Urgent Unschedule Care (UUC)

As a GP, you will need to be capable of handling urgent and emergency presentations who present in an unscheduled manner. By unscheduled, we are referring to patients who want to see a doctor acutely (i.e. they did not book into a routine scheduled appointment). There are a variety of settings in which patients present urgently in an UNSCHEDULED manner.

• Duty Doctor for the surgery (i.e. on-call surgeries)
• Out of Hours Emergency GP Centres
• GP centre attached to A&E departments
• GP Extended hours work where the appointments are for acute unscheduled problems and not routine.
• Other primary care emergency/acute services delivered within a secondary care or community care provider.

So, don’t just rely on one of these places for gathering evidence for your engagement in Urgent Unscheduled Care. Your experience (and evidence) should be from a mixture of working with these services.

GP trainees must ensure they have

1. completed all due employment processes prior to undertaking both observational and clinical sessions
2. had an enhanced DBS check
3. met occupational health requirements and
4. undertaken required safeguarding training.

The Clinical Supervisor is trained and selected appropriately to be responsible for overseeing a specified trainee’s clinical work and providing constructive feedback during their placement. You should have a clinical supervisor who you can refer to for every clinical session you do – for both urgent and routine work. So, when your doing on-call for your practice, be sure to find out who your clinical supervisor is and make sure you touch base with them.

It might be a different doctor every time you do in-house practice on-call. During OOH sessions, you will be told who your Clinical Supervisor is. They will closely supervise you, unless they feel you are good enough to start working a little more independently. Even then, you should always ensure every clinical session is debriefed with them.

GP trainees undertaking direct, near and remote sessions should have an identified individual who will, (for the duration of that session) have the lead responsibility for ensuring the safety of both the trainee and patients and who has been appropriately trained.

• Clinical supervisors should raise concerns where appropriate.
  • For clinical competence concerns,
  • Even if the trainee fails to attend a session.
  • They should know who to contact and the appropriate pathways to raise concerns.

Remember, never act beyond your capabilities. If you feel unsure about something or feel something is beyond your expertise, seek advise from your Clinical Supervisor. Patient safety is paramount.

You will be able to use experience from the following placements to contribute towards the evidence to showing that you are developing capabilities in Urgent Uscheduled Care work.

• A&E
• Paeds (esp Paediatric Emergency Assessment Units)
• Medical Assessment Units
• Psychiatry on-call

HOWEVER, this alone WILL NOT be enough to show that you have addressed the full range of urgent, unscheduled and out-of-hours capabilities.

• In a nutshell…
  • You MUST engage in GP Out-Of-Hours work
  • You MUST engage in GP in-hours emergency work (i.e. on-call)
  • These two things will provide most of your evidence for capability in UUC work
  • To supplement that evidence further, you can use experience from A&E, Paediatric Assessment Units, Medical Assessment Units, and Psychiatry on-call. To do so, you can’t just reflect on your experience. There needs to be some FOCUSED discussion between you and the clinical supervisor about your UUC experience in terms of one or more of the Professional Capabilities and contextualised to your future work as a GP.

No! Some can be done in-hours (for example on-call duty doctor) but other sessions need to be based out-of-hours. Why? You need to show that you are capable of working in isolation when there is a relative lack of supporting services (which is often the case in out-of-hours work than in-hours work).

Whilst it is recognised that knowledge and skills needed to develop urgent and unscheduled capabilities may be gained “in hours” and in varying secondary / community / urgent care services there remain particular features more likely encountered in a primary care urgent care setting that require specific educational focus.

Write your UUC experience from the aspect of one or more of the 13 Professional Capabilities. The 13 Professional Capabilities have been grouped into 5 Professional Capability AREAS.

1. RELATING TO YOU AND OTHERS

• Fitness to Practice
• Communication Skills
• Ethical Approach

2. CLINICAL KNOWLEDGE, SKILLS & DECISIONS

• Data Gathering
• Clinical Examination & Procedural Skills (CEPS)
• Making Decisions
• Clinical Management

3. COMPLEX & LONG-TERM CARE

• Managing Medical Complexity
• Working with Colleagues & in Teams

4. ORGANISATIONS & SYSTEMS

• Perfomance, Learning & Teaching
• Organisation, Management & Leadership

5. THE PERSON & COMMUNITIES

• Practising Holistically & Promoting Health
• Community Orientation
• Safeguarding

Before qualifying as a GP, you need to show that you have the requisite capabilities to work across the full spectrum of primary care as delivered in all four nations of the UK.

