GP Specialty Training (GPST1-3): Practice-Level Governance
This resource provides GP trainees and trainers with a comprehensive framework for understanding and engaging with practice-level governance during specialty training. It bridges the gap between clinical learning and the operational realities of running a CQC-compliant general practice, offering actionable guidance for audit, quality improvement, and inspection readiness.
Integrating Practice Governance into GP Specialty Training
For GP trainees, understanding practice governance is not an optional extra but a core component of becoming a safe, effective, and responsible GP partner or salaried practitioner. The three-year training programme (GPST1-3) offers a unique opportunity to learn governance principles in a supported environment.
The Governance Learning Curve Across GPST1-3
Trainee involvement should be developmental, increasing in complexity and responsibility with each training year.
GPST1: Foundation and Observation
- Focus: Familiarisation with practice systems and basic governance structures.
- Key Activities: Attending practice meetings (e.g., significant event analyses, practice business meetings), understanding the practice's clinical protocol folder, learning the process for reporting safety incidents via the practice's designated system (e.g., Datix, Radar).
- Trainer Role: To explicitly signpost governance processes and explain their purpose.
GPST2: Participation and Application
- Focus: Active participation in governance activities and undertaking a first clinical audit.
- Key Activities: Leading or co-leading a Significant Event Analysis (SEA), completing a full audit cycle on a straightforward topic (e.g., NSAID prescribing and GI protection in line with NICE guidance), contributing to discussions on CQC readiness.
- Trainer Role: To mentor the trainee through their first audit cycle and provide feedback on their contributions to governance meetings.
GPST3: Leadership and Integration
- Focus: Taking a leadership role in quality improvement and demonstrating readiness for independent practice.
- Key Activities: Designing and leading a more complex quality improvement project (QI-P), critically appraising a local policy against national evidence, preparing a section of the practice's evidence for a CQC inspection or internal review.
- Trainer Role: To act as a critical friend, challenging the trainee to justify their governance decisions and prepare for the responsibilities of a qualified GP.
Practice-Level Governance and CQC Readiness
A training practice's governance framework is intrinsically linked to its preparedness for Care Quality Commission (CQC) inspection. The CQC's assessment framework, centred around Quality Statements, provides a clear structure for both practice organisation and trainee learning.
CQC Alignment: Learning from the Framework
Trainees should understand how practice activities map to the CQC's key lines of enquiry. For example:
| CQC Quality Statement (Example) | Relevant Practice Activity | Trainee Involvement Opportunity |
|---|---|---|
| Learning culture The practice has a proactive and positive culture of learning, improvement, and innovation. |
Significant Event Analysis (SEA) meetings, audit and QI projects. | GPST2/3: Lead an SEA. Present audit findings to the team and implement changes. |
| Safe and effective staffing People have their care, treatment, and support provided by competent staff who are properly qualified and skilled. |
Induction processes, supervision arrangements, appraisal systems. | GPST1: Experience the induction process. GPST3: Reflect on how they would induct a new staff member. |
| Evidence-based care and treatment People’s care, treatment, and support achieves good outcomes, promotes a good quality of life, and is based on the best available evidence. |
Implementation of NICE guidance, clinical protocols, prescribing audits. | All Stages: Conduct audits against NICE guidance. GPST3: Critically review a local protocol. |
Actionable Steps for Trainees and Trainers
- For the Trainee: Request to see the practice's CQC report and any subsequent action plan. Use this as a basis for understanding the practice's strengths and areas for development.
- For the Trainer: During the trainee's induction, explicitly discuss the practice's governance structure. Assign the trainee a "governance buddy" (e.g., the practice manager or a partner with a governance lead) for practical queries.
- Joint Activity: Together, review the CQC's Key Questions and Quality Statements and identify one area where the trainee can contribute to evidence generation during their placement.
Navigating Guidance: When to Use NICE vs. Local Policy for Audits
A common challenge for trainees is determining the appropriate standard against which to audit practice. The decision-making process is a key clinical governance skill.
The Hierarchy of Evidence for Primary Care Audits
As a rule, national guidance takes precedence unless a robust, documented rationale exists for a local variation.
When to Use NICE Guidance (NG, QS, CG)
NICE guidelines represent the gold standard of evidence-based practice. They should be the default benchmark for audits relating to clinical management, especially for:
- Diagnosis and management of specific conditions (e.g., NICE NG28 [Type 2 diabetes in adults] for HbA1c monitoring).
- Medication prescribing and safety (e.g., NICE NG80 [Sepsis] for antibiotic prescribing in suspected sepsis).
- Preventative care (e.g., NICE CG181 [Cardiovascular disease] for statin prescribing).
Example: An audit of hypertension management should primarily reference NICE NG136 [Hypertension in adults]. The audit standard would be the percentage of patients under 80 with a confirmed diagnosis of hypertension who have a clinic BP below 140/90 mmHg.
When Local Policy May Be Appropriate
Local formularies, pathways, or protocols are valid audit standards in specific circumstances:
- Operational Efficiency: Auditing adherence to a local referral pathway for suspected cancer (2-week-wait), which may specify required investigations before referral.
- Resource Rationalisation: Auditing against a local CCG/ICB formulary for a specific drug class (e.g., insulin analogues) where choice is restricted to ensure cost-effectiveness.
