Every member of the practice team should be keen to expand their knowledge and the QOF provides the means to encourage them, as Dr Nigel Watson explains


Keeping up to date through education and training is an important factor in providing good patient care. Education and training therefore form one of the five areas within the organisational section of the nGMS contract’s Quality and Outcomes Framework (QOF).1

There are nine education and training indicators (Table 1), worth a total of 29 points. In 2005/6, each point is worth approximately £125, so achieving maximum points would net the average practice of 5891 patients more than £3600.

Life support skills – Indicators 1 and 5

Fortunately, members of the primary care team rarely encounter cases of cardio-pulmonary collapse. However, it is important that they have the training to deal with such an emergency in the event that it does occur.

To fulfil Indicator 1, there must be a record of practice-employed clinical staff having undergone training or updating in life support skills during the preceding 18 months. To meet Indicator 5, all staff should have had training during the preceding 36 months.

Although Indicator 1 sets a timescale of 18 months, it should not be difficult to organise a training event each year.You must then keep a record of those who have undergone training or skills updating and, more importantly, of those who require training.

Training providers include the local A&E department, PCO or out-of-hours provider. A range of national bodies also provide training courses (Box 1).

During the first year of the nGMS contract, two problems relating to these indicators arose in the Wessex LMCs area (see Box 2).

Table 1: Education and training indicators
Indicator Points
Education 1 4
There is a record of all practice-employed clinical staff having attended training/updating in basic life-support skills in the preceding 18 months  
Education 2 4
The practice has undertaken a minimum of six significant event reviews in the past 3 years  
Education 3 2
All practice-employed nurses have an annual appraisal  
Education 4 3
All new staff receive induction training  
Education 5 3
There is a record of all practice-employed staff having attended training/updating in basic life support skills in the preceding 36 months  
Education 6 3
The practice conducts an annual review of patient complaints and suggestions to ascertain general learning points which are shared with the team  
Education 7 4
The practice has undertaken a minimum of 12 significant event reviews in the past 3 years which include (if these have occurred):
  • any death occurring in the practice premises
  • two new cancer diagnoses
  • two deaths where terminal care has taken place at home
  • one patient complaint
  • one suicide
  • one section under the Mental Health Act
Education 8 3
All practice-employed nurses have personal learning plans which have been reviewed at annual appraisal  
Education 9 3
All practice-employed non-clinical team members have an annual appraisal  

Box 1: Useful resources for the education and training indicators
Life support skills training
Significant event review
  • Royal College of General Practitioners. Significant Event Auditing: Occasional Paper 70. London: RCGP, 1995
  • Robinson LA, Stacy R, Spencer JA, Bhopal RS. How to do it: use facilitated case discussions for significant event auditing. Br Med J 1995; 311: 315-18
  • Acas (Advisory, Conciliation and Arbitration Service): www.acas.org.uk
  • BMJ learning website (for evidence-based learning resources for the whole practice team): www.bmjlearning.com


Significant event review – Indicators 2 and 7

To achieve Indicator 2, the practice must have carried out a minimum of six significant event reviews in the past 3 years. For Indicator 7, a minimum of 12 significant event reviews must have been held in the same period, and six of them, if possible, should relate to particular types of event defined by the contract (see Table 1).


Significant event reviews are designed to ensure that practices can learn from their experience. Reviews can equally well arise from events that go well as from those where mistakes were made.

To get the most out of discussing significant events, it is important not to apportion blame, and to involve all practice team members.A framework for significant review might involve the following:

  • Introduce the concept to staff at a multidisciplinary meeting
  • List the events that should be important to the practice. Topic headings could include preventative care, acute care, chronic disease and organisation
  • Make a record of events as they are identified. The record book or computerised record should be available to all team members
  • Hold a significant event meeting. This should ideally be multidisciplinary, and there should be a chairperson. Everyone who attends should be encouraged to contribute a significant event. Discussions should arrive at a conclusion, which can be: a celebration of excellent care; no change needed; an audit should be carried out; immediate change is needed
  • Follow up the conclusions at the next significant event meeting.

A report of each significant event should cover:

  • What happened
  • Why it happened
  • Any insight that was demonstrated
  • Any change that was implemented.

Box 1 gives some useful sources of information on significant event review.

The lessons learned from some significant events can usefully be applied across all practices in an area, although practices cannot be compelled to share their experience (Box 3).

Box 2: Problems relating to life-support skills training
Do Indicators 1 and 5 apply to GPs?
A GP partner in one practice had not attended a training session for more than 2 years, and the PCT refused to award the points for these indicators.The LMC referred the PCT to the QOF, which states that Indicators 1 and 5 relate to practice- employed staff, and not to partners.The practice was therefore awarded the points.
The LMC suggested that although there was no requirement for partners to undergo skills updating, perhaps it would be a good idea for them to do so.The practice arranged two training events, one for the clinical staff and the other for the non-clinical staff. All the partners attended and found the training helpful, so they have decided to update their skills annually.
Can staff members opt out of life-support skills training?
A member of staff at one practice refused to attend training. The partners explained that they wanted to make sure that if a patient collapsed at the surgery when no clinical members of the practice were present, someone with life-support skills training would be able to take action.
When the staff member understood what was involved he readily agreed to undergo training, explaining that initially he feared that if he attended the training session he would be called upon every time a patient collapsed.
It should be a requirement of every staff member’s contract of employment that he or she attend training in life-support skills.

