Dr Nick Pendleton

About Bolton Out of Hours Service Bolton was the first region in the UK to organise itself into a Cooperative to share the burden of Out of Hours work and improve GPs working lives GPs still did Saturday morning surgeries and paid the cooperative per patient seen at other times in the Out of Hours Period. A lot had a surgery on-call rota for evenings and weekends and only used the service overnight

The Opt-Out Offer In 2004 all GPs in the UK, were asked whether they wanted to sacrifice 6% of their income to not have any out of hours responsibility. (Nearly) Everyone said ‘YES PLEASE!’ In January 2008, an Out of Hours Service which had been commissioned with Bolton PCT as the provider opened at Waters Meeting Health Centre

What Happened Next? A very well resourced Out of Hours Centre with full time clinical leadership and development support from the PCT. Very good access for patients: a responsive and available service. Often patients can be offered an appointment in an hours time. Also Walk-in Centre seeing up to 300 patients a day in the town Centre.

The Urgent Care Mantra Government’s message at that time was: ‘Patients should be able to see a GP when it suits them, if they think its Urgent, then it is Urgent!’ Urgent is defined by the patient!

So, whats wrong with that? Any guesses?

NHS

LORD DARZI ‘Transforming Community Services’ Which meant: Existing Services Must Be Merged

WHY? A cheaper model Economies of scale Fewer staff needed Opportunity for ‘Service Re-design’

So what? Bolton PCT Provider Arm Services which included the Out of Hours Service, Merged with Bolton Hospitals Foundation Trust last year. GP Out of Hours Service currently being managed by the local hospital, and possibly sited in A&E in the future...

CLOSURE OF WALK IN CENTRE

? Are these changes good or bad? What are the potential benefits? Who are the potential winners? Who are the potential losers? The truth is its very complicated! Interesting times! Especially for GP Commissioners?

Will this affect the training? Hopefully not this year! ‘Change happens very slowly in large organisations’ May affect next years group & training will probably look & feel different Will affect you if you want a job in OOHs

Your Out of Hours Training The year ahead

‘Why do we need to do OOH sessions?’ Different but complementary skill set Dealing with limited information and uncertainty Risk management and Safety-Netting Dealing with acutely ill people and managing emergencies

Why do we need to do OOH sessions? Value in having Clinical Supervision and Educational Opportunities outside the practice Understand organisation of Out of Hours care Appreciate existence of other services locally Many work with the service when qualified

Feedback from a Previous Group I found the graded exposure extremely useful and vital in confidence building. I enjoyed the one on one training and found the teaching to be of an extremely high standard. The trainers were enthusiastic and gave really good feedback. Was nice to get honest and constructive feedback. These sessions have really helped with my confidence. Really well organised course probably one of my favourite parts of the ST3 year

The Timing of CSA and OOH Sessions Some people fed back that they found having OOH sessions close to the CSA was too pressured. However, having a 4 hour session in OOH in the week before the CSA was felt by some to be useful. Tell us when your CSA is as soon as you know We will always try to accomodate you even if we do not get it right first time!

Structure of the Sessions 12 sessions: 6 before Christmas & 6 after 1 st 6 sessions: 1 : 1 supervision, 2 x at base consulting (4h), 2 x triage (4h), 2 x visiting (6h) 2 nd 6 sessions: 1 : 2 supervision, moving towards working autonomously

Who are the Trainers? Local GPs Some are GP trainers Some are not but have an interest in teaching Wide range of experience and background Several are specialists in GP Education and/or Urgent Care Talk to them, ask them questions, listen to them, challenge them! Thank them.

Educational themes 1. Ability to manage common, medical, surgical & psychiatric emergencies 2. Understanding organisation of NHS OOH care 3. Making appropriate referrals to hospital and other professionals 4. Demonstrating communication & consultation skills required for Out of Hours Care 5. Individual personal time and stress management These are the 5 key competencies required for OOH care

Telephone Triage Why do we do it? How is it different to face-to face consultation? What are the risks? How do make it safe? In a nut shell: Identify yourself and the service you represent, quickly establish rapport & identify whether this is a life threatening emergency through the use of open & closed questions, decide the best course of action for the patient & the service. Record your decision

Safety- Netting What is it? High Risk Clinical Situations 1. The diagnosis is uncertain and the differential diagnosis includes serious illness, particularly illness that can progress very rapidly. 2. The diagnosis is certain but carries a known risk of complications. 3. The patient (for reasons of age or co-morbidity) has an increased risk of serious illness or complications.

Be Honest & Be Specific If you are uncertain about the diagnosis, then tell the patient/parent Tell them exactly what to look out for Say what to expect about the time course Tell them how to seek help, record the advice given Adapted from: ‘Diagnostic Safety-Netting’, Almond, Mant & Thompson. BJGP, Nov 2009

Prescribing in Out of Hours Think about: What information you need to prescribe a drug safely What do you need to tell the patient or relative about the medication you have prescribed? Is there a local formulary? eg. Antibiotics What should we do about requests for supplies of repeat medication? What systems are in place for regulating the prescription of Controlled Drugs? Is it necessary to prescribe anything at all in the first place?

Record of Out of Hours Sessions LEAVE 20 MINS AT THE END TO DEBRIEF AND DOCUMENT: TYPES OF CASES SEEN : SIGNIFICANT EVENTS : (including clinical incidents, complaints & compliments) COMPETENCIES DEMONSTRATED : LEARNING NEEDS IDENTIFIED : DEBRIEFING NOTES FROM CLINICAL SUPERVISOR :

IMPORTANT! Save one copy of your record sheet in your named folder on the shared drive This allows clinical supervisors to have access to information about your previous sessions and builds up a library of the experience you have had: any common learning needs, any problems? And Upload one copy to your e-portfolio Dr ST eportfolio

Sharing of Learning Use the SHARED LEARNING folder to communicate things you have learned that may be of use to other trainees. Interesting or useful new facts learned Unusual or striking clinical scenarios Information about procedures or systems that you have spent time and effort working out how to use, and that may benefit others Telephone numbers or service contacts. Reference charts Significant events and incidents that we all can learn from (these should also be shared and discussed with your session supervisor and clinical lead)

Key Messages High support at first, moving to autonomous working Clinical supervisor always available 1:1 then 1:2 Ask questions! Find out where things are and how things work If there are any problems or worries then let us know Let us know about planned leave and the CSA If there are concerns about you then we will discuss them with you and your trainer: knowledge level, skill level or attitudinal/professionalism. !

Contact details NHS Bolton Out of Hours Service, Waters Meeting Health Centre, Bolton, BL1 8TT. Patients Tel Staff Tel GP Clinical Lead for Bolton Out of Hours Service Dr Sohail Abbas: Rota and Programme Support Staff Lead: Marj Broughton.

Departmental Orientation Home visits : Laptops, Drugs, Equipment in Cars Other Staff including Advanced Practitioners/triage nurses Emergency equipment : O2, masks, defib, nebuliser Location of emergency drugs Other equipment; ECG, Sats monitors Child Safeguarding e-package Clinical IT System and Appointment System

Clinical IT system (Adastra) The purpose of having 1:1 supervision is so that you can be shown how to use the computer, ask questions and not feel out of your depth! These slides and other information is on the Bolton Medical Learning Zone Website: ANY QUESTIONS?