus the notion that this issue might be a wider problem. So,you source some leaflets in Punjabi and by doing that, you are being COMMUNITY ORIENTATED.

HOSPITAL POSTS: It is often difficult to show evidence for this capability when in a secondary care (hospital) post. But it is not impossible! Just remember, it has to relate to the community at large. For instance. you decide to join a hospital diabetic team that are trying to improve education in the community.Or perhaps the department is doing a campaign to encourage breastfeeding to new mothers. Or your General Medicine department wants your help on how to write more effective discharge letters that will help GPs (and thus ultimately patients) better.

Examples:

• You decide not to prescribe an expensive branded version of a drug (that a consultant wants you to prescribe) but a generic one because the money saved could provide more NHS services to the population at large.
• You have a patient in front of you who you feel could do with some Mindfulness therapy but not sure if this is available – in your research, you find something available on the NHS and you let other doctors and patients know.
• A patient wants an MRI of their back (no red flags); you decide to follow the local guidelines on MRI (developed because GPs are ordering MRIs unnecessarily) – you decide not to refer because one has to be protective of the NHS budget so that the greater population can be served better.
• You get involved with the CCG lead on sexual health to help deliver a better service.
• You notice that chlamydia is rife in your practice population but the uptake of screening is low – so you work with one of the partners to develop a “Get Tested” campaign.
• You attend a patient participation group because you want to hear what patients want.
• You attend LMC meetings because you want to help shape health at a population level.

Things to write about

• What did you learn from this patient that you are going to apply to all other patients with a similar characteristic?
• Have you made any changes to services to other patients as a result of this case?
• Have you developed a resource or something for other patients as a result of this case? e.g. back pain leaflet for patients who speak Latvian because there are quite a number of Latvian speaking patients.
• Have you reviewed any community services and how to make best use of them?
• Did you get involved in developing a new service?
• Have you helped shape the practice to encompass the variety of cultures and diversity within its practice population?
• Have you attended meetings to shape future health e.g. CCG/Primary Care Networks/Patient Participation Group meetings
• Have you been involved with voluntary groups and offered your help?
• Any natural moments where you have explored individual vs population health care?

Theoretical concepts you can write about

• Health and Social Care Act 2012
• Health Inequalities
• Inverse Care Law 1971
• Black Report 1980
• Global Burden of Disease study 2015
• English Index of Multiple Deprivation
• Adverse Childhood Experiences (ACE) Study 2015
• Whitehall Study of British Civil Servants
• The Acheson Report 1998
• The Marmot Review 2010
• An amazing article that covers everything above: https://www.healthknowledge.org.uk/public-health-textbook/medical-sociology-policy-economics/4c-equality-equity-policy/inequalities-distribution