Out of Hours Doctor Handbook for GP Trainees

Table of Contents

A. Introduction - 2 B. Sign up form: GP trainees at Queen Mary’s Hospital OOH - 3 C. GP trainees at Bexley OOH/UCC - 4 D. Complaints and Significant Events - 8 E. Duty doctor shifts - a guide to what’s involved - 9 F. National Quality Requirements (NQRs) - 10 G. Special Patient Notes/Co-ordinate My Care - 11 H. Mental Health and Capacity - 12 I. Verification of Death - 13 J. Hospital Pathology Results - 13 K. Whistleblowing - 14 L. Record Keeping - 15 M. Prescribing Policy - 16 N. Safeguarding - 16 - 17 O. Confidentiality - 18

Version 2

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This document has been prepared to provide Out of Hours (OOH) doctors with an outline of the way HURLEY GROUP - OUT OF HOURS SERVICE, BEXLEY operates. The information contained within it will change continually, so please let us know if any part of the document is out of date or if there is additional information you would like us to include.

Dr. Omar Hashmi MBBS BSc MRCGP Local Medical Director – Bexley OOH Service. GP Partner – The Hurley Group T: 07737102435 E:[email protected]

Dr David Whittington MB ChB DCH DRCOG MRCGP Hurley Group Medical Director Unscheduled Care T: 07894980052 E: [email protected]

http://www.hurleygroup.co.uk

September 2016

THE HURLEY GROUP - OUT OF HOURS SERVICE, BEXLEY

The Hurley Group is a GP Partner lead NHS organisation, based at the Hurley Clinic, Kennington. It runs a number of Practices, Walk in and Urgent Care Centres across London. We have been providing patient centred care since 1969, working to deliver excellent quality care to some of the UK’s most deprived communities. The Hurley Group is growing, developing and changing with today’s NHS.

Mission Statement

It is our aim to provide the best care to those that need it most.

THE HURLEY GROUP - OUT OF HOURS SERVICE, BEXLEY requires all duty doctors to complete the attached form and provide the relevant information before they undertake OOH shifts.

It is your responsibility to provide THE HURLEY GROUP - OUT OF HOURS SERVICE, BEXLEY with any changes in circumstances or to the information you, have provided and to send any updated copies of certificates.

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Brief form to capture GP trainee details and enable GP trainees to book OOH supervised sessions

Please complete this form and return to [email protected]

Name:

Contact e-mail:

Contact tel no:

Educational Supervisor Name:

Contact e-mail:

GMC number:

Medical defence organisation and number:

Training start date:

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GP trainees at Bexley OOH

Brief description of OOH training to support the requirement to do a minimum number of supervised sessions during OOH as part of your training.

1. Sign up to book sessions

Please e-mail [email protected] You will be sent a (very) brief form to complete with contact details, GMC, educational supervisor, etc. Please use this as the subject field of your e-mail: GP Trainee Bexley OOH Or if you’d rather call, the number is: daytime 020 7820 0171/ On call hours: 07958772335

NB: GP Partner on call available by phone - 07701289461

2. Booking sessions

Once we get your completed form back, you will be sent a log-in for our online booking system. When you log in, you will be able to see available sessions for the weeks/months ahead and book into available sessions. We will initially publish the next 2-3 months, but will soon add sessions for the entire year ahead.

Bookings can be made via http://hurleyrota.co.uk/securitylogin.asp

3. Availability of sessions

Sessions will be available for the following times: Tuesday 7pm-12am Thursday 7pm-12am Saturday 8am-1pm

Maximum number per session will be 3x GP trainees and 1 GP supervisors. On Saturday shifts we aim to also have an additional GP trainer on site as the “OOH Float Dr”.

You will get the opportunity to do: · Telephone triage of OOH calls · Base consultations · Home visits (driver and car provided)

4. Induction

We will contact you directly about booking a brief (30 mins) induction session at the Queen Mary’s Site.

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5. Any queries/questions/problems

Please e-mail me if any queries at all, or contact your Programme Director.

Address: Tel no:

Urgent Care Centre 020 8308 5611 Queen Mary’s Hospital Frognal Avenue, Sidcup Kent, DA14 6LT

What it looks like:

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Map of the Hospital – Urgent Care Centre is in A Block

Parking: is Pay & Display, but we do have some permits! Please ask the UCC/OOH Operations Manager on site.