Box 3: Problems relating to significant event reviews
Can the PCT alter the terms of the Indicators?
Staff at one PCT felt that an accounting period of 18 months for significant event reviews was preferable to one of 3 years, and tried to impose this shorter period on the practices in their area. A copy of the relevant page of the QOF was sent to the PCT, and it was pointed out that because the QOF is part of the nationally negotiated nGMS contract, the PCT could not place local variations or interpretations on any aspect of it. However, it was suggested that the PCT could offer additional financial incentives to practices if it wished to impose the shorter period. The PCT backed down and agreed to abide by the contract.
Clearly, unless a shorter accounting period is formally agreed, there is no point in practices completing all the significant event reviews within a short period and then stopping the process. Significant event review should be an ongoing process.
Should the PCT know the details of practices’ significant events?
One PCT insisted that practices should report all significant events to the PCT, which would then share the information with all the practices in its area.
The PCT had no right to ask for this information and when challenged agreed that they were in the wrong.
In one practice, a staff member gave a tetanus vaccination in error, thinking it was an influenza vaccination - the two pre-filled syringes were very similar in appearance. The practice held a significant event review and decided to store the syringes in different coloured containers in separate parts of the fridge. The practice itself decided to share this information to enable all the local practices to review their procedures.


Indicators 3, 8 and 9 reward practices for good employment practice, in carrying out an annual appraisal for all staff.

In assessing these indicators, the PCT may ask to see the practice’s appraisal policy, but it should not be asking to see the documentation relating to individual staff members’ appraisals (Box 4).

Box 4: Problems relating to appraisals
Can the PCT ask to see confidential documents relating to appraisals?
One PCT asked to see the documentation relating to nurse appraisals, including the confidential reports and a list of training issues that arose from them.
It was pointed out that the PCT had a right to be shown the process and proof that the appraisals had taken place, but that confidential material must remain confidential.

Nurse appraisals – Indicators 3 and 8

Carrying out an annual appraisal for all nurses meets Indicator 3, worth two points. Indicator 8,worth another three points, stipulates that the annual appraisal should include the nurse’s personal learning plan.

Appraisal provides an opportunity to review a staff member’s objectives and skills in a constructive way. Learning needs should be identified, and these can be individually tailored to the nurse being appraised or related to the practice. Consider clinical issues separately from those of administration and management.

Structured appraisal schemes employ a variety of professionals to fulfil the role of appraiser. In some practices, the nurses’ annual appraisal is carried out by the practice manager, without input from a clinician. This is not a performance appraisal but a peer-led review. It is important to ensure that the practice manager and a doctor or senior nurse or other professional are involved in annual appraisal.

Appraisals must be confidential, but if common training issues are identified ensure that these are fed into practice education and training plans.

Non-clinical staff appraisals – Indicator 9

As with the nurse appraisals, the learning needs that arise out of an appraisal for non-clinical members of staff can be personal or related to the whole organisation.

You could use the opportunity to review and update the staff member’s job description.

See Box 1 for useful sources of guidance on appraisals.

Induction training – Indicator 4

A structured, but flexible, induction programme can ensure that staff joining the practice quickly become effective team members. In addition to employment terms and conditions, the topics the programme should cover include: practice standards and regulations, areas of responsibility, overtime arrangements and employment procedures.

Update your practice’s induction training regularly. It is a good idea to see if you can find out what other local practices offer and compare their training with yours.

At assessment visits, the newest member of staff, if he or she joined after 1 April 2003, is often asked about their induction training.

Patient complaints – Indicator 6

No one wants to receive a complaint from a patient, but it is important to see any complaints in a positive light, as potential sources of learning.

You should record all the complaints – and suggestions – made to the practice, and hold a meeting each year to review them. It is a good idea to sort them into categories because you may identify some common themes.

Summarise each complaint and make a note of any learning points that you identified during your discussions.

It is important to make sure that the learning points are communicated to the whole team, and it can be a good idea to nominate one individual to oversee any changes that need to be made in the practice.

Since the introduction of the inhouse complaints procedures, most complaints are resolved at practice level and go no further.

The reports generated by the review meeting can feed into Indicators 2 and 7 by forming part of the evidence for significant event reviews.


The education and training section of the QOF has rewarded many practices for work that was already being done – many practices have identified education and training as a high priority. Despite the fact that improvement in this area can be difficult to measure, the indicators have enabled many practices to focus on things that could be done better.


  1. British Medical Association. Investing in General Practice: the new General Medical Services Contract, supporting documentation. London: BMA, 2003. www.bma.org.uk.

Guidelines in Practice, October 2005, Volume 8(10)
© 2005 MGP Ltd
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