The Office of the SHAs, Southside, 105 Victoria Street, London SW1E 6QT
Out of Hours (OOH) Training for
GP Specialty Registrars
Position Paper 2007
This revised document updates the position paper issued by COGPED in December 2004 which provided guidance on the way in which General Practice Specialty Registrars (GP StRs) gain experience in out of hours (OOH) care. This update reflects the changes in regulation of GP training, the development of the GP curriculum, the new Membership examination of the Royal College of General Practitioners (MRCGP), and GP StR portfolio, the increasing time spent in the general practice component of training programmes and the differing structures and pathways in out-of-hours and unscheduled care.
The Committee of General Practice Education Directors (COGPED) has consulted with the main stakeholders in this process, including the General Practitioners Committee (GPC), Royal College of General Practitioners (RCGP), provider and commissioning organisations, to seek and incorporate their views throughout the development of this paper.
In the months and years ahead COGPED will continue to liaise with representatives from the GPC, the Registrar subcommittee of GPC, RCGP, providers of OOH services, NHS Employers, Primary Care Organisations (PCOs) and others to review and consider issues of importance in the future for OOH training of GP StRs in the light of experience and further development of the OOH services
Following the introduction of the new GMS contract GPs were able to transfer their responsibility for OOH work. From 31 December 2004 PCOs took full responsibility for ensuring effective OOH provision, except in very exceptional circumstances. A substantial majority of doctors no longer undertake OOH work. However, many GP trainers and their colleagues from training practices continue to provide clinical supervision out-of-hours, and additionally other doctors working for OOH providers have received training to fulfil this role.
The strong view of all the organisations contributing to this document remains that 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.
It is the responsibility of the Postgraduate Deaneries to ensure that GP Speciality training provides the experience and assessment of generalist competencies, and for the Competent Authority to be satisfied that all generalist competencies have been successfully assessed in order for a Certificate of Completion of Training (CCT) to be issued.
The way in which general medical services are delivered continues to evolve. The development of emergency care pathways and services for both out-of-hours and unscheduled care provides a variety of learning opportunities and environments for
GP StRs to gain experience and competence in the care of acutely ill people.
Whilst further restrictions on working hours under the European Working Time Directive (EWTD) will come into effect in 2009, it is unlikely that this will impact significantly on the training for GP StRs.
The ideas and competencies presented in this paper were initially espoused by McLean and Houghton and subsequently incorporated into the GP Curriculum. These are fully endorsed by COGPED. In order to develop the OOH training programme COGPED has facilitated the involvement and agreement of all the appropriate organisations and stakeholders in the provision of OOH primary care.
Out of Hours service: The new General Medical Services contract (nGMS) has defined the normal working day for general practice to be between 08.00 and 18.30 on all weekdays except public holidays. Thus, OOH is defined as that work undertaken between 18.30-08.00 and all day at weekends and on public holidays. However, for the purpose of this paper, OOH is also taken to mean the type and style of working that takes place in this time.
This paper recognises that the processes for providing general practice and primary care, both during the normal working day and outside, are continuing to evolve and these processes provide different models of working, requiring different knowledge and competencies by GPs. The ability to undertake efficient yet safe telephone triage is one example.
It is important to make clear that these do not just refer to the management of emergencies, but also to the experience of dealing with patient contacts in a different quantity and context to the normal working day. In other words, emergency care is a feature of both in-hours and out-of-hours work but there are particular features of the out of hours period, such as isolation, the relative lack of supporting services and the need for proper self care, that require a specific educational focus.
Educational supervision of the GP StR: This is usually undertaken by the GP Trainer who undertakes overall supervision of the individual’s learning experiences, manages the process, commissions learning opportunities and is responsible for the delivery of formative assessment, workplace-based assessment and preparing the GP StR for the other elements of the MRCGP examination. Others may provide the educational supervisor with data to inform these processes.
Clinical supervision: may vary according to the learning situation. At its most basic, clinical supervision is a clinical governance issue ensuring the quality of care and patients’ safety. In this context it is taken to mean this, as well as the supervision of a GP StR’s learning and experience. In some areas the clinical supervisor is termed an associate or assistant trainer (and in secondary care a consultant trainer).
It is desirable for the clinical supervisor to have additional skills to that of being a proficient professional and these will include the ability to teach, observe, assess and feedback to learners. The clinical supervisor could be a GP who is beginning the process of becoming a GP Trainer, or one who has recently retired, or a suitable GP who has had appropriate training or suitable GP who has had previous educational experience or who has received specific training as a supervisor. When it comes to the delivery of training in specific skills in particular, clinical supervisors need not necessarily always be GPs. However, with the overall context of the GP StR’s training firmly in mind, Postgraduate Deaneries will want to ensure that experienced GPs retain an appropriate and significant input into OOH training for GP StRs. Those doctors already approved as GP Trainers by their Postgraduate Deaneries will be automatically deemed qualified to supervise GP StRs.
