MRCGP & GP Training
Quick top tip before doing any UUC work - always do and know your vitals...
Before we go on about Urgent and Unscheduled Care (UUC), here is a quick top tip for you when doing UUC work. Always record the vitals, because if they are off, you generally need to worry! And always come back to the vitals when you are not sure what is going on – because they can help you decide whether to worry or not. The vitals are…
- Pulse or HR
- Blood Pressure
- Capillary Refill Time (CRT)
- Oxygen Sats
What is UUC & Where is it done?
UUC stands for Urgent Unscheduled Care (UUC) in primary care. Whilst your in hospital posts, you will engage in the department’s on-call programme – whatever that may be. However, when you are in your GP posts, you will need to engage with and collate evidence of your capability in Urgent, Unscheduled Care. But what is Urgent, Unscheduled Care? The word Urgent is self-explanatory, but the word Unscheduled refers to patients who have NOT pre-booked an appointment. In other words, you need to demonstrate that you are capable of handling patients who turn up with acutely wanting to be seen.
There is a wide variety of places where urgent unscheduled care is provided. Most of you will think of the local Out Of Hours (OOH) centres dotted throughout the UK. They see patients out-of-GP-surgery-hours. But Urgent, Unscheduled Care is provided during surgery hours in the practice via the on-call duty doctor. And yet there are other urgent unschedule care services in primary care. Take for example GPs attached to A&E departments, the paramedics, the mental health crisis team, the palliative care emergency service and so on. GP training needs to ensure that our GP trainees are exposed to and get experience in this variety. In the past, GP training was more interested in the number of hours a GP trainee spent in an OOH centre. But that has now all change – GP Training is now more interested in the trainee being exposed to a variety of Urgent Unscheduled Care service types. And although the large majority of your evidence will come from OOH centre work and by doing on-call duty doctor for the surgery, you are encourage to explore other providers.
GP trainees must ensure they have..
- completed all due employment processes prior to undertaking both observational and clinical sessions
- had an enhanced DBS check
- met occupational health requirements and
- undertaken required safeguarding training (child, adult & PREVENT training).
There are quite a few places.
UUC services directly with GPs
- Duty Doctor for the surgery (i.e. on-call surgeries)
- Out of Hours (OOH) Emergency GP Centres – mobile & base sessions
- GP centre attached to A&E departments
- GP Extended hours work where the appointments are for acute unscheduled problems and not routine.
- Telephone triage session (in practice, OOH or elsewhere)
UUC with allied health care professionals
- Paramedics & Regional Ambulance Services
- Mental Health Crisis Team
- Palliative Care Urgent Service e.g. Gold Line in Airedale & Bradford
- A&E departments, emergency Paeds services, emergency Psych services
So, don’t just rely on one of these places for gathering evidence of your urgent unscheduled care capabilities. Your experience (and evidence) should be from a mixture of engagement with these services. Having said that though, most of your experience will probably come the local OOH centre AND from being the duty on-call doctor for your GP practice.
You can BUT…. it should NOT replace OOH or on-call duty doctor experience. You still need to do the latter. You will be able to use some experience from the following placements to contribute towards the evidence to showing that you are developing the six generic urgent & unscheduled care capabilities.
- Paeds (esp Paediatric Emergency Assessment Units)
- Medical Assessment Units
- Psychiatry on-call
HOWEVER, this alone WILL NOT be enough to show that you have addressed the full range of urgent, unscheduled and out-of-hours capabilities IN THE PRIMARY CARE SETTING. So, in a nutshell…
- You MUST engage in GP Out-Of-Hours work
- You MUST engage in GP in-hours emergency work (i.e. on-call)
- These two things will provide most of your evidence for the 5 UUC capabilities.
- To supplement that evidence further, you can use experience from A&E, Paediatric Assessment Units, Medical Assessment Units, and Psychiatry on-call. To do so, you can’t just reflect on your experience. There needs to be some FOCUSED discussion between you and the clinical supervisor about one or more of the 5 UUC capabilities and contextualised to your future work as a GP.
Yes! Phone triage is acceptable for part of Out Of Hours experience. Remember, there needs to be an appropriate balance with face-to-face sessions.
Absolutely NOT!!! You need to do both!!! There is no problem in you doing some in-hours sessions (for example on-call duty doctor) but other sessions need to be based out-of-hours. Why? You need to show that you are capable of working in isolation when there is a relative lack of supporting services (which is often the case in out-of-hours work than during in-hours work). And you need to show that you can work comfortably in an urgent unscheduled setting that is not your usual comfortable place of work like the GP practice to which you are attached.
Whilst it is recognised that the knowledge and skills needed to develop urgent and unscheduled capabilities may be gained “in hours” and from a variety of secondary care and other community-based urgent care services there remain particular features more likely encountered in OOH that require specific educational focus and training.
Yes. Where general practitioners are not available on site, allied care practitioners can contribute towards trainee supervision as part of an effort to learn from and appreciate the skills held by these colleagues, considering their increased presence within UUC services. However, there must be safeguards – i.e. ensure there is a qualified GP to whom issues can be escalated if needed.
The UUC Capabilities
“WHAT, MORE CAPABILITIES?”, I HEAR YOU SAY…
Actually, THERE ARE NO NEW UUC CAPABILITIES. The capabilities that you have to demonstrate are really the 13 Professional Capabilities that you are already familiar with that run throughout GP training and the Work-Place Based Assessments.
BUT I’M SURE I HEARD THAT THERE ARE 5 NEW UUC CAPABILITIES?
That’s not quite true. Actually, the 13 Professional Capabilities (PCs) are grouped into 5 Capability AREAS – but in themselves, they are NOT Capabilities. It is the 13 Professional Capabilities that remain. You may not know this, but the 13 PCs have always been categorised into these 5 capability areas,
SO, WHAT ARE THESE 5 CAPABILITY AREAS?
The 5 UUC competencies in a nutshell
- You and Others
- Clinical Knowledge, Skills & Decisions
- Complex & Long-term Care
- Organisation & Systems
- Persons & Communities
SO, WHICH DO I WRITE ABOUT WHEN WRITING UP AN UUC SESSION – the 5 Capability Areas vs the 13 Professional Capabilities
- Simple – stick to the 13 PCs.
- When writing up your entries, a good focus would be to write about several of the 13 PCs that you are used to.
- By doing that, you will automatically provide evidence for the 5 Capability Areas – because it is these 13 PCs that serve as jigsaw piece subcomponents for the 5 areas.
Things you may want to write about
Click on each area to get an idea of what to write about…
YOU & OTHERS
- You might want to write about how you manage a stressful environment. There’s lot of unpredictable things that come your way when you are doing UUSC. Urgent clinical presentations, urgent clinical tasks, urgent requests from other health professionals, urgent requests from admin and non-clinical staff, urgent blood results, urgent phone calls and lots more. Then there are angry patients who have been waiting for ages. So, what effect does all of this have on you? How do you stop yourself from breaking down? How do you manage your stress levels. How do you maintain your composure?
- Here, you might want to talk about how the UUC settting can present a personal security risk to you. For example, dealing with angry patients. Or visiting someone at their home alone whilst the driver sits in the car! Or perhaps a situation which is risky to your own health or to others who work with you (someone who has been stabbed or electrocuted or exposed to a harsh chemical like an acid burn). You could also talk about the security risk to those around you – for instance, the admin staff who might have to deal with aggressive patients or are at risk of being exposed to an infectious disease. And also to other patients in the waiting room. You could also link this with Working With Colleagues and/or (Organisation) Management & Leadership, pending how you write it up.
- So, if you have encountered any of these in your session, write about what you did and compare it with what should have been done.
- Clearly this one is about communication skills – which is an umbrella term for a whole host of of communication things like…
- Breaking Bad News
- Calming down the Angry Patient
- Telephone Consultation Skills
- Exploring ICE and PSO
- Negotating with the Patient
- Motivational Interviewing Skills
- Self-Help Management
- and lots more!
- But there is more. Consultation skills also refers to…
- Data Gathering skills,
- Person-Centred Care,
- Skills for using the Computer in the Consultation,
- Handling carers, relatives and families.
- You will encounter ethically puzzling or interesting situations in the UUC setting. For example, the patient who refuses to go into hospital or goes against your medical advice. The relatives who want something doing or not doing about their father/mother without them knowing. The 14 year old who comes for emergency contraception and doesn’t want anyone else knowing – what is competence?
- Whatever the situation, try and write about it and then link it to the ethical principles that you know about. Linking them to these things shows you understand Ethical Practice.
- Here is a list of ethical principles.
- Patient Autonomy
- Justice or fairness
- The principle of Utility – doing the greatest good for the greatest number
- Rights-based ethics – every individual has an equal right.
- Aristotle’s principle of morality (to do the right thing, good people do good things)
- Competence to make decisions
- Understand information
- Retain information
- Weigh up Pros and Cons
- Make a decision
- Gillick competence for minors
CLINICAL KNOWLEDGE, SKILLS & DECISIONS
- Data Gathering is in essence History and Examination.
- Detail exactly what were the most important things to ask for in the history and detail the findings. Same goes for examination – but write it under the CEPs subheading (see below).
- So, for History, you might write: dull chest pain, right hand side, not radiating down the left arm or the neck, no sob, no sweating, no palpitations, happens at any time, not exertional, lasts >4h each time, no FH of IHD, but he smokes 20/d for 11 years. (get the idea?)
- CEPS stands for Clinical Examination and Procedural Skills
- When you write about CEPS, you must provide the detail. So, you cannot just write “chest examination normal”. For example, for a LRTI, you should write something like “Chest: air entry vesicular, good air entry both sides. Some left basal creps. No signs of resp distress. Percussion normal. No effusion. RR=22, SaO2 = 98%, HR 76, Apyrexial.”
- The same goes for any procedures you do. Provide the detail to give the reader faith that you can do it. “took arterial blood gases” is not good but writing “took arterial blood gases using aseptic procedure and the appropriate equipment. Made sure to apply pressure afterwards to ensure healing.” is way better.
- Did you manage to make a diagnosis? How did you make that diagnosis?
- What decisions did you make in terms of management?
- How did you make these decisions? Did you use any scoring tools or other aids? And guidance or protocols?
- This one is pretty easy to understand because it’s a territory that you’re familiar with. It’s all about the medicine. The clinical knowledge and management. Do you know your doctor stuff? The ability to manage common medical, surgical and psychiatric emergencies?
- Did you know what to do medically? If you were stuck, how did you work out and decide what to do? Did you use any resources to help or guide you? What was helpful and what was not helpful? Are there things you need to brush up on?
COMPLEX & LONG-TERM CARE
- Managing Medical Complexity confuses many trainees and trainers.
- Here are some examples of what it is about…
- Managing several medical conditions – both chronic and acute. However, the mistake a lot of trainees make is that they think in terms of numbers – “Oh, I managed 3 little things, so I must be able to get Managing Medical Complexity”. Wrong! It is about managing or juggling several not-so-straight-forward medication conditions. So, manging tonsillitis, an ear infection and dry skin does NOT mean you get this capability because there’s nothing complex in there! But managing someones COPD and Heart Failure does because in this instance, it’s difficult to know which one is the cause of SOB. Or for example, some has renal failure but also has bad BP and you want to uptitrate BP medication without affecting the renal function.
- Managing Medical Complexity is also about working out and discussing risk with the patient. And also about uncertainty in General Practice.
- Did you discuss any case with your colleagues? Why? What did they provide that was helpful? Did anyone approach you for advice or help? What does it mean in terms of working with colleagues in your future life as an independent GP?
- Did you do any referrals to anyone in today’s UUC session? Who to? Was it appropriate? How did you decide? Were there any criteria for referral? How did you communicate? What was the minimum data set you provided for the referral.
- If via phone, did your Clinical Supervisor listen in? What did they make of your telephone conversation? How did you perform? How could you have done better?
- Did you write a letter? What did you include or not include? Was it concise? What did the Clinical Supervisor think of it?
ORGANISATION & SYSTEMS
- This one is about your own learning and self-development. What learning needs have you identified for yourself and how are you planning to satisfy them?
- As a result of today’s UUC session, was there anything you looked up to learn about further? Anything on the net? Guidance? YouTube videos? e-modules? A book someone advised you to get?
- Have you decided to go on any particular training course?
- You might want to talk about how you manage your time – for example, how you prioritise and delegate in the UUSC settings. When you’re on-call, there is usually a mountain of stuff that comes your way. How do you keep on top of it all without crumbling? How do you ensure the safety of your patients? How do you make sure you don’t end up rushing and doing the wrong thing.
- You may wish to explore how the UUC centre you are working in works. Not just the doctor side of things – but what would you have to be mindful of if you were setting up the service from scratch? Is there anything that surprised you, or you were blind to before you engaged with today’s session (in terms of how the service is run)?
- What are the training requirements and provision for doctors working in these UUC services? Is it adequate? What would you suggest?
- You may wish to reflect on how OOH and other acute UUC primary care medical services are generally provided in the UK. Has anything from today’s UUC session made you think about the way it is currently organised? How could we improve it to meet the changing needs of society? How do we balance need and demand? Think at a local level. Think at a national level.
- Please have a good discussion about it with your UUC Clinical Supervisor. They can help you resolve your dilemmas and push you to thinking even more deeply.
THE PERSON & COMMUNITIES
- Practising Holistically is understand the complaint in the context of the patient’s lives.
- This boils down to exploring the effect of the problem on the patient’s home, social and working lives. It’s also about exploring their ideas, concerns and expectations (i.e their conceptual framework and what they think is going on).
- Why is it important? Because it not only tells you how bad things have been but actually, the effect of a problem on a person’s life can be a red flag item and help you make a timely decision of doing something when something important is kicking off. And that in itself can help improve your clinical skills as well as stop you from being sued!
- For example, consider the patient who vision has been a bit funny for the last few days. Is that important or not important? Difficult to say? What if I add in a few more things. Let’s say his husband bought him in because it got bad today. He didn’t see the coffee in front of him which spilled and cause a scald on his leg. Or let’s say at work, he was using the drill and misjudged something and nearly went straight through someone else’s hand. Are you now MORE or LESS worried about his vision?
- Community orientation means focusing on the community. Again, this is a common area that both trainees and trainers struggle with. It’s quite simple really. All it is asking you to do is to determine whether you can reflect on the care provided to AN INDIVIDUAL PATIENT and extrapolate it to improve care for A GROUP OF OTHER PATIENTS with a similar condition or commonality.
- At the end of the day, we need to do two things. Provide good care at the individual level. Provide good care at the practice population level – and that means care for community groups. A community does not necessarily mean the whole practice population. A community is a group of individuals who have something in common.
- For example, you notice that a patient you saw never realised how serious prediabetes is and what it really means (i.e. a golden opportunity where he or she can change things for themselves). If you then decided to write a Pre-diabetes leaflet (or set up a YouTube video on Prediabetes on your website or for all pre-diabetes patients to watch in the future), then this is Community Orientation.
- Community Orientation is also about rationing of care. We do not live in a world where resources are limitless. So, not doing unnecessary CTs and MRIs is important if the NHS is to survive. Thinking about the NHS, its survival and protecting it for patients is community orientation.
- Merely writing a one liner statement saying you referred a patient for “Community Counselling” or a “Community Group” does NOT (in my opinion) good evidence of Community Orientation. You have done nothing very active here in terms of MAKING THE CARE OF THE COMMUNITY BETTER. You have simply referred an individual to a community group. The person who set up that group or who runs it, is the one who is showing evidence of COMMUNITY ORIENTATION in practice. Of course, I am not asking you to set up a big new service and run it, but there are loads of other “quick wins” that you can do.