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Service Overview

The Urgent Care Centre at Queen Mary’s Sidcup (QMS) is open 24 hours a day, 365 days a year. We see walk in minor injury and illness cases throughout these opening hours.

We are also responsible for the out-of-hours (OOH) cases for patients registered with a Bexley GP. Our GPs will triage calls, can call appropriate cases into the UCC to be seen and also undertake home visits.

What we see

1. Minor illness cases that walk into the UCC. 2. Minor injury cases that walk into the UCC – these will be seen either by the Urgent Care doctors or by the very experienced Emergency Nurse Practitioners (ENPs) on site. If you do see an injury case, there will be colleagues on site to discuss the case with if necessary. All X-rays are reported by a Consultant Radiologist within 48 hours to ensure no missed fractures. 3. Minor illness or injury cases brought in by ambulance – these should be discussed with a clinical staff member to make sure that they are appropriate referrals 4. There is a separate Adult and Paediatric areas in the UCC, a resource room with 4 telephone consultation bays. There is also an area in the UCC that where there is an UCC technician, wound care & plastering areas. There is eye room, and isolation room as well as up to 3 monitored resuscitation bays. 5. GP OOH cases are seen after 18:30 on weekdays until 08:00 the following day, and all day Saturdays and Sundays, when local GP surgeries are closed. Calls all go via 111 initially. Our involvement is then: a. Telephone Triage of cases passed through by 111 to “speak to a GP”. Speak to the patient and either close the case down or invite into the UCC for face-to-face review if you need to see them. b. Base visits – of those cases invited in following triage by a GP (or base visits direct from 111). c. Home visits – these will be done by a standby GP. We have a car and a driver who takes the GP to the patient’s house. 6. Suspected DVTs – pathway in place to diagnose suspected DVTs. 7. Children of any age. There are dedicated Paediatrics Nurse Specialists on site from 8am to 10pm for advice

Protocols

There are hard copies of departmental, local CCG and national clinical protocols on site – please ask reception for the appropriate folders. These are also available online at the UCC/OOH “dropbox” site: https://www.dropbox.com/login

Username: [email protected] Password: Hurley01

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Medical Emergencies

The Queen Mary’s site was an Emergency Department up until 2010 and unwell patients may still walk in. We have an emergency area with a trolley and defibrillator, emergency drugs and oxygen,

Staff will support you to call a 999 ambulance and stabilise the patient before transfer to the nearest Emergency Department.

Clinical System

We use Adastra, which many of you will be familiar with from OOH sessions elsewhere. You will be issued with a log in and we can arrange an induction on arrival.

A copy of your clinical notes is passed to the patient’s own GP electronically by 8.00am the following morning after the patient is discharged.

Vision360

It is possible to access shared records from the patient’s regular Bexley GP via this portal. It is available in the OOH telephone room on all computers. Online access can be arranged via email to HMB. Prior to accessing this you will be prompted to seek consent from the patient first

What other clinicians are on duty with you?

The OOH will be staffed by at least one GP 24 hours/day making your shift supervisor and yourself as supernumerary at all times. There will be more GPs during peak periods, and a standby GP to be called in for home visits or if there is a staff shortage at the UCC. There may be Associate Specialists on duty with you (all Emergency Department trained and capable of seeing minor illness and injury cases).

There will always be a number of Emergency Nurse Practitioners (ENPs) on duty too. They are all experienced and have an Emergency Department background. Do ask them for help if required.

What to do if you have a problem

Speak to a colleague at the UCC or the UCC Operations Manager, who will be on site during core hours or contactable by phone.

Out of hours, there is always a Hurley Partner on call, who can be contacted via Hurley Medical Bank (HMB) or the number above if any advice is required.

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Complaints & significant events.

If you have an informal complaint or need assistance regarding any of the above please speak to/email the on call site manager (daily contact details will be at reception desk)

Significant event forms are available onsite or on the shared folder: significant-event-reporting.ca067325@qms-ucc.hurleygroup.podio.com

Major incidents:

While GPs have little role to play in major incidents due to the requirement of trauma life support skills, in a major incident we would be expected to take “green” walk in patients as well as play a supportive role in the local response. Please liaise with the operational manager who will have access to the business continuity plan for the site.

Duty doctor shifts - a guide to what’s involved.

