MRCGP & GP Training

Out of Hours (OOH)

Why do I need to do OOH when I don't plan on doing any when I qualify?

The opinion of the College is that GP trainees should continue to be trained in OOH work, as this remains a core part of the  GP’s role. However, opinion doesn’t mean anything without justification, so here goes:

  1. Some of the skills and  competencies needed for OOH care, for example those exhibited in undertaking  telephone triage, also take place during the normal working day, and therefore is a good opportunity for more practise and consolidating learning
  2. You cannot predict your future. Your circumstances might change where you might need extra income and thus engage in OOH. For that reason, isn’t it better to have had some training than none?

The aim of doing Out Of Hours (OOH) work is for all GP trainees to gain additional experience in this particular setting.  You will get experience of both face-to-face care and telephone triage.  More specifically, it will help you to

  • Be involved in the management of acutely unwell patients in a primary care setting.
  • Understand how out of hours Primary Care service can be organised
  • Experience a range of consulting styles in an out of hours centre, on home visits and using the telephone.
  • Have feedback from being observed consulting.
We realise that GP trainees are human and like most doctors are not overcome with a love of on-call. You are paid a significant uplift in your salary for on-call and so cannot opt out. However, you might find it helpful to remember that your GP training scheme’s approach is an educational one rather than just providing a service.

"Out-of-hours services present a high risk to both patients and staff. All parties involved in the provision and purchase of out-of-hours services need to ensure that there are sufficient suitably trained and experienced clinical staff, particularly doctors, engaged in planning and delivering these services.”

CQC, 2010

So, what's the basic rules with OOH?

Basically you need to do on call. 

  • In hospital posts, this will be whatever the department has organised. 
  • In general practice posts, you will participate in a rota for on call with the out of hours service providers. 

The rota will have already been worked out in advanced and is available on this website (go to the bottom section of the home page).  We realise that GP trainees are human and like most doctors are not overcome with a love of on-call. BUT you are paid a  significant uplift in your salary for on-call and so cannot opt out.  In fact, not engaging with OOH yet still being in receipt of a full salary which includes pay for OOH is a probity issue! You might also find it helpful to remember that the Yorkshire-Humber approach to OOH is an educational one rather than a punitive or service approach.  Yorkshire & Humber being so diverse in geography has different problems about on-call in different areas.  There are a number of organisations involved in the delivery  of OOH and unscheduled care services, including GP co-operatives, commercial  services, NHS Direct, NHS 24, nurse triage, urgent care centres, minor injury  centres, primary care walk-in centres (eg Darzi centres), GPs embedded within A&E departments  and some remaining individual practices.

What number of OOH sessions do I need to do?

In terms of the numbers…

  • All trainees will do a MINIMUM of 18 sessions of OOH by the time they finish their GP training.
  • A full-time trainee currently spends 18 months in General Practice posts and 18 months in Hospital posts (or equivalent).    This means that a full-time GP trainee needs to do roughly 1 per month during their GP post placements (18 months = 1 per month = 18 sessions).  
  • DO NOT LEAVE IT TO DO ALL IN ST3!  Start doing your OOH sessions as soon as you start your first GP post.  And aim for 1 a month – simple!
If you don’t get 18 sessions done by the time of your last ARCP (in your final year) – you are playing with fire!  You wont get your CCT.   Sometimes, it is acceptable to have done a minimum of 16 OOH sessions by the time of your ARCP – PROVIDING the outstanding 2 are booked and you can give dates in your ePortfolio when they will be.    Your TPDs will need to check after your ARCP to make sure you have done these.   However, as you can see, if you don’t do all 18 by the time of ARCP, it becomes messy and you end up starting to create work (work that could have been avoided) for others – like the TPDs.   So, please think about the people who work hard in GP training for you; lessen their work-load, be responsible and choose the path of least resistance.   

As a trainee, you need to plan and think about how you are going to fulfil your out of hours commitments during your post.   Please do not leave this till the last minute – otherwise there will be little opportunity to complete a sufficient number of  sessions toward the end of your post and this will create problems when an ARCP panel  assesses your portfolio.  Plan and get your sessions booked!

How does it all work? And where is the OOH centre? Can I do OOH sessions elsewhere?

