GP practice policies should have a planned review date and be reviewed sooner whenever relevant legislation, guidance, risks or working arrangements change. There is no single review interval that suits every document. An annual review is a useful starting point for higher-risk policies, but it is not a blanket CQC requirement for the whole policy library. The interval should reflect the subject, any specific requirements and how quickly the practice’s arrangements may change.
For a busy Practice Manager, the challenge is making that approach workable. An inherited library may contain conflicting dates, duplicate documents and policies whose named owners have left. Giving everything a new annual date does little to resolve those problems.
A useful review checks whether the policy remains accurate, whether staff can follow it and whether the arrangements it describes actually work.
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Description textCQC’s Regulation 17 guidance does not set a universal annual review deadline for GP practice policies. The legal requirement concerns effective governance: assessing and improving quality and safety, managing risks and maintaining appropriate records. Policy review can help demonstrate those systems, but a recent date alone does not establish that they are effective. See CQC’s Regulation 17 guidance.
CQC references here apply to England. Practices elsewhere in the UK should check their own regulatory and contractual arrangements.
Under CQC’s published assessment framework, often called the Single Assessment Framework, policy management may support the Governance, management and sustainability quality statement. This addresses clear responsibilities, accountability and proportionate management of risk. It does not prescribe a review calendar. See CQC’s governance quality statement.
The assessment approach is also changing. CQC’s June 2026 update describes testing new frameworks alongside existing inspections, with evaluation planned for November. Practices should therefore check the latest guidance when preparing for assessment. See CQC’s assessment update.
For everyday management, record why a deadline applies. A legal or contractual requirement, an NHS guidance recommendation and a review interval chosen by the practice have different status. A template’s default date should not be presented as a national requirement without checking its source. goes here
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Set the interval by considering the consequences of an error, the likelihood of change and any requirements specific to the policy. Higher-risk or rapidly changing areas need closer attention. Longer intervals need a clear rationale and a reliable way to identify changes between scheduled reviews.
An annual review will not always be frequent enough. Conversely, rewriting a stable administrative policy every year may add little value.
Topic-specific guidance helps inform the decision. HSE’s health and safety policy guidance recommends regular review. Separately, its leadership guidance recommends reviewing health and safety performance at least annually, including whether the policy reflects current priorities. These are related activities, but not interchangeable. See HSE’s advice on reviewing performance.
For data protection, the ICO explains that accountability measures must be reviewed and updated as necessary, with more frequent attention where processing changes regularly. That supports review when circumstances change, rather than reliance on a calendar alone. See the ICO’s accountability guidance.
What should trigger a review before the due date?
A policy should be reconsidered whenever something changes that could affect its accuracy, safety or usefulness. The scheduled date is a backstop. It should never delay action on a known problem.
Useful triggers include:
New or amended legislation, national guidance or relevant contractual terms.
A safety alert, significant event, complaint, near miss or audit finding.
Changes to clinical systems, referral routes, premises or service delivery.
New responsibilities, staffing arrangements or external providers.
Staff feedback that instructions are unclear or cannot be followed.
A change in the way clinical correspondence is processed, for example, should prompt a check of responsibilities, escalation arrangements and absence cover before the new process begins. This is a practical application of CQC’s guidance: practices can design their own systems for test results and correspondence, but need to demonstrate effectiveness and audit how those systems work. See CQC’s guidance on managing test results and clinical correspondence.
Changes across a PCN also deserve attention. A shared service may alter who receives information or follows up an action. Updating a central document is only part of the job; each affected practice should check how it connects with its own arrangements.
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A policy review should test the document against current requirements and the way the practice operates. It should involve someone who understands the subject and, where useful, staff who carry out the work. Changing the date without making those checks is an administrative update, not a substantive review.
Start with the source material. Check whether cited guidance is still current and applicable to the practice’s services. Then work through the operational detail: named roles, contact details, systems, escalation routes and links to related procedures.
Ask someone who uses the policy whether the instructions are workable. A policy might assign a task to the duty doctor without explaining what happens when that doctor is unavailable. Another might refer reception staff to a screen or folder that no longer exists.
The Practice Manager can coordinate the process, but clinical content should receive appropriate clinical input and approval. For shared policies, identify who approves the common content and who checks local details.
A review can legitimately conclude that no amendment is needed. Record the checks completed and the decision. There is no benefit in rewriting sound instructions merely to make the document look different.
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Keep enough information to show who reviewed the policy, what they checked, what they decided and how any changes reached the people affected. The record can be short. It should allow someone else to understand the decision without reconstructing it from emails.
A useful review entry includes:
Policy title, version and responsible owner.
Review date, reviewer and approval details.
Guidance checked and relevant audit findings or feedback.
Changes made, or a recorded decision that no changes were needed.
Next review date and the reason for the interval.
Any communication, training or follow-up action.
Keep the current approved version easy to find and separate superseded copies from the working library. Record the effective date where it differs from the approval date.
Match communication to the change. A correction to a telephone number needs a different response from a revised process for escalating urgent results. Staff acknowledgement may help show that information was circulated; discussion, observation or audit can provide better evidence that a changed process is understood.
This approach is consistent with CQC GP governance guidance, which describes considering staff accounts, meeting records and how decisions are communicated. Policies become useful governance evidence when they connect with working practice.
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An overdue review should prompt an assessment of the policy’s content and risk. It does not, by itself, establish that every instruction is wrong. Equally, an in-date policy may already be unsafe or inaccurate because circumstances have changed.
Prioritise documents affecting patient safety, safeguarding, medicines or sensitive information. Check whether staff are currently relying on incorrect instructions and address any immediate risk. Give the full review a named owner and a realistic deadline; record any interim arrangements and who authorised them.
Avoid simply moving the date forward to clear an overdue report. If more time is justified, preserve the original due date and record the reason for the revised deadline.
Other problems can undermine even a tidy review schedule. Duplicate policies may be updated differently. A supplier’s revised template may still contain gaps in local responsibilities. Historic versions may remain in reception folders or staff shortcuts. Several documents can describe the same process without anyone realising that they conflict.
A review programme needs to address those inconsistencies as well as dates.
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Check whether the practice can identify what is due, allocate the work and confirm that completed reviews have reached staff. A manageable schedule with clear ownership is more useful than a large annual exercise that repeatedly slips.
Use this checklist:
Check the register: does it identify the current version, owner, last completed review and next due date?
Verify deadlines: can you distinguish externally specified intervals from local choices?
Test a small sample: compare several higher-risk policies with what staff actually do.
Check responsibility: does each owner know they have the role, with cover if they leave or are absent?
Look beyond due dates: have recent incidents, service changes or guidance updates triggered reviews?
Check access: can staff find the approved document without encountering conflicting copies?
Spread the workload: allow time for consultation and approval before the due date.
A short monthly check of forthcoming and overdue reviews is a practical local option. It need not become another meeting: an existing management or governance agenda may be sufficient.
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Item descriptioStart with the policies where inaccurate instructions could have the greatest consequences. A focused first pass can reveal whether the review system works before you tackle the full library.
Select five higher-risk policies and check their content, owners and review history.
Confirm the basis for each review interval.
Allocate any corrections, approvals and staff briefings.
Put the next three months’ reviews into a realistic work schedule.
The aim is to know that the instructions staff rely on remain accurate, usable and supported by the way the practice works.