There are a number of shifts available for duty doctors:

Telephone Calls:

Telephone doctors are required to carry out phone consultations for patients transferred from 111. Urgent call backs are to be attended to wherever possible in 20 minutes, all others within 60 minutes.

In times of high demand the priority is given to answer all urgent calls on the screen and to delay the non-urgent calls until all the urgent calls have been dealt with.

The GP is encouraged to review the case notes from 111 and if they feel the case needs to be re prioritized from non-urgent to urgent they are encouraged to do so. However urgent calls should generally not be downgraded.

For OOH Trainees, it has been agreed wherever possible that they will see at base the patients that they have called. Where possible this should also be with home visit requests.

COGPED Levels

OOH Trainees are divided into different levels of independence. (COGPED 2010)

1. Direct supervision the GP StR is supervised directly by the clinical supervisor [red]

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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 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’. [green]

GP Shifts:

Advice/calls: Calls Drs. are required to do phone consultations only. If there are no calls on screen they are to help see UCC patients.

Visits doctors are required primarily to carry out home visits but if the service requires they will also be requested to carry out telephone consultations and see patients for a consultation at base.

Float: The float Dr. both supports the calls Dr. and the UCC by seeing patients in turn on the ADASTRA screen where most required.

National Quality Requirements (NQRs)

All Out of Hours Providers are measured against National Quality Requirements (NQRs). The HURLEY GROUP - OUT OF HOURS SERVICE, BEXLEY team need to work together to ensure we achieve compliance and maintain high quality patient care.

Following the review of out of hours services by the Department of Health, commonly known as the "Carson Review", a set of standards were developed for providers. These were revised in October 2004 and renamed the National Quality Requirements.

There are 13 requirements, ranging from speed of access to the quality of care and arrangements for "special" patients.

Key requirements for clinicians are; 1. NQR 4 – Audit 1% of all Clinicians work and report findings to the CCG 2. NQR 9 This measures the length of time it took for a clinician to contact the patient after the call handler completed the call taking process.

Requirement -

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Start Definitive Clinical Assessment (doctor call backs/ Patient waiting time to speak to a doctor).

1st Call Back (Doctor Advice) requirements: (urgent) 20mins 100% (Routine) 60mins 95%

*any call that goes over the requirement is classified as a fail, even if it’s only a minute over!

3. NQR 12 – This measures the waiting time for base and home visit Requirement -

Start of face to face consultation (Base and Home Visits)

(Emergency) 1hour 100% (urgent) 2hours 100% (Routine) 6hours 95%

Emergency calls are those that do not requirement 999 response but cannot wait for 2hours.

THE HURLEY GROUP - OUT OF HOURS SERVICE, BEXLEY’s performance is reported monthly to Bexley CCG

To help us meet these requirements we have estimated the following average times per consultation for GPs (longer for GP Trainees);

Telephone Advice: 5-10mins Treatment Centre / Face to Face: 10-15mins

Language/hard of hearing support services

Staff are encouraged to use Google translate when communicating with patients with English language difficulties.

Special Patient Notes/Coordinate my Care

There are often circumstances where it is useful for THE HURLEY GROUP - OUT OF HOURS SERVICE, BEXLEY duty doctor to be forewarned of significant circumstances pertaining to a patient. Examples include:

• Palliative Care patients – community/care information/instructions on patient preference re home v hospital/hospice. • Individuals with special needs, unusual or dangerous illnesses. • Violent patients. • Frequent callers • Care plans for those with mental illness. • Patients who may call for drugs of dependence.

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• Those subject to Child Protection legislation.

These are stored on the system and called up when a call is received from the patient. The notes are added directly to our database by the patients registered doctor and in future other carers of the patients like palliative care teams, district nurses etc.

In the case of non-registered patients, any health professional may post an SPN. Urgent cases should be brought to the attention of the Supervisor, who must inform the on-call Manager for urgent and non-urgent requests.

The instruction on the special notes should be followed at all times.

The special note shall remain in force as until it gone passed its review date and where no further instructions are received the note on the system will lapse after the review date. All Surgeries are sent reminders to review the notes on their patients

Shared Data can be accessed on the Coordinate My Care database from Bexley OOH Base. Please visit http://coordinatemycare.co.uk to obtain login details

Mental Health

The Principles of the Mental Capacity Act 2005

The main principles of the Mental Capacity Act should be used when making decisions on patient care. • A person must be assumed to have capacity unless it is established that they lack capacity. • A person is not to be treated as unable to make a decision unless all practicable steps to help them to do so have been taken without success. • A person is not to be treated as unable to make a decision merely because they make an unwise decision. • An act done or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in their best interest. • Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person's rights and freedom of action.