There are three main types of OOH doctor

  1. The doctor who does telephone triage.  You will need to attend an OOH Telephone Induction before you can start signing up for telephone sessions.  The session will cover System One for triage, call pilot software and access to the LCD Mobiles on your smart card.  
  2. The doctor who sees acute patients in the OOH centre.
  3. The doctor who goes out with a driver doing home visits to acutely unwell patients (called mobile sessions).   You will normally meet them and your supervisor at the OOH centre before you all set off. 

You will gain experience in all of these roles.   You will have a Clinical Supervisor with you in all of these roles.    

There may be more than one OOH centre in your area.   
For example, for Bradford…

  1. Face-to-face or telephone sessions will happen at Eccleshill Hospital, Newlands Way, Eccleshill, Bradford BD10 0EP.
  2. Mobile sessions – you meet the driver at Westbourne Green Community Hospital in the car park.  Westbourne Green Community Hospital, 50 Heaton Rd, Bradford BD8 8RA  Phone:01274 322093. 
  3. There’s also OOH sessions at Bradford Royal Infirmary’s Primary Care Centre (PCC) – based in the basement beside, but not actually in, A+E.  It will be clearly indicated if your session is here, but most sessions happen at (1) or (2).
  4. Telephone triage currently runs at LCD at Lexicon House in Leeds. 

OOH sessions are clearly available in other areas.   

You may be able to attend these if you’re struggling to get the numbers in.   But have a word with your Training Programme Director with lead responsibility for OOH to discuss this first to ensure there is a reciprocal arrangement.

Different regions of the UK are so diverse in geography that there are different on-call systems in different areas. There are a number of organisations involved in the delivery of OOH and unscheduled care services, including GP co-operatives, commercial services, NHS Direct, NHS 24, nurse triage, urgent care centres, minor injury centres, primary care walk-in centres (formerly called Darzi centres).  In some places GPs are still embedded within A&E departments and some remaining individual practices and practitioners. The model of service provided is out of necessity varied; this also means that one model as an answer does not fit all.  Don’t be surprised if what you are doing differs from a peer on another scheme.

How will I be supervised? (The duties of the Clinical Supervisor)

Depending on what stage you are at in your training and how experienced you are, your clinical supervisor may either oversee your work in detail or take a step back and see how you get on.

  1. Direct Supervision – the GP trainee is supervised directly by the  clinical supervisor and takes no clinical responsibility.
  2. Close supervision – the GP trainee consults independently but with  the clinical  supervisor  close at hand e.g. in the same building.
  3. Remote  supervision – the GP trainee consults independently and  remotely from the   clinical supervisor, who is available by telephone. An    example   of such  a session would include a session ‘in the ‘car’ supervised by another GP ‘at  base’.
This document outlines the duties of the Clinical Supervisor.   Clinical Supervisors – you may wish to use this form as a feedback form for your appraisal.

Do trainees really get referred to ARCP panels for not engaging with OOH?

 We’ve noticed that some trainees are being referred to ARCP panels for making unsatisfactory progress with respect to OOH training, either…. 

  1. not doing the minimum required number of sessions.  
    Please remember that you are paid to do Out of Hours – it is included in your salary! It makes up 30% of your salary!  How would you feel if your salary was 30% less?  
  2. (more commonly) not writing them up in a way that shows their reflection and learning. 
    The Panel will expect evidence of the educational quality of your OOH experience – so make sure that each session is supported by a log entry clearly indicating what you’ve learned. Ideally you should make clear how this relates specifically to the OOH setting (as opposed to what you might have learned from the same case in a routine setting).  You can maximise the chances of your OOH experience being accepted if you write an extra OOH log entry as detailed below.   Please try to make the job of your Educational Supervisor and ARCP panel easy – they really do want to push you to get through but cannot do that if you don’t provide the right information or evidence! 
Satisfying the panels that OOH competencies have been acquired is one of the most frequent problems trainees encounter at ARCP time and at the end of the training programme this is a high stakes issue – so please do not to take this issue lightly. Ask your trainer to read your OOH entries early to see if you are on the right track.

The 6 OOH Competencies

The 6 OOH competencies are….  (mnemonic T-SCORE)

  1. Individual personal Time and stress management.
  2. Maintenance of personal Security and awareness and management of the security risks to others 
  3. The demonstration of Communication and consultation skills required for out of hours care.
  4. Understanding the Organisational aspects of NHS out of hours care (nationally & locally)    
  5. The ability to make appropriate Referral to hospitals and other professionals.
  6. Ability to manage common medical, surgical and psychiatric Emergencies.     
Yes, on top of the 13 RCGP Professional Competencies, there are 6 OOH competencies that have been defined which you are meant to aspire towards achieving.  In my personal opinion, I feel all six still fit neatly into one or more the the 13 Professional Competencies.  Here are the 6 and I’ve put what fits in which Professional Competency afterwards (mnemonic: T-SCORE)

Additional Notes

  1. Individual personal Time and stress management.
    If you’re talking about personal time management, then this would be ORGANISATION, MANAGEMENT & LEADERSHIP.
    If stress management, then think FITNESS TO PRACTISE.
  2. Maintenance of personal Security and awareness and management of the security risks to others 
    Again, this relates to a combination of FITNESS TO PRACTISE, WORKING WITH COLLEAGUES and ORGANISATION, MANAGEMENT & LEADERSHIP.
  3. The demonstration of Communication and consultation skills required for out of hours care.
    Clearly this one is about COMMUNICATION SKILLS and you can even talk about telephone consultation skills if on triage.
  4. Understanding the Organisational aspects of NHS out of hours care (nationally & locally)    
    This ties in with ORGANISATION, MANAGEMENT & LEADERSHIP.
  5. The ability to make appropriate Referral to hospitals and other professionals.
    Again, you could talk about MAKING DECISIONS, COMMUNICATION SKILLS (how you communicated to others) and WORKING WITH COLLEAGUES
  6. Ability to manage common medical, surgical and psychiatric Emergencies.     
    Here, you can talk about MAKING DIAGNOSES & DECISIONS and CLINICAL MANAGEMENT

Therefore, when writing up your entries, a good focus would be to write about one or more of these specific aspects.   Most of your OOH log entries will probably be about 3, 5 and 6.   But don’t forget about 1, 2 and 4 (which often get overlooked!.

Reflecting on OOH and Writing an OOH Log Entry

A Bad Entry

    • Date:  July 21st 2018
    • Supervisor: Dr A Dunbar
    • Type of OOH session:  face to face consultations
    • Venue: Airedale GPEC
    • Time: 19:00 – 23:00 (5 hours)
    • Number of patients seen: 15

Type of patients seen:

  • Several minor respiratory infections – children and adult
  • Acute back pain
  • Probable depression
  • Drug abuser seeking medication
  • New migraine
  • Emergency contraception.

A Good Entry

    • Date:  July 21st 2018
    • Supervisor: Dr A Dunbar
    • Type of OOH session:  face to face consultations
    • Venue: Airedale GPEC
    • Time: 19:00 – 23:00 (5 hours)
    • Number of patients seen: 15

 
Type of patients seen:

  • LRTI – 64 yr old Asian lady with COPD &CKD seen with daughter interpreting. Symptoms and signs of LRTI, admitted due to tachypnoea, tachycardia, and dehydration.
  • Abdo pain – 18 yr girl with Down’s syndrome, seen with parents, crampy abdo pain and 3 wks alternating constipation and diarrhoea.
  • Threatened abortion – 19 yr old + partner 6 wks. Scan 1w, patient unhappy with wait.
  • 2yr old, wheezy & pyrexial from URTI.  Separated parents, much confusion between them about which inhalers were prescribed. Desperate to help child sleep. Child well, (wheeze and pyrexia settled), to see own GP for clarification of long term Mx plan. 
  • Acute back pain – 24y old, 3 days..  No alarm features.  Analgesia & mobility.
  • Migraine – 45 y old with typical migrainous headache (hemicranial, photophobia, aura etc) – given im sumotryptan

 

REFLECTIONS

  • Acute back pain – the patient wanted stronger pain killers than paracetamol.   Difficult to manage and so we gave them in the end.  We tried our best with our communication skills to calm him down. 
  • Probable depression – Has not been to see GP yet.  Interesting that she came to OOH – perhaps she reached crisis point.    So we started her on Sertraline and see her GP. 
  • Methadone user – came in for a sore throat.   Am surprised that he didn’t ask for any drugs – I was expecting this!   And he took on our advice and thanked us.  
  • Migraine diagnosis – this lady had true migraine (photophobia, phonophobia and has to lie down in a dark room).   So we gave her an injection.   Poor lady, you could see how dreadful she looked at a glance. 

