Training in an out of hours (OOH) setting remains an essential component of training for General Practice. By the end of vocational training GP registrars should be fully competent to work unsupervised in a GP OOH setting and trainers will have to document this on the e-portfolio. Here is the revised COGPED paper.
RCGP Curriculum and out of hours work.
The curriculum statement “Care of acutely ill people” has 6 generic competencies embedded within it:
- Ability to manage common medical, surgical and psychiatric emergencies in the OOH setting
- Understanding of the organisational aspects of NHS OOH care
- Ability to make appropriate referrals to hospitals and other professionals in the OOH setting
- Demonstration of communication skills required for OOH care
- Individual personal time and stress management
- Maintenance of personal security and awareness, and management of the security risks to others.
These are the key out of hours competencies, but clearly other areas of the curriculum will be covered during out of hours sessions.
Minimum time that must be undertaken in out of hours during training
GP registrars are contracted to work at least 72 hours in an OOH setting during their ST3 year. For those doing some general practice in ST2 they must complete an additional pro-rata amount of time (ie 36 hours in a 6 month attachment). Any registars who have an extension of training must also do a pro-rata amount of time in out of hours during that attachment.
Attachments to other out of hours services (non GP)
We recognise that valuable learning opportunities may be provided by attachments to other services (eg. Ambulance service, MacMillan service, NHS direct, Mental Health Crisis teams). Such experience should normally be done during your GPST1/2 attachment, and in any case should not exceed a total of 18 hours. Extended hours surgeries should not be included as out of hours experience.
Level of Supervision during out of hours work
We recommend using the traffic light guide to clinical supervision. Clinical supervisors (in discussion with educational supervisors if necessary) must be confident in the GPST's ability before moving through these levels. GPST3s should be able to consult with remote supervision (green) for at least 18 hours at the end of their training.
In the event that a GP clinical supervisor goes off sick at the last minute or is unavailable for any reason
- The OOH provider organisation should identify this at the earliest stage and endeavour to contact the trainee concerned preferably before they arrive at the treatment centre
- A senior manager/supervisor should discuss the options with the trainee namely: cancel their shift and go home, go to an alternative TC where there is a GP clinical supervisor, work remotely with a clinical supervisor on the telephone, spend a shadow shift with another OOH provider organisation employee.
- If the trainee wishes to stay on a GP clinical supervisor with appropriate availability for the level of the trainee experience must be identified
- Trainees should be reassure the OOH provider organisations are large multidisciplinary organisations with paramedics, emergency care practitioners, nurse practitioners and GPs who they can contact at any time to seek advice or hands on face to face assistance.
Trainees must remember the GMC guidance "Duties of a Doctor" and ensure they do not practice outside of their competency so if they feel they are being asked to practice at a level they are not yet competent to do they must say no.
- Direct Supervision - the GPST is supervised directly by the clinical supervisor and takes no clinical responsibility.
- Close Supervision - the GPST consults independently but with the clinical supervisor close at hand e.g. in the same building.
- Remote Supervision - the GPST 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'.
- Detailed Guide to Competency and Supervision Progression
- OOH workbook for GPSTs
- OOH Session Log Sheet
- OOH Record for eportfolio
Communication and Recording
All OOH sessions must be recorded on the e-portfolio(and “shared” with the educational supervisor). In addition, a record of each OOH session must be documented using the OOH Record Template, which should be signed by both educational and clinical supervisors and uploaded onto the e-portfolio. Cancellation of Sessions
Late cancellation of booked out of hours sessions is not acceptable unless there are exceptional circumstances. Out of hours clinical supervisors should report all cancellations to the trainer.
Reminder to Trainees and Trainers about OOH work and EWTR
When organising OOH shifts trainees are reminded about the European Working Time Regulations and need to be compliant with these. The main features are:
- a maximum average of 48 hours working time each week, measured over a reference period of 26 weeks for doctors
- a minimum of 11 hours continuous rest in 24 hours
- a minimum of 24 hours continuous rest in 7 days (or 48 hrs in 14 days)
- a minimum of a 20 minute break in work periods of over 6 hours
- for night workers, an average of no more than 8 hours work in 24 over the reference period.
More details can be found on NHS Employers page for this at http://www.nhsemployers.org/PlanningYourWorkforce/MedicalWorkforce/EWTD/Pages/EWTD.aspx
It is the responsibility of trainees to let their practices know if they need to adjust their daytime practice working hours to be compliant eg if finishing an OOH shift at 11pm should not start work the following day until 10am. However trainees still need to do their usual 40 hour working week so if starting late will need to make up the time elsewhere in the week or at a later date. Hours worked can be averaged over a several month time period. This can be done in a number of ways and how trainees and practices choose to do this will be up to individuals to organise. Trainees need to remember that practices usually need at least a months notice and ideally 6 weeks or more to re-organise surgeries as most will have surgeries open for booking at least a month in advance so re-organising surgeries at short notice is very time consuming. If it is not possible or trainees do not wish to organise a late start then an evening OOH shift could be finished at 10pm as an alternative. If trainees plan to work an overnight shift these should only be booked for a Friday or Saturday night unless the trainee has arranged to take the following day off and if working on a Friday night they should ensure an adequate break between daytime work and starting an overnight shift.