All GP registrars are required to undertake 108 hours of out-of-hours training, spread over the 18 months that they are attached to a training practice, averaging six hours a month.
These hours can be achieved by undergoing sessions with the out-of-hours service provider commissioned by the local PCT, by observing district nurses, members of the local ambulance trust or NHS Direct staff during the out-of-hours period.
Updating basic life support or simulated medical situation training for a limited period is also acceptable.
It is up to the individual GP registrars to ensure they achieve not only the number of hours required but also competency in 'care of the acutely ill'.
This means that there is no prescribed number of hours required in telephone triage, primary care centre (PCC) consultations or home visits, only that the GP registrar achieves competency in each area.
Each out-of-hours service provider is obliged to provide sufficient training capacity under deanery-approved out-of-hours clinical supervisors, who hold the responsibility for clinical governance and educational supervision.
The GP registrar expects certain standards from the service provider, including:
1. A central booking system for out-of-hours sessions, making the arrangements for sessions in telephone triaging, PCC and home visits simple.
Many out-of-hours service providers have web-based booking systems for their sessional GPs, and the sessions with approved clinical supervisors can be booked directly by GP registrars once registered by the out-of-hours service provider.
2. Sufficient clinical supervisors providing sessions on weekdays, evenings and weekends, to allow GP registrars flexibility in achieving the required hours. These sessions should be supernumerary to the usual out-of-hours service cover.
3. Adequate consulting rooms and work stations for the GP registrar to consult independently and access clinical information from web-based sources.
4. A nominated clinical governance lead to ensure the quality of consultations undertaken by the GP registrar is audited and fed back to both the registrar and trainer.
5. A structured induction process with adequate review of progress during the out-of-hours training.
6. Active teaching during out-of-hours sessions with feedback to the GP trainer on subjects to be discussed in greater depth during structured tutorials.
While these are the standards expected from an out-of-hours service provider there are other factors, which ensure that the GP registrar receives a good grounding in out-of-hours medicine:
1. When telephone triaging, the telephone system should allow 'piggy-backing' so the clinical supervisor can monitor the triage consultation. This ensures the GP registrar develops the correct telephone style, making a diagnosis, discussing a plan of action, confirming the plan and ensuring what action should be taken if the condition worsens (safety netting).
2. The clinical induction process should cover specific areas:
- Management of death, confirming death, communicating with bereaved family and carers.
- Controlled drug use, including administering a controlled drug, and the recording of controlled drug movement and usage.
- Medicines management, including the dispensing of medication and recording on FP10rec forms, communication with community pharmacists and the use of patient group directions.
- The out-of-hours service provider significant event and complaints policy, how to report a significant event.
- The out-of-hours service provider's safeguarding child and vulnerable adult policy, how to report a concern.
3. The operational induction process should cover:
- Area covered by the out-of-hours service provider, including base and major hospital sites.
- Teaching use of the computer system used by the out-of-hours service provider.
- National quality requirements for triaging and face-to-face consultations.
- Working with other members of the out-of-hours service provider team in the community.
Once the induction process has been completed, the GP registrar should be able to explore subjects related to the core areas with the clinical supervisor, and access material on the internet during the sessions and at the debriefing period of the session.
Feedback to the GP registrar and GP trainer can be through the 'record of out-of-hours session', however, structured clinical audit is also vital.
This should cover achieving time constraints in triaging and face-to-face consultations, adequate clinical notes and appropriate disposition, prescribing and follow-up.
A minimum of five calls per quarter should be audited and forwarded to the GP registrar. This feedback is vital for the completion of the GP registrar's CPD folder, with the 'record of out-of-hours session' having the dual purpose of confirming the hours worked, and also to confirm that the GP registrar is competent in that aspect of out-of-hours medicine.
Finally, a good out-of-hours service provider should have friendly staff members who are prepared to assist the GP registrar in undertaking their out-of-hours sessions, show flexibility in arranging sessions and ensure that the GP registrar is exposed to the full range of medicine used in the out-of-hours period.
- Dr Law is medical adviser on out-of-hours services for the East of England Ambulance NHS Trust in Essex
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