Some comments….   Notice how the trainee in the GOOD write up indicates (signposts) which clinical competencies her statements and learning points relate to.   And she not only writes about that competency but she reflects on it in a truly analytical way.   For a professional competency to be awarded, you must show some meaningful analytical reflection on that particular competency (rather than just some sort of description of what happened). 

Here are the competencies the Clinical Supervisor awarded…

  • Communication Skills
  • Data gathering & interpretation
  • Practising holistically
  • Making diagnoses/decisions
  • Practising Ethically

 

REFLECTIONS

  • I found the case of the girl with Down’s syndrome interesting as I presumed I was going to have immense communication and cognitive difficulties with her. I was also anxious not to miss a serious problem – perhaps she would not be able to accurately present her problems. But this couldn’t be further from the truth! The patient was charming and cooperative. She spoke quite a few words to me and we didn’t really need much input from her parents (although they did contribute, of course).   
  • COMMUNICATION SKILLS: I built rapport in this particular case by introducing myself and showing interest in her comments about cartoons and toys. This helped the consultation to ‘flow’.  Of course, there were other things that made this consultation ‘flow’ – such as keeping questions and language as simple as possible.
  • DATA GATHERING: It was important to engage other people present in the consultation (in this case, the parents) not only to triangulate the information received but to get a fuller picture and make them feel involved and heard.  During the examination I was conscious that it was important to keep things as comfortable as possible for her while still completing the necessary exam as I did not want to lose her trust and possibly make her frightened of doctors in the future. In fact she expressed no pain and giggled throughout her abdo exam. 
  • Learning points –  I must not presume that someone with learning disabilities means the consultation will be more difficult (communication skills).   I should treat all patients from an equal starting point and not prejudge them (practising ethically).
  • MAKING DECISIONS: In the end, I was relieved to exclude an acute abdomen and was pleased that the consultation went well with the invaluable input of the patient’s parents. I think she had constipation. I made this diagnosis on the basis of what she was able to tell me, what the parents were able to tell me and my clinical examination.   In summary, she hadn’t been to the toilet for several days, her motions prior to that were round pellet like and the pain was crampy and colicky in nature. There were no alarm features and the history was fairly acute 

Some practical tips for OOH

  • Get your SystemOne/EMIS smartcard updated so you can use it at LCD – ask your gp training scheme administrator how to do this; drop them an email.  Do this well in advance – can take up to 2 weeks to set up!
  • Please take the equipment you usually use for home visits (drugs, note paper and prescription pads are provided by LCD).
  • Also, print off (or email to yourself) the OOH reflection form (see QUICKLINKS above).
  • You may need to arrange with your practice to finish in time to get to the OOH centre.   After a late (2300hr) finish you may need to arrange with the practice a late start to work the next day to meet EWTD rules.
  • Make the most of it educationally: don’t just get on with doing the work, but reflect whilst doing it!  You will have the opportunity to observe supervising GPs consulting, for them to observe you and for you to see patients alone but with the supervising GP available for immediate advice.   Also a good opportunity to get some CEPS signed off.
  • At the end of the session (or even better if periodically throughout), make sure you sit down with your Clinical Supervisor and go through the OOH reflection form and perhaps use the 6 OOH competencies as a framework for discussion.
  • Cancel in good time : As with any other part of your job, just not turning up is not an option, if you cannot make it because you’re sick or you are running unavoidably late ring them as soon as possible

By the way, how does one become a Clinical OOH Supervisor?