In the past, GP trainees were expected to do 18 sessions over the 18 months of General Practice. That equated to roughly ONE session per month – each session lasting 4-6 hours.

However, in their latest guidance, the RCGP is moving away from number of sessions. Instead, they want you to do enough sessions to provide adequate evidence of capability in all of the above 5 Professional Capability Areas (or 13 Professional Capabilities).

“Time served” should not be seen as the model against which to define the attainment of Urgent & Unscheduled Care capabilities.

The only exception to this new guidance is if you have a contractual requirement to complete a certain number of OOH sessions – your TPDs will be able to tell you.

However, we know trainees like to have numbers. So, whilst we would like to make it clear that there is no mandatory minimum number of OOH, on-call duty or other emergency sessions that the RCGP expect you to do, if you must have numbers, think about 48 hours. If you can provide ample evidence for all Professional Capability areas in less than this – then that’s fine too (but only do so if you are sure). Remember, it’s more about providing a good amount of evidence for each of the Professional Capability areas. Providing just one or two pieces of evidence for each area is UNLIKELY to be enough.

As the unscheduled care capabilities are new, we suggest that trainees that have already done ST1 prior to their induction still do around 48hrs in ST3 as a way of linking enough evidence to these competencies for their final ARCP panel.

You must engage in urgent and unscheduled care in all posts that are based in General Practice (including GP posts in the ST1 or ST2 stage). You should space them all out and not do them all in one go towards the end.

What you might do at different ST stages is outlined below.

ST1:

1. Discuss how OOH works, on-call duty doctor, other emergency service models.
2. Shadow on-call duty doctor in practice and reflect on this.
3. Attend induction to OOH courses.
4. Attend telephone triage courses.
5. Attend Urgent Care-orientated Consulting Skills courses.
6. Do some actual OOH/On-call sessions – seeing patients – must be directly supervised face-to-face. The trainee does not take final clinical responsibility for any patient: this rests with the clinical supervisor. This is currently not possible in Sheffield due to low availability of shifts.

ST3:

1. The GP trainee moves gradually from supervised to consulting independently.
2. Must receive appropriate formal induction to OOH services.
3. The clinical supervisor should be physically near by. This means that the trainee and patient have timely access to a nominated clinical supervisor who can directly assess the patient in person.
4. Later on, perhaps in ST3-2 (as the GP trainee gains more experience and confidence and has had enough near-by supervision sessions), the clinical supervisor can decide to be available remotely (via telephone or other appropriate interface). However, this is not a required achievement prior to CCT. This should only be done IF the clinical supervisor has faith in the abilities of the GP trainee to work a bit more independently. This decision and responsibility rests with the Clinical Supervisor. There should be a clearly defined process for monitoring the safety of trainees when working remotely visiting patients at home or in other locations.

– All these sessions are to be counted towards “clinical” sessions in the weekly timetable.

Use the form provided by the RCGP to log your learning with respect to each Urgent Unscheduled Care session you are involved in. The link to the form is provided below.

We need trainees to monitor their own working hours to ensure they are not working long shifts and are getting enough rest. Not getting enough rest and working long shifts can have an adverse effect on thinking and decision-making – it is crucial to protect this, especially in the urgent care setting. Patient safety is paramount.

• That the employed doctor (GP trainee, salaried doc etc.) works no more than an average of 40 hours each week (excluding lunch hour and time taken to travel to and from work). The average is worked out over a period of 6 months (26 weeks): i.e. divide the number of hours worked over 6 months, by 26 weeks.
• They must get 11 hours continuous rest in a 24 hour period: for instance, if they do an evening shift on top of their day time work.
• They must get 24 hours continuous rest in 7 days (or 48 hrs in 14 days): for instance, if they do extra work at weekends.
• They must get a 20 minute break in work periods of over 6 hours.