Out-of Hours Care

1. Out-of Hours Care Tunbridge Wells VTS Pembury 04.09.13

2. Who am I? 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

3. 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)

4. 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

5. 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

6. IC24 TEAM Locality Operations Managers West Kent Donna Springatedonna.springate@IC24.nhs.uk01227 285931 East Sussex Tracy Wickham tracy.wickham@IC24.nhs.uk01233 505528 Associate Medical Directors West Kent Meriel Wynter meriel.wynter@IC24.nhs.uk01227 285932 East Sussex Robin Warshafsky robin.warshafsky@IC24.nhs.uk01233 505531 07918 642946

7. 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?

8. NEED TO KNOW OOH Training for Registrars CLEO (Clinical Excellence Online) 111 – NHS Pathways - DOS

9. 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

10. 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

11. 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

12. 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

13. 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.

14. 6 Key Competencies • 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

15. 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

16. HOW TO GET HELP! 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

17. PATIENT FLOW THROUGH THE SYSTEMCLEO

18. CLinical Excellence Online • 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!

22. 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)

24. TAKING A CALL Read the call handler note Assess urgency Check the history tab See if there is a special patient note- palliative (Share My Care) Check recording process Do the business Note Save as.......

25. APPOINTMENT AT A PRIMARY CARE CENTRE 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”

26. 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.

27. DISHING OUT DRUGS 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

28. REQUEST FOR REPEAT Rxs 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

29. 111 - NHS PATHWAYS 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

30. THE WORLD OF 111 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

31. THE WORLD OF 111 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

32. THE WORLD OF 111 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!)

33. THAT’S IT! • Thank you • Questions?