Summary of processes for Urgent & Unscheduled Care Training in General Practice
The competencies pertaining to ‘care of acutely ill people are;
1. The ability to manage common medical, surgical and psychiatric emergencies in the out -of-hours setting.
2. Understanding of the organisational aspects of the NHS out of hours care.
3. The ability to make appropriate referrals to hospitals and other professionals in the out-of-hours setting.
4. Demonstration of communication skills required for out-of-hours care.
5. Individual personal time and stress management.
6. Maintenance of personal security and awareness and management of the security risk to others.
However these competencies have been replaced, in the New Curriculum, by a statement of capabilities relating to the role of the GP in ‘acute and unscheduled care’, thus;
- Make the patient’s safety a priority. Recognise patients with urgent needs and act promptly and effectively to ensure correct and timely treatment and reduce the risk of death or morbidity
Meet the additional challenge of gathering information and communicating effectively, professionally and sensitively with patients, carers and family members in urgent and unscheduled care contexts. This includes accurately assessing a patient who may be acutely ill through phone, email and face-to-face consultations
- Co-ordinate care with other services and professionals (e.g. ambulance service, community nurses and secondary care) and follow agreed protocols where appropriate, ensuring appropriate referral or follow up where necessary
Maintain patients’ autonomy in urgent situations where you may need to make decisions in their best interests. Consider the appropriateness of interventions according to the patient’s wishes, the severity of the illness, any co-morbid diseases and best evidence, while managing any differences of opinion with and between relatives and carers
- Offer patients and carers tailored advice on self-management and when and who to call for help if their problem worsens or does not follow the expected course of recovery (‘safetynetting’).
The key point here, of course, is that these competencies are generic and not limited to the ‘out of hours’ environment.
Under the new Junior Doctors’ Contract any time spent working Out of Hours (OOH) will not be additional to the 40h working week, but will be deducted from it. Therefore for all trainees from August 2017
First GP post (generally ST1)
- GP Trainees will not usually undertake any OOH work
- Instead they should be prepared for later work in this field by:
- Experience gathered through educational interventions which could include telephone triage, consulting skills in hours
- Observation of urgent / unscheduled care provision within hours
- In Hours experiential work in the practice
- Sessions where there is no service delivery should be regarded as educational sessions; where there is some service delivery they should be regarded as clinical sessions
Second and third GP posts (generally ST3)
The precise arrangements will vary across areas in accordance with local negotiations. However, in general terms, trainees will address their learning needs in this field through the following:
- At least 1 educational session on delivering unscheduled care should be delivered in house by the in-hours GP trainer (clinical supervisor), and one day should be spent delivering such care under close supervision
- 1 or 2 induction session(s) should be delivered by an OOH provider in-hours as study leave; this would cover basic induction to the work, the provider’s systems and specific training in telephone triage. It may cover a range of other subjects. Attendance is mandatory, and in addition to the current regional teaching programme
- During OOH training trainees are supervised either by a Trainer, or by a GP who has been trained and approved by the School of Primary Care to act as a Clinical Supervisor
- Trainees’ competence for remote supervision is confirmed by the trainer using the OOH3 and OOH4 forms (see below). The traffic light system is used i.e.
- Red = Not ready for own OOH caseload (OOH5)
- Amber = Can manage own shift, with supervisor present (OOH3)
- Green = Can manage own shift with remote supervision (supervisor on the phone, actively supervising and available to attend centre if needed) (OOH4) Green shifts might be solo (at quiet more rural centres) or alongside a non-supervising doctor in a more urban centre (with the supervisor typically at home or nearby). All green and amber shifts should have protected time for feedback.
- Once certified amber or above by the trainer, the trainee will undertake 4-6 sessions of OOH work in each 6m post with local provider, working within their normal shift pattern where possible, but with no overnight shifts. The time will be deducted from in-house clinical sessions. The precise arrangements will depend upon what the OOH provider has undertaken to deliver and will vary slightly from one Training Programme to another.
The above arrangements will still satisfy the current COGPED requirement for a minimum of 72 hours training to the RCGP curriculum statement 3.03 Care of Acutely Ill People, the underlying curricular competence behind OOH; simply some of it will be delivered in hours.
- Occasionally the clinical needs of a patient or an unusually timed shift might mean that hours are worked in excess of this norm, but this excess time would normally be taken back from a later OOH shift rather than in house clinical work, with a tolerance of no more than two hours in total for any one trainee per 6m WTE work.
- Where practices provide extended hours clinics (6-9pm and at weekends) either individually for their own patients, or through federations on behalf of practices, there is obviously complementary value in trainees being exposed to this kind of work. It is now a feature of general practice, and there are clear overlaps both with in-hours general practice and “traditional” OOH work. Where practices specify in their work schedules that trainees are expected to experience this kind of work:
- The total hours worked each week should not exceed 40 hours
- EWTD regulations about rest periods should be observed along with compliance of the 2016 T&C’s (available on NHS Employers website)
- When added to the trainee’s work with the OOH provider, the trainee will not work on more than 3 weekends per 6m WTE post
- Such work is complementary to and does not replace OOH shifts
- No hours are worked in the practice between 9pm – 7am.
- Any trainee in an extension, or receiving targeted training would have a decision made on a case by case basis by their support TPD, entirely governed by their educational needs and where they would best be addressed, which might involve no OOH work, or that of, but not usually exceeding, an ST3 post. Such trainees should, by the end of their training, have completed, at a minimum, the same number of sessions as a standard trainee.
- Any trainee rated red should be actively withdrawn from their OOH commitments and the matter referred to their support TPD / the Training Programme
Details of the documentary process
The supervisor creates a record of the shift (OOH1) which the trainee takes back to the trainer, for debriefing and for recording in the educational record of that trainee. The session record should include the shift duration in the title and OOH1 be scanned onto the learning log entry for that date.