- The more you truly think about it, the more you realise what you CAN do, rather than what you cannot.
- Promoting Health is usually combined with Managing Medical Complexity. The official term for the capability is “Managing Medical Complexity and Promoting Health”. Personally, I think these two capabilities should be separated out and not combined, as the RCGP has done for UUC. These two things – Medical Complexity and Promoting Health – are two distinct things. And the skills to do each of them well are also significantly separate – which again, supports the reason why I feel they should be kept separate as re-defined as two distinct Professional Capabilities. I also think Promoting Health should perhaps be “Promoting Health and Positive Health”
- Promoting Health is something we all should be doing – but at the right time. And this is the thing trainees often don’t do. They want to “score the point” and will sometimes do “Promoting Health” work out of the blue, in a consultation which was really sensitive, deep and meaningful. And this then just makes it look weird and perhaps downgrades patient-doctor rapport.
- Of course, we need to educate and empower our patients about their health – things like…
- Stopping smoking
- Cutting down alcohol
- Drinking more
- Eating better
- Exercising and
- Looking after our work-home life & mental well being.
- But this should happen when it’s just feels right and natural to talk about it.
- Of course, if I am talking to a patient about their new diagnosis of pre-diabetes, then I will want to spend quite a bit of time educating them and trying to get them to see how a lot of their health is in their control. And thus working WITH THEM about how to eat better. Alternatively, I might have a patient with migraines and I help her with that. And in doing so, we get a superb rapport. Then I might see I have a few moments and notice that she still smokes and feel it is comfortable just to dip into that lightly today to start the ball rolling.
- Notice that health promotion does not need to be all done in one session. You can start off a conversation very lightly so that you can lay the foundation to talk about it gradually over the next few future consultations.
- And all of this has to be done in a patient-centred way because the research says patients then listen to your advice and are more likely to act on it. In real life, what this means is that rather than telling patients what to do, use motivational interviewing techniques to understand their starting point, create a dialogue and getting them to see the bigger picture. And the way you do this is by ASKING questions to explore their reality so that you can then move them rather than TELLING them your instructions for life!
- Personally, I am having trouble with Safeguarding – is it a capability? The college seem to think so for UUC work, but then it doesn’t feature in the general 13 PCs. I’ve been mulling it over and am still left wondering whether it should be a capability. Don’t get me wrong, I understand the importance of Safeguarding. There’s not question about that. But is it a capability? Is Safeguarding more of a curiculum item – an area that we must be trained in, and to do it well requires the other Professional Capabilities that already exist (good Data Gathering, Practising Holisticallym, Good Communication, Working With Colleagues, etc.)?
- So, for the time being, as it is included as a capability item for UUC work, I would suggest you provide evidence in the form of your encounters and training in Adult and Child safeguarding.
- And of course, don’t forget about your encounters and training for vulnerable patient groups like Learning Disabilities, War Veterans, Homeless, Sex Workers and so on.
What number of OOH sessions do I need to do?
To be very clear, what we are saying is that you now need to provide evidence of your ability in UUC from a variety of primary care urgent and emergency care settings. Out Of Hours is just one of them. Having said that, most of your experience and evidence will come from (1) Out of Hours sessions and (2) being on-call duty doctor for your GP surgery.
So how many sessions?
In the past, GP trainees were expected to do 18 OOH sessions over the 18 months of General Practice. That equated to roughly ONE session per month – each session lasting 4-6 hours. But as we said above, it is not the hours spent in UUC that is important. What is important is that you do enough sessions to provide enough EVIDENCE of adequate experience demonstrating your ability across the Professional Capabilities (listed above). “Time served” should not be seen as the model against which to define the attainment of Urgent Unscheduled Care capabilities. In all cases, to be deemed as “competent” in UUC will need to be justified by the evidence provided – not by the number of hours or sessions.
The only exception to this rule is if your GP trainee contract stipulates a number of OOH sessions that you must do because they say there is an uplift in your salary for it. So, go back to your employing body (in many places, it is the hospital trust) and ask them if OOH is part of your contract. Alternatively, read your GP contract – it should be in there somewhere. Or you can ask your GP Scheme administrator or TPDs – they will know too. And if there is a contractual requirement, then you have to do the minimum number of OOH sessions that it stipulates (usually 18 sessions).
Of course, even if you are lucky enough to have a GP trainee contract that DOES NOT stipulate a minimum number of OOH, we often get asked if something as low as 30 hours experience in UUC will do. Firstly, it would be difficult to provide evidence of the Professional Capabilities with such a low number. Providing enough evidence of the UUC capabilities is what ultimately matters and it would probably be difficult to show this in less than 48 hours of UUC experience. So, for those of you who like to have numbers, approximately 48 hours of experience should be regarded as a minimum figure that should allow a GPST to demonstrate that they are capable in UUC.
Whilst we would like to make it clear that there in no mandatory minimum number of OOH, on-call duty or other emergency sessions that the RCGP expects you to do, if you must have numbers, think about 48 hours. If you can provide ample evidence for all UUC capabilities in less than this – that’s fine too (but we would imagine it is unlikely that you will be able to do that). And do remember that it is all about providing a good amount of evidence for each of the UUC capability areas. Providing just one piece of evidence for each of the areas is UNLIKELY to be enough.
It doesn’t matter if you are part-time or not. Remember, it is not the number of sessions that count. You simply have to make sure that you have enough evidence in your ePortfolio for all the UUC capabilities. If you have – great! If you haven’t, then you need to do more sessions! There is no need to consider ‘pro rata’ UUC work given there is no specified minimum or maximum numberof hours any trainee must complete.
Again, it doesn’t matter if you are in an extension or not. Remember, it is not the number of sessions that count. You simply have to make sure that you have enough evidence in your ePortfolio for all the UUC capability areas. If you have – great! If you haven’t, then you need to do more sessions! The ARCP panel who gave you the extension (or your TPDs) will advise you whether you need to do more. If they don’t, ask them!
You basically need to carry on doing UUC until you feel you have a good amount of evidence for the UUC capability areas. If you want to do more beyond that, then that’s okay if the aim is to build your confidence further. If that’s the case, make a PDP entry about it.
However, before you go down this route, clear it with your GP Trainer and Educational Supervisor AND ALSO MAKE SURE it will not be at the expense of any outstanding work you need to do for Work-Place Based Assessment.
There is no upper limit on the number of hours trainees can work in the UUC setting so long as they adhere to the limits of safe working practice as detailed their Contract of Employment. Time spent working in UUC is taken out of the trainees clinical working week in the GP training practice and it can be hard to accommodate on the practice’s clinical rota and can lead to the practice being short of appointments.
So, speak to your GP Trainer and Practice Manager and be mindful and respectful of the practice’s need to provide a sufficient number of clinical appointments. Respect their decision.
We hope this section provides clarity over European Working Time Regulations (EWTR) and how they apply to the organisation of out-of-hours (OOH) in General Practice training or involvement in other UUC services that also operate out-of-hours. It is important that working arrangements (both in-hours and OOH) for practice-based trainees are compliant with the EWTR, both to provide a fair working environment for the trainee and to ensure that the employer is properly fulfilling their statutory obligations. Full information on the EWTR is available on the BMA website but we deal below with those issues that are most likely to raise practical concerns.
- The EWTR dictate that, within a 24-hour period, a trainee can work continuously for a maximum of 13 hours and that there should be 11 hours rest between work periods.
- They also state that there must be an average maximum working week of 40 hours.
- This average is taken over a reference period of 6 months, so it is possible to have some weeks busier than others.
Some practice-based GP trainees will have a contractual obligation to complete 6 hours of OOH experience for each month worked in general practice, i.e. during a 6-month attachment they will complete 36 hours in Out of Hours environments. This work is in addition to their usually contracted daytime responsibilities. If their OOH sessions are organised in good time and with sufficient thought given to when those sessions should take place, there is no reason why completing their OOH responsibility should put them in breach of the EWTD. Below are some examples of how this might be arranged:
A trainee working a 6 hour evening week-day session
- Normal Surgery work from 9.00 hours to 16.00 hours
- The trainee starts the OOH session at 18.00 hours & finishes at midnight. The total number of hours worked that day will be 13 hours.
If the following day is a normal working day:
- The following day instead of starting at 9.00 hours the Trainee starts a late Surgery around 11.00 hours (to ensure an 11 hour break)
- Uses their private study session as post OOH session instead of a late start in practice.
A trainee working an overnight session
- Such sessions are best worked on Saturdays, when a trainee would be able to work up to a 13 hour session with sufficient rest on either side of the session.
- A trainee who works a similar length shift in the week will be unlikely to be able to meet their practice responsibilities as they will need time off both on the day before and the day after their shift.
If a trainee wants to work a midnight to 8.00 am session in the week
- They can work up to 13.00 hours on the day before the shift
- They cannot work until 19.00hrs on the post OOH session day.
- The employer could offer an additional half-day in addition to the private study session. However the additional half a day could be re-claimed by the employing surgery when the trainee is not busy.
The Trainer and the Trainee should realise that the OOH training experience should be a balanced mixture of evening, weekend and overnight sessions. An Educational Supervisor shouldn’t sign up a trainee as competent if they have done only one type of session. However we anticipate most sessions will be undertaken in the evening or at weekends.
It is the trainee’s responsibility to ensure that they book their OOH sessions in good time and with consideration to keeping within the EWTR. If they organise their OOH care in such a way that they are unable to meet their daytime practice responsibilities, then this will need to be agreed with their trainer and the GP trainee will be expected to make up any practice sessions that are lost.
- The GP School expects educational supervisors, and their training practices, to support trainees learning in UUC. It is however recognised that practices need to plan rotas, rooms and other logistics and therefore need to know when a trainee will be working.
- The GP School would encourage trainees to give a reasonable amount (to be agreed in each practice but usually of the order of 4-6 weeks) of notice for clinical time off in lieu (TOIL) due to urgent care shifts worked. If reasonable notice is given, we would expect practices to be able to accommodate this.
- When the previous guidance was in place many practices scheduled six hours of time off in lieu per month into timetables, to assist forward planning and to balance out time worked in UUC outside the practice. A comparable system could be agreed between the trainee and practice if preferable.
How will I be supervised? Depending on what stage you are at in your training and how experienced you are, your clinical supervisor (CS) may either oversee your work in detail or take a step back and see how you get on.
- Observing– this is where you will sit in and watch your Clinical Supervisor with a discussion at appropriate points. You will not see any patients. Observing also includes induction, orientation or other training sessions for OOH work – like a telephone triage workshop.
- Direct supervision – the GP trainee is supervised directly, face-to-face, by the CS. Trainees might suggest a clinical management plan, but they will take no clinical responsibility because it is the CS who will make the final clinical decisions.
- Nearby supervision – the GP trainee consults independently but with the CS close at hand if needed e.g. in the same building (i.e. the trainee starts some independent working).
- Remote supervision – the GP trainee consults independently and remotely from the CS, who is available by telephone. An example of such a session would include a session ‘in the OOH mobile ‘car’ session, supervised by another GP ‘at base’.
Remember, never act beyond your capabilities. If you feel unsure about something or feel something is beyond your expertise, seek advise from your Clinical Supervisor. Patient safety is paramount.
GP trainees undertaking direct, near and remote sessions should have an identified individual who will, (for the duration of that session) have the lead responsibility for ensuring the safety of both the trainee and patients and who has been appropriately trained. That person is called the Clinical Supervisor (CS).
The CS is trained to be responsible for overseeing a specified trainee’s clinical work and providing constructive feedback during their placement. You should have a CS who you can refer to for every clinical session you do – for both urgent and routine work. So, when your doing on-call for your practice, be sure to find out who your CS is and make sure you touch base with them. It might be a different doctor every time you do in-house practice on-call. During OOH sessions, you will be told who your CS is. They will closely supervise you unless they feel you are good enough to start working a little bit more independently. Even then, you should always ensure every clinical session is debriefed with them.
Such supervision should include:
- Sufficient time to enable clinical discussion in the case of “direct supervision” for each patient seen and in “near” and “remote” supervision as requested by the trainee
- A proactive approach by the supervisor to supporting / monitoring the trainee during the session
- A discussion at the end of the session sufficient to allow for review of cases the GP trainee wishes to discuss and to enable the provision of feedback.
Clinical supervisors should have undertaken training sufficient to enable them to meet the competency framework for medical educators as described by the Royal Academy of Medical Educators in Academy of Medical Educators (2010) A framework for the Professional Development of Postgraduate Medical Supervisors. The training is usually provided by HEE GP Schools. Specifically, they should:
- Ensure safe and effective care through their supervision of the GP trainee
- Create a clinical learning environment that is safe and conducive for learning
- Provide direct guidance on clinical work being undertaken by the trainee
- Provide constructive critical feedback
- Reflect critically on their own performance as a clinician and educator through seeking feedback from trainees, through annual appraisal and through undertaking re-approval as an educator as required by their own professional body
The supervision in the urgent care setting should be a GP. Only when absolutely necessary can other NHS professionals be used – but again, a lead GP providing medical support for the service must still be identifiable and available. These other NHS health professionals must work within their own sphere of practice when supervising and MUST adhere to escalation and other organisational policies and not seek medical advice from the GP trainee.
- Clinical Supervisors should raise concerns where appropriate – for clinical competence concerns – and even if the trainee fails to attend a session.
- They should know who to contact and the appropriate pathways to raise concerns.
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.
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 HEE GP School.
At the start of each shift the supervisor and trainee should sit down to discuss the supervision level they both feel is appropriate. It is expected that the trainee will provide the supervisor with an updated copy of their training passport preferably before but at the latest at the start of each shift to support this conversation.
Following discussion, the supervisor and trainee will agree on a level of supervision. If there is any discrepancy between their wishes it would generally be expected that they would start the shift at the highest level of supervision requested, but then consider progressing to less supervision if both parties were happy following further discussions.
Factors to consider are previous UUC experience, level of supervision at in hours work at that time, familiarity with the provider set up/shift type/IT etc. The workload on the shift should not directly impact on the decision regarding supervision level given to the trainee i.e. if it is busy this is NOT a reason to relax supervision if it would not otherwise have been felt to be appropriate for that trainee.
What UUSC things should I be doing at ST1, ST2 and ST3?
ST1 & ST2
You only need to engage with UUC in your GP posts. In all other hospital based posts, you engage in the on-call programme for that department. In your first GP post, you will mainly be OBSERVING or under DIRECT SUPERVISION (i.e. seeing patients but all need to be seen and reviewed by the CS before they leave).
These are the things you might do with respect to UUSC:
- Discuss how UUC works – OOH, on-call duty dr for the practice, other acute medical primary care services, different models of OOH work and on-call duty dr provision.
- Training courses – OOH induction or orientation. Telephone triage course. Urgent care orientated consulting skills courses.
- Sit in & Observe: observe telephone consultations, on-call duty dr sessions, OOH surgeries
- Do some Directly Supervised sessions: in OOH or on-call duty doctor surgeries. See some patients, but all must be reviewed face-to-face by the CS – either by sitting in with you or entering the room after you have finished whilst the patient is still there. The trainee does not take final clinical responsibility for any patient: this rests with the Clinical Supervisor.
- Formal induction not required as the GP trainee is not undertaking the clinical delivery of care to patients and the CS will be there at all times.
- Sessions of type 1-3 should count towards “educational” sessions in the weekly timetable.
- Sessions of type 4 should count towards “clinical” sessions in the weekly timetable.
The ST3 GP trainee should gradually move from supervised to consulting independently. There should be:
- DIrectly Supervised: at the beginning only (first 2 months?). After appropriate formal induction to OOH services and on-call duty doctor sessions, trainees are expected to see patients under direct supervision – where the CS either sits in observing the trainee consult with the patient OR sees the patient with the GP trainee after they have finished their initial consulting. This should happen with the majority of patients. After a settling in period, the trainee should then progress to nearby supervision.
- The CS should be physically Nearby. This means that the trainee sees the patient and both will have timely access to a nominated clinical supervisor who can directly assess the patient in person IF NEEDED.
- Later on, perhaps in ST3-2 (as the GP trainee gains more experience and confidence and has done sufficient near-by supervision sessions), the CS can decide to be available Remotely (via telephone or other appropriate interface). However, this is not a required achievement prior to CCT. This should only be done IF the CS has faith in the abilities of the GP trainee to work a bit more independently. This decision and responsibility rests with the CS. There should be a clearly defined process for monitoring the safety of trainees when working remotely visiting patients at home or in other locations.
- All these sessions are to be counted towards “clinical” sessions in the weekly timetable.
Writing it up in the ePortfolio & The Bradford VTS UUC Learning Log Form
One reason why trainees get referred to ARCP panels is because there is a lack of good evidence in their ePortfolio for the Professional Capabilities even though they may have been engaging with things like OOH. So, as well as engaging, please write up your UUC sessions very carefully. In fact, just write them in terms of one or more of the Professional Capabilities. Use the Capabilties as your headers to keep your writing focused. And remember the 4 key elements of a good reflective log entry…
- There should be a brief description (i.e. INFORMATION), followed by
- Some documentation about your thoughts (CRITICAL ANALYSIS)
- And your FEELINGS,
- With a final closing conclusion about EVALUATING what you have learnt and key messages you are taking home.
Satisfying the panels that the Professional Capabilities 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. This is what the RCGP say: Before qualifying as a GP, you need to show that you have the requisite capabilities to work across the full spectrum of primary care as delivered in all four nations of the UK. Ask your trainer to read your UUC log entries early to see if you are on the right track.
Ultimately, you have to demonstrate evidence of the Professional Capability areas. Here are some tips on how to do this…
- Download the Bradford VTS UUC learning form BEFORE your session.
- After or during the session: pick several areas that you felt were demonstrated or important in today’s UUC session.
- Start by writing your own thoughts about those areas.
- Then have a discussion with your CS about those areas.
- Add any key points from the discussion with the CS.
- Then upload the form to your ePortfolio; use the heading “UUC session”.
Don’t forget to also use the UUC mapping tool provided on one of the pages in “The ES Workbook”. Both links are provided below but also available in the HOT DOCS downloads section above.
Examples of UUSC Log Entries
In both examples below, there is a bad version and a good version. Accompanying each one is a critique from the GP Educator. We hope the comparisons between the good and bad versions (along with a critique) will help you understand exactly what it is that makes a good reflective UUC learning log entry. Writing good reflective learning log entries requires thinking and evaluation on top of merely regurgitating the facts or stating what happened. And in doing so, it makes you learn from the event by helping you have deeper thoughts than you would have had if you had not thought about it so much. Both examples demonstrate this nicely.
Remember, the act of writing or typing something out makes your brain really slow down and think about the event carefully and contemplate a wider range of thoughts and possibilities than if you considered the event just in your head.
Do I need additional cover than that provided by NHS Indemnity?
Trainees in general practice will be subject to the normal processes of clinical governance, GMC regulations and civil law. Although NHS indemnity is provided GP trainees should recognise that additional personal indemnity is STRONGLY advised. There are other professional activities, which may not be covered by the NHS or Crown Indemnity. Therefore, you are strongly advised to maintain membership of a recognised medical defence organisation or insurer for these purposes.
It will also give you that extra peace of mind should you be involved in a medico-legal case. Medical indemnity organisations usually say that the GP trainee standard membership will provide cover for unscheduled and urgent work, but this should be confirmed by GP trainees with their individual provider. Double check! Ask specifically “Does the cover include provision for Urgent, Unscheduled and Emergency Care work?”.
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.
Final few FAQs on UUSC
Workplace based assessments should reflect the full scope of training. As a result, we would encourage trainees to complete a proportion of these assessment in the UUC setting if the CS is trained in use of the WPBA tools.
The competence record will detail the evidence which the trainee feels demonstrates attainment of each competency. If there is concern or uncertainty, then we would encourage dialogue between the trainee and ES. If further clarification is sought, we would encourage the ES to speak to the clinical supervisors working with the trainee or seek further advice from the GP School via their local TPD team.
FAQs specifically on OOH
There are three main types of OOH doctor
- 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.
- The doctor who sees acute patients in the OOH centre.
- 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…
- Face-to-face or telephone sessions will happen at Eccleshill Hospital, Newlands Way, Eccleshill, Bradford BD10 0EP.
- 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.
- 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).
- 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.
Many HEE GP schools run “Care of the Acutely Ill” or “Urgent & Unscheduled Care” courses. Unscheduled care = acute care. Ask your TPDs or the GP training scheme administrator for more information. They will know whether your HEE GP School or Training Scheme runs one. If not, suggest it to them!
- 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 UUC reflection form (see HOT DOCS area at top of this page).
- 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 UUC reflection form and use the Professional 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
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.
We need trainees to monitor their own working hours to ensure they are not working long shifts and are getting plenty rest. Not getting enough rest and working long shifts can have an adverse effect on thinking and decision-making – it is crucial to protect this, especially in the urgent care setting. Patient safety is paramount.
- The employed doctor (GP trainee, salaried doc etc.) works no more than an average of 40 hours each week (excluding lunch hour and time taken to travel to and from work). The average is worked out over a period of 6 months (26 weeks): i.e. divide the number of hours worked over 6 months, by 26 weeks.
- They must get 11-hour continuous rest in a 24-hour period: for instance, if they do an evening shift on top of their daytime work.
- They must get 24-hour continuous rest in 7 days (or 48 hrs in 14 days): for instance, if they do extra work at weekends.
- They must get a 20-minute break in work periods of over 6 hours.
So, if you are doing an OOH shift or work in any other UUC setting (other than in-house surgery on-call), please let your Practice Manager know in advance so that they can make changes to your rota for that week so that you don’t break the 40 hours per week Working Time Directive. Your GP Trainer and Practice Manager cannot second guess when you are doing these external shifts. But you will know in plenty of time because you will be booking onto them directly. Therefore, let the practice know in plenty of time so that they can make early adjustments rather than cancelling surgeries at the last minute and then upsetting patients.
The HEE GP School 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.
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.
Firstly, you shouldn’t cancel unless it is absolutely necessary. If it is…
- First try and swap that session with one of your colleagues; it is your responsibility to do this.
- 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).
First of all, it’s not just Out Of Hours experience you have to provide evidence for. You are providing evidence of your capability across a range of Urgent, Unscheduled and Emergency Care situations. Out of Hours is only one place where you will encounter Urgent, Unscheduled and Emergency Care. Another is the duty doctor on-call sessions every GP has to do for the surgery. As listed above, there are others too!
Why do you have to demonstrate your ability in Urgent, Unschedule and Emergency Care situations? Because these are the situations which present a high risk to both patients and staff. All parties involved in the provision of these services need to ensure that there are sufficient suitably trained and experienced clinical staff, particularly doctors, engaged in planning and delivering these services.
And even if you are not planning to do OOH when you qualify, you still need to provide evidence that you have the skills to do OOH because the college expects you to demonstrate your skills across a range of urgent clinical environments. You may think you’re not going to do OOH for the moment, but you cannot be certain of what the future holds. At the moment, 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. And besides… 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 practice and consolidating learning
So remember, it is not just about OOH but about the management of acutely ill patients across a variety of primary care settings. In doing so, you will be involved in the management of acutely unwell patients in a primary care setting. You will also understand how out of hours Primary Care service can be organised. You will gain experience of a range of consulting styles in an out of hours centre, on home visits and using the telephone. And you will get invaluable life-changing feedback from being observed consulting.
Yes, you will definitely get referred. Remember, UUC is all about you showing evidence for the Professional Capabilities across a range of settings. Only engaging as the practice’s on-call duty doctor is NOT enough – this is not a range of settings! We would suggest the bulk of your evidence for the capabilities needs to come from engaging in OOH AND as on-call duty doctor for the practice. If you can engage with other acute primary care medical services – even better, but OOH and on-call duty doctor should form the bulk.
No. You can only do OOH work if you are in a GP placement. In hospital posts, you should be engaged in the department’s own on-call rota programme.
Absolutely not. It is unlikely you will be covered by your indemnity provider.
Remember what we said. IT IS NOT ABOUT THE NUMBERS. The aim of doing these sessions is to gather EVIDENCE for the Professional Capabilities. If your session was quiet then use it as an OPPORTUNITY to spend time with the Clinical Supervisor discussing things that will provide evidence for the other capabilties – like organisation, time-management, IT systems, principles of safety and so on. Make the most of it. Don’t just sit there twiddling your thumbs!
If the session was super quiet, and you failed to discuss anything… then you won’t have gathered any evidence for the capabilities and YES, you will have to do more sessions. But seriously – it would be hard for a session to provide NO evidence – there’s always room for discussion with your CS.
So, if it is quiet – don’t just sit there – make the most of it…
- Talk to your Clinical Supervisor
- Go through the Professional Capabilties and pick one or more to talk about.
- For example, discuss the organisation of OOH, models of OOH/UUC care elsewhere, safety and security, communication issues in the OOH setting, top tips and so on.
- Get up and go over to the admin area
- Sit in with reception staff and see how they field calls.
- Have a look at the triage system and understand how it works.
- 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.
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 he or she 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.
No. Even if you’re a capable ST3. GP trainees are not advised to assume responsibility for the supervision of other health care professionals whilst undertaking clinical work in an unscheduled / urgent care / OOH setting. You may not be covered by your indemnity should something go wrong with the person who you were informally supervising. Besides, they should have their own formally approved Clinical Supervisor.
- Concerns have been raised over probity issues. It is suggested that non-attendance by the GP trainee for a booked OOH session without good reason is a professional offence. This should be viewed as an equivalent of not turning up for a booked surgery in their own practice without reasonable notification being given.
- The OOH provider may raise late arrival of the GP trainee with the OOH Clinical Supervisor since calls and visits may be accumulating, each with a target time window and in some situations the OOH Clinical Supervisor may not have been informed that the GP trainee has swapped sessions, is ill or absent elsewhere. Please make every effort to inform your Clinical Supervisor via e-mail or preferably phone if you are unable to attend or are running late. Please ensure you have their contact details.
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