All Clinical Supervisors must be able to teach, although they will not necessarily require the educational expertise required  of GP trainers.  The following are considered to be fit:

  • GP Trainers,  GP Associate Directors and GP Programme Directors
  • Holders of postgraduate  certificates, diplomas or degrees in education.
  • GPs who have been on the Deanery’s Clinical Supervisor’s training course.
  • Doctors with  significant teaching experience (postgraduate or undergraduate)  within the last five years, subject to the  approval of the patch Associate GP Director.
  • Non-GP  clinical supervisors:
    • Those recognised  by their own profession as qualified to teach students of the level to which  they will be teaching GP trainees.
    • Those who have  completed a Clinical Supervisor’s training course with the Deanery

Some other FAQs

Different GP training schemes have different organisational set-ups for how their OOH works.   Most will have a Training Programme Director with lead responsibility for Out of Hours work.   Ask him/her or your Training Programme Administrator.     Some schemes will slot you into the rota automatically and it is up to you to arrange swaps and changes.   Others leave the rota open for you to directly book in yourself.  

The General Medical Services contract (GMS) has defined the normal working day for general practice to be between 08.00 and 18.30 on all weekdays except public holidays. Thus, OOH is defined as that work undertaken between 18.30-08.00 and all day at weekends and on public holidays. OOH is also taken to mean the type and style of working that takes place in this time – including both face-to-face care and telephone triage. 

  • The bottom line: 18 sessions of OOH by the end of your training.  
  • For a full-time GP trainee: roughly 1 session per month in GP.
  • Duration of each OOH session: should be 6 hours (minimum 4 hours).    But this does not mean you can finish a 6h shift early.  6 hours is 6 hours!  You do what your Clinical Supervisor on that day has to do.   If each session in your region only lasts 3h, then clearly, you need to do twice as many (3h x 2 = 6h; simple maths!).
  • Failure to complete the requisite number of sessions will lead to a face-to-face deanery ARCP panel review.  
  • If you are a less than full-time trainee, they the number of sessions you engage in per month will need to be adjusted on a pro-rata basis.
  • And finally, don’t forget:  it’s not all about the numbers. The educational quality of the sessions count too. If an on-call session is very quiet and provides little education – it is UNLIKELY to count; you will need to do another session.

Trainees who are working less than full time in a traditional GP post are not expected to do the same level of on call as a full timer. Their slice of the cake should be pro-rata.  As most LFTTs will be working part-time on a 50% basis, the frequency of OOH sessions should be reduced proportionately – in this case, one OOH session every 2 months instead of every month.  However, by the end of training, they will STILL need to have done 18 sessions – it’s just that the length of time they have to do it will be longer.

YES – you still need to engage – not only in OOH but all the other requirements for GP training like number of CBDs, COTs, etc.   In terms of number of OOH sessions, you need to do 1 OOH session per MONTH of being in a GP post if you are full-time; pro-rata otherwise.   So, if you have been given an full-time extension of 3 months, then you need to do 3 extra OOH sessions on top of the minimum 18.   If 50% part-time 3 month extension: round UP = 2 extra sessions.

Yes!  Phone triage is acceptable for part of Out Of Hours experience providing there is an appropriate balance with face-to-face sessions.

No!   Being the duty doctor and doing on-call surgeries for the surgery does not count.  Doing telephone triage for the practice does not count.   It has to be ‘out of hours’ – that means, outside of practice hours.  Although Extended hours is generally outside of practice hours, it is not classed as OOH work because patients are booked in and are not ‘unscheduled’.  Trainees are to be encouraged to do some Extended Hours but this is not compulsory and certainly not in replacement of OOH.  However, it is still good to make use of this experience and record a log of it in your ePortfolio to show some evidence for the ‘Care of the Acutely Ill’ curriculum heading.

The Deanery considers that non-attendance by the GP trainee for a booked OOH session without good reason is a professional offence and views this as equivalent of failing to turn up for a booked surgery in their own practice. In such instances the OOH clinical supervisor should notify the trainees GP Trainer and the trainee must put an entry in the portfolio explaining the circumstances surrounding the event.

Firstly, you shouldn’t cancel unless it is absolutely necessary. If it is…

  1. First try and swap that session with one of your colleagues; it is your responsibility to do this.  
  2. Failing that – you can cancel the session.

In all instances, phone the OOH centre and let them know as soon as possible to enable them to make changes.   You may also need to inform your TPD/GP Training Scheme administrator (depends how your GP training scheme runs OOH training for GP trainees).  

Trainees must make every effort to inform their OOH providers and Clinical Supervisors if they are unable to attend or are running late and should ensure they have the relevant contact details.  The OOH provider will raise late arrivals of any GP trainee with their OOH Clinical Supervisor for that session. If such behaviour is continued the GP Trainer will be informed.

