Out-of Hours Care
Tunbridge Wells VTS
Pembury 04.09.13
Dr Robin Warshafsky, MD, CCFP, FCFP, MRCGP
Deputy Medical Director Integrated Care 24
30+ years full time GP (27 years in Toronto area)
~20 years A&E/urgent care /OOH in Canada
6 years OOH in UK
robin.warshafsky@IC24.nhs.uk
Who are we?
Integrated Care 24
 Formed by the mergers of:
 Seadoc & Brightdoc (April 2005) -> South East Health (SEHL)
 Stourcare & SEHL (April 2008)
 On Call Care & SEHL (August 2008)
 Rebranded as Integrated Care 24 Limited (June 2013)
 Northamptonshire - GYW NHS 111 – South Essex
 Main call centre Ashford
 ~5million patients
 30 primary care centres/600 doctors / 100 nurses
 500, 000 calls / annum
 Additional services (/DN/GPLHC/MIUs Warwickshire Health Line)
Integrated Care 24
Not for profit!
“… the Social Enterprise Mark … guaranteed social enterprise,
committed to reinvesting at least 50% of profits back towards … social
purpose”
Top management ~50% clinical – GPs and Nurses
federation of Social Enterprise Unscheduled Primary Care
Providers committed to providing the highest quality of care for
patients.
Driven by clinical excellence and patient satisfaction:
complaint rate = 0.08% of contacts
IC24 TEAM
Rota Administrators (most important people, be nice to them!)
West Kent: Tracy Flynn, Julie Rice 01227 285937
wkadmin@IC24.nhs.uk
East Sussex: Kate Orton 01233 505517
Kate.orton@IC24.nhs.uk
On-line session booking:
“Rota Master” www.IC24.com
Rota administrator will provide you with log in name/password
IC24
TEAM
Locality Operations Managers
West Kent Donna Springate donna.springate@IC24.nhs.uk 01227 285931
East Sussex Tracy Wickham tracy.wickham@IC24.nhs.uk 01233 505528
Associate Medical Directors
West Kent
Meriel Wynter meriel.wynter@IC24.nhs.uk 01227 285932
East Sussex
Robin Warshafsky robin.warshafsky@IC24.nhs.uk 01233 505531
07918 642946
What is OOH for?
Assess all patients who contact us, but not to see them all,
18:30 and 08:00 weekdays, all weekend, and public holidays
Therefore, OOH provides the bulk of primary care, in terms of
time, ie >70% of primary care is in the out of hours period
See those whose clinical need on assessment indicates that
management would benefit from an OOH F2F consultation.
What are the consequences of seeing “on demand” ?
When should we visit?
NEED TO KNOW
OOH Training for Registrars
CLEO (Clinical Excellence Online)
111 – NHS Pathways - DOS
OOH Training for Registrars
WHY?
‘…the generalist role of the GP should be maintained and that newly accredited GPs will be
expected to have demonstrated their ability to perform competently in OOH primary care’
OOH Training for GP Speciality Registrars, Position Paper COGPED 2010
Historical: GPs always did this
System efficiency:
?GPs do it best (but not the only ones who are doing it!)
WHERE?
Integrated Care 24 sponsored and administered
West Kent: Tonbridge, Maidstone, Cranbrook
East Sussex: Crowborough, Uckfield, Brighton, Newhaven, Eastbourne, Bexhill,
Hastings, Rye
WHY DO OOH?
Variety of presentations: generally see an interesting & unusual acute
case once per shift
“A typical shift may present the usual UTIs, bad backs and sore throats but
will also throw up the occasional diagnostic conundrum or emergency”*
“Far removed from the comfort zone of a familiar surgery, it can be
particularly satisfying effectively to manage acute LVF in the middle of the
night, or diagnose a perforated viscus or pleural effusion.”*
Team working: “stimulating skill mix, with GPs working alongside nurse
practitioners, paramedics, drivers and call handlers, and mutual
mentorship provides support for all team members who each have vital
roles to fulfil.”*
*Dr F Gilroy, GP Clinical 12.03.08
OOH Training for Registrars
WHO?
IC24
Offer induction to registrars
Make sessions available
Provide access to trained supervisors
Clinical supervisor
Trainer
(Associate) Medical Director
Rota Administrator
Locality Operations Manager
WHEN?
Average one session/month, or about 72 hours
HOW?
Check that you are on the Performers’ List
Register with your local OOH Provider
Send in application with your documents, usual stuff
Pick up your OOH RECORD SHEETS from VTS (also find them on website)
Discuss your readiness to start OOH training with your Trainer
Before a session: ensure you and your Trainer have completed the top of the
Record Sheet
Do a session
After the session: complete the OOH Record Sheet with your supervisor,
ensuring the supervisor signs it and takes their copy
Share the OOH Record Sheet with your Trainer at next convenient meeting
Ask your Trainer to sign the Sheet and scan into your e-portfolio
Make an OOH log entry
Complete required number of sessions and log each one on your e-portfolio
Towards Competency & Independence
Red sessions (direct supervision)
Direct supervision by the clinical supervisor no clinical
responsibility.
Amber sessions (close supervision)
GPStR consults independently but with the supervisor
close at hand e.g. in the same building.
Green sessions (remote supervision)
GPStR may consult independently and remotely from the
clinical supervisor, who is available by telephone.
6 Key Competencies
1.
2.
3.
4.
5.
6.

Ability to manage common medical, surgical and psychiatric emergencies in
the out-of-hours setting.
Understanding of the organisational aspects of NHS out of hours care.
Ability to make appropriate referrals to hospitals and other professionals in
the out of-hours setting.
Demonstration of communication skills required for out-of-hours care.
Individual personal time and stress management.
Maintenance of personal security and awareness and management of the
security risks to others
Novice –> Competent -> Proficiency
Assessment of Competency
responsibility of the Trainer
supported by evidence supplied by GP StR, documented systematically in
ePortfolio
feedback from Clinical Supervisor
Duties
clinical governance to ensure quality of care and patients’ safety
supervision of a GP StR’s learning & experience
teaching, observing, assesing & feedback to learners
Who? Identified by shifts available on Rota Master
any suitably qualified health professional who has undertaken a Deanery approved
Supervisors course
GPs: beginning process of becoming a GP Trainer/recently retired/suitable GP who has had
appropriate training/suitable GP who has had previous educational experience or received
specific training as a supervisor.
Nurse Practitioners,
Retained Doctor Educational Supervisors,
Undergraduate Medical Student Teachers
Clinical governance for the Clinical Supervisor
must maintain & update skills
subject to 3yrly re-approval based on the feedback from GP SpRs
Clinical
Colleague working alongside you/Colleague at another base
IC24 Intranet – local knowledge
Electronic record system has lengthy list of links
Registrars at hospitals
Specialist nurse practitioners: CPNs, Hospices
Associate Medical Director/Medical Director my number
Operational
any IC24 clinician as above
receptionists/drivers, many have been with organization long time
Duty manager for locality
Duty manager at Ashford HQ
Developed with BT and IBM support
Much more flexible than Adastra
Reporting of
Outcomes
Productivity
Linked to audit scores
A good basis for feedback, a long time coming
Training will be provided!
Instructions
Dear Colleagues,
This young woman keeps going to RSCH A/E with abdominal pains. She
has been seen by the gynaecologists and surgeons and nil serious has
been found. She will frequently try to get extra diazepam from this
surgery and it may well be that she is now going to A/E in attempt to
get morphine.
She has certainly been very constipated and morphine like drug will not
help this-nor help her keep boundaries that the CMHT and i are trying
to set. She may start seeking your help.
Please be very circumspect about giving her powerful analgesia. We
giver her her medication on a regular weekly basis and she not need
extra from you. Thanks for your help, R…….. B……. (25/08/2012 LR)
Read the call handler note
Assess urgency
Check the history tab
See if there is a special patient notepalliative (Share My Care)
Check recording process
Do the business
Note
Save as.......
Clinic appointments are given if a face to face consultation
is felt to be needed by the triaging clinician. It is wise at
busy times to warn the patient of possible delays and
that sometimes patients are seen according to clinical
priority and not arrival times
The receptionist will phone the patient to arrange a time if
you save the call as “base”
SEEING A PATIENT
 Read the 111 notes
 Read the triage notes if any available
 Check if special patient notes
 Think about CCG pathways
 Do the business
 Check registered GP noted as does not always filter from
111 if not add this with help from receptionist staff if
unsure.
FP10s
Green, to send patient to chemist
Purple, if dispensing stock so SEHL re-imbursed from PCT
Complete packs- except?
Controlled drugs- sign in and out, CD register
Regular part of workload
Adds to the clinical load at times when demand highest
(weekends and Bank Holidays)
Uniform approach important
Safe for patient
Does not fuel demand
7 days
Suite of evidence-based clinical content providing
electronic clinical decision support
Linked to a directory of services
For specially trained call handlers (60 hrs training) &
clinicians (ie 1 nurse per 6 lay CHs)
Designed for telephone based healthcare
First went live in 2005
Safely handled several million calls
SEC NHS 111 has radically altered the GP OOH service
Partial loss of telephone consultations and capability
Proposed to become a “see and treat” service only
Current retention of triage via professional helpline for
nursing home staff and clinical colleague contacts
SEC 111 “Speak to GP” option, but
111 GPs unable to do telephone scripts
Base calls re-assigned to advice at IC24:
at patient request, just want advice, didn’t get it
consider yourself for: simple UTI, mild early pregnancy
bleeding without pain, non-sinister low back pain, etc
Very little/sporadic clinical information from 111 call
handlers/GPs, but improving
Patients may have waited a long time to speak to 111 call
handler (angry!)
THAT’S IT!
Thank you
Questions?