Postgraduate Deaneries and some OOH providers have delivered educational packages or courses to enable GPs to develop the skills required for effective clinical supervision. There will be an ongoing need for such interventions to maintain the pool of clinical supervisors. Deaneries as well as clarifying the requirements of the job for the OOH provider organisation have a quality assurance function and should monitor the competencies of the clinical supervisors for this role,
Formal lines of communication between GP trainers, OOH clinical supervisors and others involved in clinical skills training are necessary to deliver continuity of information and feedback to ensure the validity of the trainer’s assessment of each GP StR.
The Assessment System: The formal assessment of the GP StR remains the responsibility of the Trainer, supported by evidence supplied by the GP StR, documented systematically in their portfolio as well as feedback from the clinical supervisor. Such evidence should include their own reflections on clinical encounters, professional conversations with their clinical supervisor or other naturally occurring evidence. GP StRs may choose to use an OOH encounter to submit for formal case-based discussion.
Royal College of General Practitioners View
The RCGP has reiterated the previous Joint Committee for Postgraduate Training in General Practice (JCPTGP) opinion that Certificates of Completion of Training license the holder to work in any capacity, unsupervised, in UK general practice and that GP training programmes should continue to be designed to equip GP Registrars to deal with all work that currently forms part of UK general practice. The opinion of the College is that GP StRs should continue to be trained in OOH work, as this remains a core part of the GP’s role.
The GP trainer should evaluate the portfolio evidence and formative feedback from clinical supervisors in the OOH organisation, validating competencies when satisfied that these have been achieved, and confirming that the GP StR has undertaken the required level of exposure commensurate with the length of the GP component of their training programme.
In some instances the demonstration of some of the skills and competencies needed for OOH care, for example those exhibited in undertaking telephone triage, could also take place during the normal working day, and could be validated by the GP trainer from personal assessment.
Expectation of GP Postgraduate Deaneries
The aim of the training is to enable GP StRs to learn, develop, practice and maintain their competencies in OOH working
The Postgraduate Deaneries will expect all GP registrars to obtain the necessary OOH experience and training to achieve the competencies both as described in the GP curriculum and required for the MRCGP examination. Where the practice has not transferred responsibility for OOH services, responsibility for providing the experience and supervision of OOH training for the GP StR remains with that practice. However, where training practices have no longer responsibility for OOH services, delegated arrangements for supervision should be made with the OOH service providers, with locally agreed criteria with the Directors of Postgraduate GP Education for training and the appointment of clinical supervisors. An approved trainer providing services for an OOH provider could supervise his or her own and/or other GP StRs.
The evidence gathered by the GP StR in their portfolio and competencies achieved, should be formally reviewed by their educational supervisor on a six monthly basis, and form part of the Annual Review of Competence Progression process.
As an indicative benchmark of the time required to achieve, and maintain the competencies, it is likely that at least one session, at a suitable clinical intensity, per month will be necessary in an appropriate and negotiated combination of learning environments. In some instances, the GP Trainer, in agreement with the GP StR, may indicate that additional time in this experience is required so that the competencies can be signed off. However, as training becomes increasingly focussed on the acquisition of competencies, arbitrary definitions of time as markers of completion of any part of training will become less reliable and relevant, although it is likely that a defined period of training in OOH will be retained for the foreseeable future.
GP StRs will be responsible for keeping completed their portfolio of experience and reflection on all sessions that they attend as evidence of their competencies in OOH training.
The key out-of-hours competencies and their assessment
GP StRs should demonstrate competency in the provision of OOH care. The overall responsibility for assessment of competency is with the GP Trainer but GP StRs have duty to keep the record of their experience, reflection and feedback in the competency domains.
The six generic competencies, embedded within the RCGP Curriculum Statement on ‘Care of acutely ill people’, are defined as the:
1. Ability to manage common medical, surgical and psychiatric emergencies in the out-of-hours setting.
2. Understanding of the organisational aspects of NHS out of hours care.
3. Ability to make appropriate referrals to hospitals and other professionals in the out-of-hours setting.
4. Demonstration of communication skills required for out-of-hours care.
5. Individual personal time and stress management.
6. Maintenance of personal security and awareness and management of the security risks to others
Provision of Out-of-Hours Services
There are a number of organisations involved in the delivery of OOH and unscheduled care services, including GP co-operatives, commercial services, NHS Direct, NHS 24, nurse triage, urgent care centres, minor injury centres, primary care walk-in centres, GPs embedded within A&E departments and some remaining individual practices and practitioners. The model of service provided is of necessity varied; however there is a need for partnership and collaboration between all agencies at the local level. This will continue to be driven and shaped by national quality standards processes. It is expected that services will follow care pathways and patient journey/s, delivered in multi-professional settings, which will include GPs, nurses, paramedics, and A&E staff etc.