Absolutely you are!  You should all try to get ALL your OOH sessions before the time your final ARCP panel is due.  Otherwise, it’s simple – you wont get your CCT.  

Sometimes, it is acceptable to have done a minimum of 16 OOH sessions by the time of your ARCP – PROVIDING the outstanding 2 are booked and you can give dates in your ePortfolio when they will be.    Your TPDs will need to check after your ARCP to make sure you have done these.   However, as you can see, if you don’t do all 18 by the time of ARCP, it becomes messy and you end up starting to create work (work that could have been avoided) for others – like the TPDs.   So, please think about the people who work hard in GP training for you; lessen their work-load, be responsible and choose the path of least resistance.   

Be aware: a later probity check will be undertaken by the Training Programme and it will be considered a serious professional offence if, once signed off, a GP trainee failed to complete any such booked OOH sessions.

Well, it depends.   Panels have been known to reject trainees who have completed the minimum 18 OOH sessions because some of those sessions had very few patients being seen and little educational reflection on the part of the trainee.  As we said above, it doesn’t look good if you only saw 2 patients during an OOH session.   The worry is that you may not be getting adequate exposure.  Therefore, you may need to do additional sessions to demonstrate adequate exposure.

If you sat around doing nothing other than twiddling your thumbs – then the session DOES NOT COUNT and you need to do another one.  Remember, the whole point of doing OOH sessions is for YOU to PROVIDE EVIDENCE of OOH competencies.  Do you think you can do this if nothing much happened in the session other than one or two coughs and colds?

Secondly, if it is quiet – don’t just sit there, make the most of it!  Talk to your Clinical Supervisor – discuss OOH – it’s organisations, top tips and so on.   Have a look at the triage system and understand how it works.   Sit in with reception staff and see how they field calls.   Do some other OOH stuff!   Even come back to this Bradford VTS OOH page to read some of the material in the DOWNLOADS section and use them as a basis for further educational dialogue with your Clinical Supervisor.  Remember, panels are assessing what’s in the e-Portfolio (i.e. the content), and not just the number of sessions done.

Oh, and to avoid quiet sessions in the future – ask the OOH reception staff when the busier sessions are and actively book into them.  Do not go for a quiet life because you may end up with a wasted session that needs repeating.  Do you really want that?

The problem with OOH sessions is that they can appear very unstructured in terms of learning because of its nature (people presenting at random, unpredicatably of what will come in etc). Some trainees feel they don’t get much out of OOH sessions whilst others say the opposite. Why the polar opposites do you think?

The reality is that trainees who get a lot out of it either have a really good clinical supervisor OR the trainee is so motivated that (s)he maximises the learning potential within the session.    It is important to make the most of it and get a wide range experience in OOH which includes differing timing of shifts and telephone/visits etc.   And for those of you planning to work in remote areas, doing OOH will be incredibly important as you might have no choice in doing OOH.

Many deaneries run “Care of the Acutely Ill” or  “Unscheduled Care” Courses.   Unscheduled care = acute care.   Ask your TPDs or GP training scheme administrator for more information.  They will know whether your Deanery or Training Scheme runs one.  If not, suggest it to them!

Trainees  in general practice will be subject to the normal processes of clinical  governance, GMC regulations and civil law.  Each  doctor will carry their own professional insurance and medical indemnity  organisations have indicated that a GP trainee’s standard membership will  provide indemnity for work undertaken during OOH training.  In short, if you have medical indemnity… then YES. But double check with your medical indemnity cover provider (like the MDU or MPS).   

By the way, being a member of these schemes is usually worth their weight in gold.  Never choose the option of being under-protected just because you want to save a few pounds because if you end up in trouble, the help that would otherwise cost £1000s will be absent.  We know sometimes things get financial tough for GP trainees but don’t put yourself or your family at risk.

Please leave a comment

What do you think of this page?  Is there anything we have missed?  Anything inaccurate, errors or broken links?  Anything you would have liked included?   Or even ask a question to get a discussion going.  Please leave a comment below and we’ll update the page.   If you would prefer to email me or send me something to share with others, contact [email protected]

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