A trainer may wish to record additional information onto the form which may help to inform the OOH provider and supervisor eg the trainee consults at X minutes. The trainee needs a higher level of supervision for mental health problems.
Each form should be scanned onto e-portfolio under OOH. The title should include the type of shift and the number of hours worked.
Safeguarding and CPR competence when working OOH
It is a requirement for GPSTRs to have a current ALS certificate on joining the programme.
- It is a CCT requirement for all GPSTRs to have a current ( within 3 years) BLS certificate at final ARCP
- OOH providers require evidence of CPR competence to align with their operational requirements. This can be via an ALS certificate (last 3 years) or BLS updated every 12 months.
- It is a personal professional responsibility to ensure that each trainee has an ‘in date’ Life Support certificate.
- Updates can be obtained either during GP posts (as part of the practice training, and therefore free), in hospital posts (where it should be possible to claim back from the Trust-administered allowance part of the placement fee) or self-sourced. There are recognised providers for this e.g. NE Ambulance. Trainees need to pay for these themselves.
- Some Training Programmes provide a BLS training course in ST3 prior to final ARCP. Check this with your individual programme
- Some trust posts require additional specific courses to be completed in order for a trainee to work in that department e.g. Paediatric Life Support. In such cases the trust will organise the training or forward details of such course to the GPSTR and the trust will cover the cost of the training.
Trainees working green shifts also need evidence of level 3 safeguarding training. Level 2 training needs to be done prior to level 3. This can be achieved either through an appropriate course or other equivalent learning. If a course certificate is not available, the trainer needs ensure that adequate evidence is logged on e-portfolio and sign the OOH4 form if the requirements have been met.
The easiest way to demonstrate level 2 and level 3 course completion is to do an e-module. These are available at http://www.e-lfh.org.uk/projects/general-practitioners/ in the section:
e-GP 3.04d - Care of Children and Young People: Safeguarding. Just doing these modules is not recommended as the only evidence needed for CCT.
GP trainer with direct responsibility for the day to day work of the training must:
- Ensure that the trainee's hours are EWTD compliant
- Allow attendance at OoH induction
- The trainee is responsible for giving the form to the provider.
- Determine when the trainee is at amber and therefore able to begin OOH work, and complete form OOH3 (see below)
- Determine when the trainee is at green and therefore able to begin working under remote supervision, and complete form OOH4 (see below)
Inform the trainee’s educational supervisor and the OoH provider about any concerns with regard to the trainee's performance and competence
The GP Educational Supervisor must:
- Ensure that a trainee has done the required number of OoH sessions and total number of hours AND that there is evidence in the portfolio that demonstrates attainment of the OoH competencies. Simply doing the shifts does not provide the necessary evidence. The trainer should see the OoH supervisor's feedback form for each shift.
- The easiest way to demonstrate the competencies is to get the trainee to complete a KEEP form detailing where the evidence sits within the eportfolio and to attach this to the eportfolio under OOH. The same form can be used to total up the number of OOH done and recorded on e-portfolio. This should be done for the final ARCP.
- If a trainer or trainee has any queries or concerns regarding OoH certification or requirements they should contact their training programme director.
- For final panel complete the box that states that the trainee has met both the requirements above for OOH care. If the number of hours is not yet complete, the ES should state this, how many hours are outstanding, what arrangements are in place to address this, and whether or not they consider the trainee competent in the five Urgent Care competencies.
GP trainee must:
- Work the required shifts under appropriate supervision. Shifts should be spread throughout the training period. A trainee who has done all of their shifts within a short time frame may be asked to undertake additional sessions to demonstrate that they have maintained their competencies.
- Attend all the sessions that they have agreed to.
- Supply the OoH provider with form OOH4 or OOH5 which informs the provider of the level of supervision that they need.
- Give adequate notice if unable to attend. Late notice of non-attendance puts patient safety at risk. Non-attendance without notice will be regarded as a negative probity indicator and may result in referral to the GMC.
- Use a learning log entry on their e-portfolio after each shift to inform their educational supervisor of what they have learnt.
- Demonstrate their competence to the level expected of the GP curriculum, and be prepared to undertake additional training should that be deemed necessary at their annual review.
- Honour any commitment to undertake out of hours sessions still outstanding when their ARCP is signed off
- Provide feedback on OoH supervision when asked. Form OOH2 can be used.
- Maintain CPR competence
- Ensure that they complete the relevant level of safeguarding training
- Complete an ST3 final ARCP checklist form detailing where the evidence sits within the e-portfolio and to attach this to the e-portfolio under OOH. The same form can be used to total up the number of OOH done and recorded on e-portfolio. This should be done for the final ARCP.
- Raise any concerns regarding any aspect of OOH training through:
- Clinical Supervisors in OOH
- Their Educational Supervisor
- TPDs/ Programme
- AD for OOH or HoS
Concerns should be resolved locally or escalated to the Programme. More serious concerns are raised formally to the Quality Team at the School of Primary Care.
A note about the European Working Time Directive
- Please note that this still applies, and any OOH schedule will need to maintain the necessary breaks / maximum shift lengths. The maximum shift is 13 hours and there has to be an 11-hour break. So, for example, if a trainee does a 6.30pm-12.30am shift they can only start work at 11.30am on the day of the shift and 11.30 the day after the shift. If that then results in them working less than 40 hours that week, they will need to add the “missing” hours elsewhere (not necessarily in the same week).
Sessions post final ARCP when outcome 6 awarded
GP trainees may, under certain circumstances, do paid OOH work at the end of training. The conditions for this are in the document below: