Registrar Induction Session

1. Registrar Induction Session Welcome to GTD David Beckett, Chief Executive Dawn Sewards, Head of Governance Dr Zubair Ahmad, GPST Training Lead - GTD Dianne Hill Operations Manager

2. Our Philosophy for Patient Care Patient Experience We put patients and their families at the centre of all we do Partnership We work together with individuals and the local community Quality Delivering evidence based care to agreed standards of excellence Continuity Focussing on delivering a seamless patient journey Innovation Developing innovative solutions to improve services

3. GTD Areas Treatment Centres • Ashton Primary Care Centre • Manchester Royal Infirmary • North Manchester General Hospital • Oldham Integrated Care Centre • Wythenshawe Hospital

4. GTD Area expansion 01.10.13

5. Patient referred to GO To DOC by NHSD/ Ambulance Control/Other Professional Patient rings GO To DOC, either directly of via phone diverted from own GP Initial call taken by call handler Straight for doctor advice Any other problem except medication request/ palliative care patient Prioritised as Emergency Patient advised To call 999 Prioritisation Questions carried out by call handler to identify urgency of call GP Telephone advice Urgent & Less Urgent Nurse Triage Nurses follow electronic TAS triage algorithm Refer for Appointment at Treatment Centre Refer for Visit GP Telephone advice Refer to Secondary Care Refer to other health care professional Self care advice given

6. GTD Organisation Charts

7. Finance

8. Governance

9. Primary Care

10. Operations

11. GP REGISTRAR OOH INDUCTION GUIDE Dr Zubair Ahmad FRCGP GP Trainer GP advisor and GPST Training Lead GTD

12. Learning Objectives & Outcomes  • History of OOH Care • OOH Care Today • Registrar Training OOH • What it involves • How to register • How to book sessions • The Art of Telephone Triage • Role Play / Scenarios • Questions & feedback

13. History of OOH • Doctors were private practitioners, responsible for their own client list • Charged accordingly • Night Journey & Consultation • 4s 6d (1855) = £192.02 (2007) • Excluding treatment • Often payment in kind • Public Insurance • ‘Poor Law’ • National Insurance Act (1911) Ref:P116 The Evolution of British General Practice 1850-1948, Anne Digby

14. History of OOH – Birth of the NHS  • 1948 – Birth of the NHS • Named GP personally and legally responsible for patient care 24 hours / day • Managed either by personal lists, or rotas within practices • Demand increased over the years • GPs on call 5 or more nights / week • 1964 – 39% • 1977 – 9 %

15. Growth of Cooperatives  • 1980’s saw increased use of deputising services and cooperatives • Amendments to GMS mid 90s facilitated this • Venue of consultation • Changes to visiting fees • Shift to co-ops lead to: • Greater use of Primary Care Centres • The increased role of telephone for triage • Decreased exposure to OOH work

16. Carson report & nGMS  • report & nGMS  • ‘Raising Standards for Patients: New Partnerships in OOH Care’ David Carson October 2000 • Single point of access for patients • Build infrastructure to meet proposed QRs • Share information • Record calls • Assure Quality • nGMS contract allowed GPs to opt-out (April 2004) • National Quality Requirements (1 January 2005) • Standards for Better Health (1 June 2005)

17. Quality Requirements  • Regularly report to PCT • Send details of consultation to registered practice by 8am • ‘Special notes’ system • Regularly audit sample of contacts • Regularly audit patient experience • Operate NHS compliant complaints procedure

18. Introduced 1st January 2005 • Manage fluctuating demand • Initial Call • Telephone  Clinical assessments • F2F Clinical Assessments • Ensure appropriate clinician treats patient’s needs, in appropriate venue (inc HV) • F2F Consultation • Interpretation services & services for hearing/vision impaired

19. How is it organised?  • CCG separate commissioner and provider role • Numerous providers • GPs who haven’t opted out (usually coops) • Not-for-profit orgs /For profit orgs (APMS) • PCTs providing their own service (PCTMS) • Others

20. OOH Training  • ‘…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’ OOHTraining for GP Speciality Registrars, Position Paper COGPED 2007

21. Why does a GPST require to have an experience in OOH • Out of Hours experience is viewed by the Deanery, and the RCGP, as an important and necessary educational component of the GP Specialty training year. The skills developed in this are part of the competences that will need to be present in order for your trainer to sign the Trainer’s report.

22. Health & Social Care Act 2012 • “The role of GP’s has changed – now both providers and clinical commissioners responsible for population health” • “Clinical Commissioning about Patients not about GPs” • “General Practice has changed – both in-hours and out of hours” • “The Urgent Care Landscape has changed” • “Biggest change NHS management programme ever” • “Just being a GP/Doctor is not enough” – “Strategic Challenge” • Understanding the wider urgent care system a key COMPETENCY

23. What are Out of Hour Sessions? • These are sessions where you shadow a GP providing medical care or telephone triage and advice. According to your experience and confidence you will be either seeing patients yourself or sitting in with the GPs consulting. You will always be supervised and supported even during telephone consultations where you will have adequate training.

24. Out of Hours for Pennine GPST’s • Out of hours is a mandatory component of GPST training and you must demonstrate competence to your educational supervisor to allow a CCT to be issued.OOH is defined as work undertaken between 18.30 and 0800 Monday to Friday, all day Saturday, Sunday and Bank Holidays.

25. Why do I have to do these? • Simple answer: It’s a training requirement. • But it’s much more than that, as a Trained GP you will be providing Out of Hours services in some capacity or the other. They are an excellent training tool, as you learn in a supervised environment to identify learning needs and put your skills into practice. • Also when you have qualified, the experience gained is invaluable as Out of Hours sessions are a good way to supplement your income.

26. In addition: • You don’t get paid extra for doing these sessions as a trainee, but you can claim for the mileage incurred travelling from your home address to the base station and back on a public transport rate (23 pence a mile – see further guidance on mileage claims guidance in 2009-pennine GPVTS website ). • Of course you are human and like most doctors you may not be particularly enamoured with doing on-call. However you are paid a significant uplift in your salary for on-call and so cannot opt out. You must do out of hours to complete your work place based assessments for the MRCGP.

27. Moreover… • High profile cases and reviews of OOHs • •Need for future GP to be fit for purpose • •COMPETENT and CONFIDENT • •Reviewed – November 2010 • •It is mandatory that GP ST2/3 maintain a portfolio of evidence of achieved competencies and experience

28. OOH Educational Supervision • This is the responsibility of your practice GP Trainer who will undertake overall supervision and management of your out of hours experience. You will need to provide your Trainer with portfolio evidence and formative feedback from your Clinical Supervisor(s) at your OOH provider. We would recommend you do this using the 'Record Of Out Of Hours Session' form as well as the out of hours session learning Log entry in your e-Portfolio under curriculum statement 7, Care of acutely ill People

29. OOH Clinical Supervision • Clinical Supervisors in OOH will complete a record of the session, using the OOH session record sheet, which the GPST must share with the Trainer as evidence of attendance. GPSTs may choose to use an OOH encounter to submit for formal case-based discussion

30. Documenting OOH experience in the e-portfolio • GPSTs should record each of their OOH sessions in their e-portfolio. Each entry has to be tagged before filing against at least one curriculum statement heading. Normally in the case of an OOH session this would be curriculum statement 7: Care of Acutely Ill People.All OOH sessions entered into the e-portfolio must be ‘shared’ with the Trainer who may choose to ‘validate’ some of these as contributing to workplace-based assessment. In this case, the entry will also be tagged against one of the twelve professional competency areas.

31. At the end of the training programme, the Trainer will search for all OOH sessions in the ‘shared entries’ in the e-portfolio (there is a filter facility for this) ensuring that the requisite number have been completed. A declaration is then completed which will appear in the ‘progress to CCT’ section of the e-portfolio.

32. How many sessions do I have to do? • an ST3 needs to do 72 hours of OOH activity (minimum 12 sessions) • The minimum total amount of documented GP OOH activity for a ST1/2 in a 6 month WTE GP Post is 36 hours (minimum 6 sessions)

33. OUT OF HOURS EXPECTATIONS – Deanery Guidance • The number and frequency of OOH sessions to be completed whilst working in a training practice is defined in Form B for each post. This is usually, but not always, at least one session in a 4 week period. • Leaving this until later might reduce your opportunities to complete a sufficient number of sessions toward the end of your post and create problems when an ARCP panel assesses your portfolio. • Complete approximately 1 session per month of GP placement of out of hours care with a clinical supervisor at GTD during your 3 years on the scheme (most GPSTs will have to do between 14 and 18 sessions in total).

34. Types of OOH sessions • GPST needs to cover all aspects of OOH care i.e. Telephone triage, emergency clinic sessions and home visiting.

35. THE GTD PATIENT PATHWAY • Type of Shift (Triage, Treatment centre, Mobile)

36. There needs to be an appropriate balance between telephone consultations and face to face consultations in your out of hours experience. As a guide it might be considered that between a third of your out of hours sessions should focus on telephone consulting. This might vary depending on how much telephone consulting is experienced in the practice in normal hours and the rate of competency progression.

37. Finally you should remember that some out of hours centres and some sessions tend to be busier than others. It may be the case that in order to demonstrate all the required competencies you might need to do more sessions than those specified in form B or more daytime "on call" activity

38. What about LTFT trainees? • As for LTFTTs – yes they do the same number of sessions as FT - but pro rata over a longer time scale. So if they are working at 50% WTE they would do their nominal 6 sessions over a year.

39. What are the different types of sessions and what can I expect in these? • As mentioned, there can be PCC, Mobile ( Home visits) or Telephone triage sessions. There are generally ample opportunities to discuss the cases with the trainers.

40. Primary Care Centre • Sitting in surgeries or consulting under supervision, you can expect to see almost anything • Its important to not forget that although they are usually not that complicated, there is no hard and fast rule. The trick is to develop the skills to deal with these safely. • These cases may be given medication, referred to specialties or A&E or even given a review appointments.

41. Home Visits: • It is best to arrive 10 minutes early at the base and go up to the Team leader and introduce yourself. They will direct you to your trainer and help you settle in. Then you set off with your trainer in a driven 4x4 / Car to do the home visits. You may be doing 6-7 visits in a 6 hour session but the time is mainly taken in travelling ‘far and wide’. You will learn how to do home visits quickly and safely in an OOH setting with limited information. • The patients can be given advice +/- meds, prescriptions or admitted to hospitals as needed. You will be expected to input the data on the laptop (extra ‘Brownie points’ for doing it while the car is on the move – saves time).

42. Telephone Triage: • After having an induction session to the IT system, getting your Smart Card set up and the operating software ( Adastra), you may be ‘sitting in’ for the first session or two just listening to the GPs consult, but eventually you will be consulting and GPs will listen in (on the second headset or speaker phone), and will guide you through the process to a point where you will consult independently. • You will be expected to consult safely, seek help when unsure and input data. The best advice I received was to actually pay attention during the listening in sessions, as this is a great opportunity to learn! Safety netting is ever more important in these sessions.

43. What should I take with me? Mobile kit and Doctors bag • Already provided • Be comfortable with its use • Familiarise yourself with prescribing in general at OOH • Please take the OOH record paperwork, fill these in as you go along and get your trainer to fill in their feedback and suggestions.

44. GPST Training OOH’s 1. Common Emergencies • Chest pain, MI • •CVA, collapse, fits • •Acute Asthma /COPD • •GI bleeds/Acute abdo • •R.Colic/Pyeloneph/retent. • •Ectopic, PID, Bld in Preg • •Obstetric emergencies • •Confus /Intox / psychotic • •Allergy, anaphylaxis

45. GPST Training OOH’s 1. Common Emergencies ….. • •ILL Child • •Infectn./Septica/ Meningiti • •Ortho./ cord comp/Back P • •Acute Eye pain/loss of V. • •Sudden Death • •Paed Emers. – Meningitis /croup/asthma/febrile con. /Gastro-enteritis. / dehydration / NAI • •MH crises/Suicide Risk A. / MH Act sections • •Basic Life Support • •Emer Drugs & equipment

46. GPST Training OOH’s 2. Organisation of the NHS URGENT CARE/OOH’s - local & national • •Processes local & national • •Roles & responsibilities – GP practices, OOH’s providers and PCT’s • •Impact of Emergencies & Health initiatives – procedures for e.g. CMO cascade, alerts • •Outbreaks – infect dx, flu, / Winter bed crisis • •Awareness of Communications OOH’s & IT systems (Connecting for Health- Best Practice Design) • •Towards paperless systems OOH’s – on the telephone, at PCC or at home (via cars) ; NB decision support systems e.g CAS, NHS Pathways

47. GPST Training OOH’s 3. Appropriate Referrals • •Aware of range of professionals & facilities • •Courtesy, Effective Communications, prompt & appropriate referrals – clear documentation & follow up arrangements • •Respect other roles & skills & work with ambulance / paramedics and others (cf ECPs , ENPs, Palliative Care staff, DNs)

48. GPR Training OOH’s 4. Communication & Consultation Skills • •Telephone consultation skills • •*Triage skills (cf Prioritisation / Streaming) • •Understanding - Patient centred (models) – e.g bad news / absence of visual or non-verbal cues – limitations of telephone consultations • •Team working – need for effective communication • •*changes with NHS 111

49. GPR Training OOH’s 5. Individual Personal Time & Stress Management • Time & workload management • •PRODUCTIVITY (4 FTF; 2-3HV; 8-10 TA / Hour) • • Problem solving & prioritising • • Difficulties of working antisocial & long hours – recognise their limitations • • Strategies to manage stress, prevent burnout and maintain good health • • Duties & responsibilities – health, safety and performance of colleagues

50. Standards for OOHs Care • National Out of Hours Quality Requirements (13) • •Initially Dec 2004 • •Revised July 2006 (no changes) • •For ALL Out of Hours providers