Compulsory admission under the Mental Health Act

There are two Sections of the Mental Health Act which allow emergency admission of patients whose mental health issues put them at immediate risk to themselves or others.

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Section 4 allows patients to be admitted and detained for up to 72 hours after one doctor has said that urgent admission is needed. An application for a Section 4 admission is usually made by an approved mental health professional (AMHP) i.e. the on-call Social Worker.

Section 136 of the Mental Health Act allows the police to take a patient from a public place to a place of safety, if they think he or she needs immediate care or control. A 'place of safety' might be a police station or the nearest A&E Department.

People can be held under Section 136 for up to 72 hours, during which time they should be seen by a doctor and by an approved mental health professional (AMHP).

If the attending duty doctor thinks that a patient requires emergency admission following assessment they must seek consent of the patient to be admitted. If the patient declines or is unable to give consent the GP must then contact the On-Call Approved Social Worker to undertake admission via Section 4.

If the patient appears threatening in any way, the GP must use extreme caution and contact the Police for assistance. The Police can facilitate admission through the application of Section 136 if they feel the patient presents an immediate risk to themselves or others.

Important Points • It is always good Practice to involve family members and next of kin in decisions to admit patients under the Mental Health Act • Always document as fully as possible in your notes reasons why it was felt admission under the Mental Health Act was required • These situations can be stressful. Please liaise with the on-call manager if you need further support

Verification of Death

If you have to deal with a death during your shift it is your responsibility to complete the death confirmation sheet and hand over to the coordinator who will ensure the patient’s own GP is informed.

Copies of the Death confirmation sheets are in the bags /Cars

GPs in the OOH settling can verify death of patients who are palliative or expected to die. Usually the regular GP will have seen the patient in the preceding 2 weeks.

Unexpected deaths should be referred to the police to verify death via 101.

Useful information can be found here: http://patient.info/doctor/death-recognition-and-certification

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Hospital Pathology Lab Results

THE HURLEY GROUP - OUT OF HOURS SERVICE, BEXLEY quite often receives Hospital Path Lab results. All results are accepted by the service and are rung through by a clinician from any Hospital Path Lab. The results are faxed or rung through to the duty Supervisor, who will try to obtain all patient information and log it on the computer in the normal way.

If the patient details are incorrect .i.e. patient has no telephone number and all other means of contracting the patient fails it is the duty doctor's decision what action to take. The patient may require a welfare home visit to ensure that there is no clinical risk. This can often be undertaken by a request to the Police via 101.

In the instances where we have no details on the patient, the call is passed to the patient’s own GP, who may provide the details for THE HURLEY GROUP - OUT OF HOURS SERVICE, BEXLEY to follow up the patient.

It is normally the case that the Lab only passes on the results to THE HURLEY GROUP - OUT OF HOURS SERVICE, BEXLEY when they think the patient cannot wait to be clinically assessed until the next day or after the weekend when the surgery re-opens.

Although it can be very frustrating when THE HURLEY GROUP - OUT OF HOURS SERVICE, BEXLEY gets these calls from the Lab with little patient information, our priority is our duty of care to the patient.

Whistle Blowing

Whistle-blowing is defined as:- The disclosure by an employee or doctor of confidential information, which relates to some danger, fraud or other illegal or unethical conduct connected with the workplace, be it of the employer or of a fellow employee(s).

A whistle blower is not a "sneak" or a "trouble maker" but someone who comes to a decision to express a concern after a great deal of thought. The law only requires that there be a genuine doubt – the individual is not expected to produce unquestionable evidence to support the concern.

Practice Policy

• This Organisation has a duty to conduct its affairs in a responsible way. • The Company encourages openness, freedom of speech and the voicing of concerns as a contribution towards maintaining and enhancing quality and ensuring high standards of governance and accountability.

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• The Company wishes to encourage and enable employees to raise genuine and legitimate concerns internally, confidentially, and without being subject to disciplinary action or any other detriment. • The Company wishes to provide an opportunity for those concerns to be investigated and for appropriate action to be taken to ensure that the matter is resolved effectively within the Practice wherever possible. • The Company wishes to enable employees to raise concerns with appropriate outside bodies in the event that the concerns are not dealt with satisfactorily internally.

