Out-of-Hours Care

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Out-of Hours Care
Tunbridge Wells VTS Pembury 04.09.13
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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
AE/urgent care /OOH in Canada 6 years OOH in
UK robin.warshafsky_at_IC24.nhs.uk
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Who are we? Integrated Care 24

• Formed by the mergers of
• Seadoc Brightdoc (April 2005) -gt 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)

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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
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IC24 TEAM
Rota Administrators (most important people, be
nice to them!) West Kent Tracy Flynn, Julie
Rice 01227 285937 wkadmin_at_IC24.nhs.uk East
Sussex Kate Orton 01233 505517 Kate.orton_at_IC24.nh
s.uk On-line session bookingRota Master
www.IC24.com Rota administrator will provide you
with log in name/password
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IC24 TEAM
Locality Operations Managers West Kent Donna
Springate donna.springate_at_IC24.nhs.uk 01227
285931 East Sussex Tracy Wickham
tracy.wickham_at_IC24.nhs.uk 01233 505528 Associate
Medical Directors West Kent Meriel Wynter
meriel.wynter_at_IC24.nhs.uk 01227 285932 East
Sussex Robin Warshafsky robin.warshafsky_at_IC24.nh
s.uk 01233 505531

07918 642946
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What is OOH for?

• Assess all patients who contact us, but not to
  see them all, 1830 and 0800 weekdays, all
  weekend, and public holidays
• Therefore, OOH provides the bulk of primary care,
  in terms of time, ie gt70 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?

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

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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
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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
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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
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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.  
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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 gt Competent -gt Proficiency

Assessment of Competency responsibility of the
Trainer supported by evidence supplied by GP StR,
documented systematically in ePortfolio feedback
from Clinical Supervisor
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CLINICAL SUPERVISOR
Duties clinical governance to ensure quality of
care and patients safety supervision of a GP
StRs 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
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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
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PATIENT FLOW THROUGH THE SYSTEMCLEO
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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!
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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)
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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.......
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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

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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.

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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

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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
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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
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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
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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, didnt get
  it
• consider yourself for simple UTI, mild early
  pregnancy bleeding without pain,
  non-sinister low back pain, etc

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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!)

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THATS IT!

• Thank you
• Questions?