- Addressing Local Population Needs: Auditing the management of a condition more prevalent in the local area, where a local enhanced service (LES) specifies a particular approach.
Crucial Check: Before using a local policy, the trainee and trainer must verify that it does not directly contradict NICE guidance. If it does, there must be a clear, minuted rationale from the practice or ICB.
Decision-Making Template for Audit Standards
Use this flowchart to guide your choice:
- Is there a relevant NICE Guideline (NG) or Quality Standard (QS)? If YES, use this as your primary standard.
- If NO, is there a relevant local policy or pathway? If YES, check it is up-to-date and evidence-based. Use it as your standard.
- If NO to both, consider basing the audit on a robust national source (e.g., SIGN, RCGP guidance) or a recognised clinical standard (e.g., QOF indicators). Document your choice and rationale.
GP-Specific NICE Guidance: Key Examples for Training and Inspection
Certain NICE guidance documents are particularly salient for general practice and are frequently scrutinised during inspections. Trainees should develop familiarity with these.
| NICE Guidance Code & Title | Clinical Relevance | Inspection & Audit Focus | Example Audit Topic for Trainee |
|---|---|---|---|
| NG28 Type 2 diabetes in adults: management |
Core long-term condition management, prescribing, multi-morbidity. | Annual review completeness (8 care processes), HbA1c & blood pressure targets, medication safety (e.g., SGLT2 inhibitor use). | Percentage of patients with T2DM and established CVD prescribed an SGLT2 inhibitor. |
| NG80 Sepsis: recognition, diagnosis and early management |
Safeguarding, patient safety, acute presentation in primary care. | Evidence of staff training, use of NEWS2 or other recognition tools, documentation of safety-netting. | Documentation of a structured assessment (e.g., ABCDE) in notes for patients presenting with suspected infection. |
| NG215 Chronic kidney disease: assessment and management |
Monitoring, medication review (e.g., ACEi/ARB, metformin), cardiovascular risk. | Staging accuracy, monitoring frequency, appropriate medication adjustments. | Appropriate dosing of metformin in patients with CKD stage 3b-5. |
| QS204 Mental health in primary care |
Holistic care, care planning, physical health monitoring in SMI. | Integrated care, annual physical health checks for patients with SMI. | Completion of annual physical health checks for patients on the SMI register. |
Practical Project Examples and Perspectives
Translating theory into practice is essential. Below are examples of governance projects suitable for different training stages, with perspectives from both trainee and trainer.
Example 1: GPST2 Audit - NSAID Prescribing Safety
Project Outline: A closed-loop audit assessing the percentage of patients prescribed an oral NSAID who have a recorded assessment of GI risk and are co-prescribed a PPI if indicated.
Standard: NICE CG177 [Osteoarthritis] and NG210 [Chronic pain] which recommend GI protection for those at increased risk.
Trainee Perspective: "This project taught me how to use the clinical system (SystmOne/EMIS) to run complex searches, the importance of clear documentation, and how to present data to the team to drive change."
Trainer Perspective: "This was an ideal GPST2 project. It had a clear patient safety focus, used a definitive NICE standard, and the results led to a tangible change—we updated our NSAID protocol and created a template for safer prescribing."
Example 2: GPST3 Quality Improvement Project (QI-P) - Improving Diagnosis Coding for Learning Disabilities
Project Outline: A QI-P to increase the accuracy of the practice's Learning Disability (LD) register to ensure eligible patients receive annual health checks, as per NICE NG54 [Mental health problems in people with learning disabilities].
Method: The trainee developed a search to identify patients with suggestive codes (e.g., "global developmental delay") or medications but no formal LD code. They then designed a protocol for reviewing these records, engaging with carers, and correctly coding confirmed cases.
Trainee Perspective: "This was more complex than a simple audit. It involved stakeholder engagement (carers, community teams), designing a sustainable practice process, and thinking about equitable access to care. It directly supported the practice's CQC evidence for 'Equity in Access'."
Trainer Perspective: "This QI-P demonstrated the trainee's readiness for partnership. They managed a project with clinical, administrative, and ethical dimensions. The outcome significantly improved our ability to provide proactive care to a vulnerable group, which was a key point discussed in our last appraisal."
Appraisal and Portfolio Evidence
Governance activities are rich sources of evidence for the trainee's ePortfolio (particularly the Quality Improvement domain) and for the trainer's own appraisal.
- For the Trainee's Portfolio: Document projects with reflection on what was learned about systems, safety, and leadership, not just clinical knowledge.
- For the Trainer's Appraisal: Supporting a trainee through a governance project demonstrates commitment to teaching, learning, and improving local clinical practice—a core requirement for GP appraisals.
Conclusion
Engagement with practice-level governance is a fundamental pillar of GP specialty training. By actively participating in audits, SEAs, and quality improvement projects, trainees move from being observers of the system to becoming skilled agents within it. For trainers, fostering this development is a professional responsibility that simultaneously strengthens the practice's own governance and CQC readiness. Using the structured approach outlined here—aligning with CQC frameworks, correctly applying NICE guidance, and undertaking staged projects—ensures that governance learning is meaningful, practical, and directly relevant to the future of safe, effective general practice.
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