The various organisations provide a range of learning environments for GP StRs to gain experience and achieve competencies and should be expected and able to offer training for GP StRs.
The role of Primary Care Organisations
PCOs are required to secure OOH services, either by commissioning from appropriate organisations or consortia of organisations or, although less frequently following recent re-organisation, by direct provision. The PCOs also have responsibility for the recruitment of competent GPs (as generalists who have adequate experience in the provision of OOH services) to serve in this area. Although the consensus opinion at present is that the element of the OOH service best provided by GPs is that derived form their training and experience as clinical generalists it is inevitable that future developments will occur and PCOs might consider the development of practitioners with special interests, including GPwSIs, in the area of OOH provision, not only to enhance the quality of the service but also as part of the overlying strategy for the retention of GPs.
PCOs should ensure that the OOH service includes the provision of appropriate training for GPs in training. This was clarified in explicit guidance from the Department of Health to Chief Executives of PCOs and SHAs
‘PCTs will need to discuss with their local GP Postgraduate Deanery the OOH training opportunities that are needed for GPRs and take steps to ensure they can be delivered through the new arrangements they are putting in place to provide OOH services. Arrangements need to be in place as soon as training practices opt-out. Advice and help will be provided by Deaneries’
The PCOs are encouraged to work closely with the Postgraduate Deaneries in establishing clinical and educational governance standards for training in OOH and assuring the quality of training in the OOH organisations.
The role of Postgraduate Deaneries
When commissioning services, PCOs must reassure themselves that the provider will not only deliver high quality OOH care, but also has the capacity and capability to deliver the required training for GP StRs. They will also need to ensure that the provider complies with the quality assurance processes of the GP training programme delivered by each deanery. Appendix 1 to this paper provides guidance on standards for clinical and educational governance for training in OOH.
The deanery will need to work with PCOs and providers to develop mechanisms to ensure that suitable quality training is available and that incentives are in place to encourage and support the provider in delivering and monitoring the training.
The quality assurance of the GP training programme in OOH will include assessment of:
• The induction processes for the initial exposure of GP StRs training in the OOH setting
• The placement’s level of workload, educational facilities and the overall quality of the learning environment.
• The clinical supervisor’s ability (which must include skills in observation and the ability to give feedback).
• The capability and capacity of the OOH organisation in delivery of the clinical supervisory process.
It is mandatory that GP StRs maintain a portfolio of evidence of achieved competencies and experience which will include their own reflection on clinical encounters, professional conversations with and feedback from clinical supervisors and any formal or informal comments made by others appropriately involved in the process.
In order to support the skills of the OOH clinical supervisors Postgraduate Deaneries should provide programmes of training and skills development for them. The Postgraduate Deanery, in consultation with PCOs, may provide on going development programme as part of professional development of clinical supervisors.
Documenting OOH experience in the e-portfolio
GP StR’s are asked to record each of their OOH sessions in the e-portfolio. The portfolio necessitates that each entry must 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. The ‘OOH session’ learning log entry in the e-portfolio will prompt the GP StR with a number of set entry fields.
Clinical supervisors in OOH will complete a session feedback sheet (see Appendix 3) which the trainee must share with the trainer/educational supervisor as evidence of attendance.
All OOH sessions entered into the e-portfolio must be ‘shared’ with the educational supervisor. In particular circumstances, the supervisor 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 12 professional competency areas.
At the end of the training programme, the educational supervisor will search for all OOH sessions in the ‘shared entries’ in the e-portfolio (there exists a filter facility for this) ensuring that the requisite number have been completed. A declaration by the educational supervisor is then completed which will appear in the ‘progress to CCT’ section of the e-portfolio.
Failure to complete the requisite number of sessions will lead to a face-to-face deanery ARCP panel review.
The role of GP Trainers
GP Trainers should make arrangements, as part of their initial educational planning with the GP StR, for their sessions with the OOH service. The Trainer should consider the range of learning environments and opportunities locally that could deliver the required competencies. Examples might include:
• Observation of NHS Direct
• Undertaking a course in telephone triage
• Updating CPR skills
• Participating in a shift with a team of para-medics.
• Working with a GP in A&E
• Working in an OOH / Walk-in Centre
• Undertaking home visits for an OOH service
Sessions should take place at a time agreed by the trainer and GP StR, following a clear evaluation of the GPR’s level of skill and competency and their learning needs.
GP Trainers should ensure that they debrief their GPR following their OOH session and assess not only the learning made, and further areas for development, but also the quality of the experience of the OOH session provided to the GPR.
GP Trainers should regularly re-evaluate the level of supervision required by the GP StR and confirm this with the OOH provider. This will be dependent on the learning environment but the following structure is suggested:
Direct supervision the GP StR is supervised directly by the clinical supervisor [red] and takes no clinical responsibility.
Close supervision the GP StR consults independently but with the clinical [amber] supervisor close at hand e.g. in the same building.
Remote supervision the GP StR consults independently and remotely from the
[green] clinical supervisor, who is available by telephone. An example of such a session would include a session ‘in the ‘car’ supervised by another GP ‘at base’.
GP Trainers should, with the GP StR, review the portfolio on a regular basis and, taking into consideration other feedback from clinical supervisors, validate competencies that have been achieved.
The Responsibilities of GP Specialty Registrars
GP StRs are responsible for organising their sessions with OOH Providers and should ensure that the required number of hours are achieved commensurate with the duration of the GP component of their training programme.
GP StRs should work in the OOH services, under supervision, in order to gain competence and confidence in the delivery of these services as a necessary part of becoming registered as GPs. The work of GP StRs in acquiring OOH competencies will be as part of their normal contract of employment.
GP StRs are responsible for maintaining a portfolio of evidence. For OOH such evidence should include their own reflections on clinical encounters, professional conversations with their clinical supervisor, relevant courses or reading and other naturally occurring evidence. GP StRs may choose to use an OOH encounter to submit for formal case-based discussion
The Role of the OOH Service
OOH providers will continue to require service input from doctors trained in, and certified for general practice work. Each OOH provider is different and faces different challenges which impact on their ability to support and deliver OOH training. One example is the differences between urban and rural settings. It is essential that the deaneries and PCOs work with the providers to understand the challenges which face them all. The OOH provider is in a good position to provide a range of training opportunities and the deaneries must work with them to develop this resource.
OOH providers should offer appropriate induction to the service including use of the computer system and any specific in-house protocols. Clinical supervisors should be trained and provide the appropriate level of supervision for the GP StRs level of experience, competence and confidence. OOH providers should also ensure that clinical supervisors have adequate time to debrief the GP StR. Appropriate documentary and oral feedback should be provided to both GP StR and GP Trainer. In order to support this, the OOH clinical supervisors will receive appropriate training commissioned or provided by the Postgraduate Deaneries.
Whilst it is recognised that there are financial implications to OOH providers in delivering appropriate induction, training and clinical supervision, the more experienced GP StR can make a significant contribution to service at no cost to the provider The OOH provider in delivering a high quality learning experience has an opportunity of promoting participation in OOH work to the future workforce.
The role of the PCO
In commissioning and quality assuring OOH services the PCO needs to ensure that each OOH provider is able to provide the necessary training opportunities, has a sufficient number of trained clinical supervisors in their organisation and that these supervisors are appropriately trained and supported. These provisions should be reflected in service level agreement with the provider. The PCOs are encouraged to consult with their GP Postgraduate Deaneries on standards for clinical and educational governance in OOH training.
Sessions in Out of Hours
The number of sessions worked by a GP StR to acquire the necessary competencies will vary according to the number of patients covered but, in an urban setting, is likely to require a indicative benchmark of a four to six hour session every four weeks adjusted in other settings on a pro rata basis. There are variations in the population numbers and patient demographics served by any one OOH organisation, therefore each GP Trainer and each Postgraduate Deanery should, focussing on the learning needs and acquisition of the required competencies, assess the provision of experience for each individual GP StR.
The educational value of experience gained in putting acquired competencies into practice is recognised and the purpose of having an indicative number of sessions worked by GP StRs, even if they can demonstrate the competencies, is that these sessions would increase the experience and exposure to different aspects of OOH work, particularly if they are undertaken in a variety of OOH settings. The negotiation of this is an issue for all involved organisations and GP Trainers.
However, allowing for a necessary period of induction into general practice and primary care for GP StRs, the indicative benchmark of twelve sessions is likely to be necessary over a practice year. For GP StRs undertaking more than twelve months of their programme in a general practice setting the number of sessions should be increased pro rata, ensuring that competencies that are achieved in the ST1 or ST2 years are maintained throughout training. It is expected that GP StRs in integrated training posts (ITPs) based in general practice should gain similar OOH experience to those colleagues undertaking traditional general practice placements. Those doctors who undertake training on a less than full-time basis should undertake the same number of sessions as their full-time colleagues but these would be attained over a longer timeframe.
The number of hours worked in any week and the rest achieved should also comply with the EWTD. In order to experience a broad range of clinical presentations it is desirable that GP StRs have experience of different models and shift times of the OOH service, and GP Trainers should be aware that a GP StR will need to be properly rested both before and after an overnight session.
Whilst it is preferable that OOH training should be distributed throughout the time as a GP StR in order that competencies acquired can be consistently demonstrated, local circumstances my dictate the need for ‘block release’ options to deliver the required OOH experience However, there are serious potential disadvantages to this pattern which risks distorting the overall training experience and such an option should be regarded as the exception chosen for compelling reasons.
Exposure to a variety of community based emergency and OOH models, as described earlier, should be provided for GP StRs as part of their training programme. This should be acknowledged and negotiated with the GP Trainer, as part of the GP StR’s PDP.
The GP StRs will be subject to the normal processes of clinical governance, General Medical Council (GMC) regulations and civil law. Their contract of employment is likely, for the foreseeable near future, to remain with the training practice or their GP Trainer, but they may be supervised by a clinician who may not be from that practice or, on occasions, a professional who may not be a doctor but who will be an approved clinical supervisor in OOH care.
In the context of OOH training medical indemnity organisations have indicated that a GP StR’s standard membership will provide then with indemnity for the work they undertake as part of OOH training.
As the situation continues to evolve and as new models are developed there will be an ongoing need to keep the situation regarding medical indemnity under review and OOH providers will need to ensure that their insurance is adequate to cover their own liabilities in connection with the work done for them by GP StRs.
COGPED recognise that the process and structures for delivering OOH care will continue to evolve, thus the processes for delivering training for OOH care for GP StRs will require regular formal review and further consultation. To this end, the steering group of appropriate stakeholders should continue to exist and meet regularly.
1. http://www.rcgp-curriculum.org.uk/rcgp_- _gp_curriculum_documents/gp _curriculum_statements.aspx
2. http://www.rcgp- curriculum.org.uk/PDF/curr_Curriculum_Guide_for_Learners_
6. British Medical Association, New GMS Contract: Investing in General Practice February 2003. 2003: London
7. Taylor E, Houghton G, Kelly S, Campbell I. Training registrars in general practice: education and service for the future workforce. Education for Primary Care 2003 14:3; 310-316
8. Longhurst S, Shipman C, Dale J. Working out of hours: the experiences and training needs of general practitioner registrars. Br J Gen Pract. 1998 48(430):1247-8.
9. McLean I, Houghton G. Training for out of hours or out of hours training? A new set of skills for general practice. Education for Primary Care 2004 15:1. 1-9
12. GPC/RCGP Good Medical Practice for General Practitioners. Sep 2002. RCGP, London.
13. Department of Health. The NHS (Vocational Training for General Medical Practice) Regulations 1997
14. National Association GP Co-operatives: recommendations on registrars.
15. Department of Health ‘Out of Hours Training for GP Registrars’ 28th April 2004
(Gateway ref 3073) http://www.gpkss.ac.uk/who/deanery/pdfs/DOHguide.pdf
16. Guide to Specialty Training in the UK – ‘The Gold Guide’
Appendix 1 General Practice Training in Out-of- Hours Care – Clinical and Educational Governance
Appendix 2 Quality Assurance of Out-of-Hours Training – Monitoring template
Appendix 3 OOH Worksheet
Appendix 4 OOH Care Pathways: Patients’ Journey 1
Appendix 5 OOH Care Pathways: Patients’ Journey 2
Appendix 6 Model honorary contract
The following individuals and organisations have contributed in writing this position paper;
Mr M Beattie, NHS Employers
Dr A. Benjamin NHS Alliance Urgent care Providers Representative, and Walsall Out-of-Hours Community Benefits Society (or CBS for short).
Dr Jill Edwards, Royal College of General Practitioners
Dr K Hill, Deputy GP Director, East Midlands Healthcare Workforce Deanery
Dr I McLean, Deputy GP Dean KSS, GP, representing UKCEA
Dr Jane Mamelock - North West Deanery
Dr T Swanwick, GP Director, London Deanery
Dr A Thompson, GP Registrar Sub-Committee, BMA
Professor A Tavabie - KSS GP Dean & Deputy Dean Director (Chairman)