Examples of serious concerns covered by the Policy

• An offence under, or breach of, any statutory instrument or legal obligation • Fraud, financial irregularity, dishonesty • Malpractice, corruption, bribery • Unethical conduct • Medical or prescribing errors • Breach of confidentiality • Miscarriage of justice • Danger to the health or safety of any individual or the environment • The deliberate concealing of information about any such matter.

Procedure • If you identify a matter of serious concern, you should in the first instance notify the Local Medical Director (LMD) in writing. • The LMD will investigate the matter promptly and inform you of the findings in writing, and a copy will be sent to the member of staff who is the subject of the allegation. • If appropriate, Practice’s disciplinary procedure will be invoked to discipline the offender. • Where there is evidence of criminal activity, the Police will be informed. • If you are dissatisfied with the outcome of the investigation you may notify the local CCG, or other relevant outside body such as the Health and Safety Executive or H.M. Revenue and Customs, depending on the nature of the matter. • Any victimisation of an employee who raises a concern, or any attempts to deter him/her from raising a legitimate concern, will be regarded as a serious disciplinary offence. • The raising of false or malicious concerns or complaints will be regarded as a disciplinary offence.

Record Keeping

All telephone consultations should be written on ADASTRA in the history section with the medical history tab filled in including medications, allergies and medical history as far as possible over the phone prior to consultation. The reason for this is that there may be elements of the past medical history/medications that if known could

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If doses of medications are unknown, then please use the lowest dose possible on the medications dropdown menu. Also, free type that “doses may not be accurate” on the Past Medical History screen so that this is formally noted. The justification for this is that if ADASTRA knows what medication is used it is more likely to alert the user of interactions, cautions and contraindications.

If a patient cannot remember their medications then please use caution. If the telephone consultation concludes the encounter then please use the appropriate outcome on the ADASTRA screen. E.g. “refer to own GP” or “refer to speciality”. Please note that if a patient has been referred via Accident and emergency then this box should be ticked too. If the patient is a Bexley patient, and following consent from the patient, please use the link to Vision 360, this will take you directly into the patient GP records should clarification be required around their medical history or medication.

Where the computer systems are not working, please use the downtime forms at reception on site. These forms should be given to reception for scanning & archiving at the end of the shift. In the meantime, the on call manager with liaise with the IT team and ADASTRA on call to try to resolve the situation.

Prescribing policy

Please only prescribe/administer medications that need to be given now. Advise that regular medications should be directed towards the regular GP to enable accurate monitoring.

Please do not prescribe more than a 2 week supply of any medications.

Do not prescribe opiate/controlled drug (morphine solution, Tramadol), benzodiazepines or Z drugs due to the risk of dependence.

Any exceptions to this rule should be clearly documented and have good evidence for prescribing, e.g. on specialist advice (record name of specialist) and/or have clear documentation in place of the drug used. Trainees should discuss such cases with the OOH trainer.

Palliative patients are an exception to this – but please be cautious with amounts prescribed

Please Adhere to local Bexley CCG antimicrobial guidance.

Use caution in the elderly with regards to CKD.

Home visits prescribing – please fill out the envelopes behind reception that each contains 10 prescriptions to note the prescription number, patient number, doctor’s

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See attached suggested formulary.

Safeguarding

For advice on: Admission to hospital - discuss with on call Paediatric registrar/consultant for discussion with named Dr/nurse for safeguarding or OOH contacts for Social services (available on Dropbox Shared Drive) https://www.dropbox.com/s/dx964lucn65jdnf/what%20to%20do%20if%20you %20suspect%20child%20abuse%20.pdf?dl=0

Appendix 1: The Following cases should be referred to the school nurse or health visitor

Confidentiality Policy

The RCGP state that “Patients often entrust health professionals with sensitive information relating to their health and other matters. They do so in confidence and have the legitimate expectation that staff will respect their privacy and act appropriately.

Patient information is generally held under legal and ethical obligations of confidentiality, and should not be used or disclosed in a form that might identify a patient without his or her explicit consent. There are a number of important exceptions to this rule, but it applies in most circumstances.

Anonymised health information, where names have been removed, is not confidential and may be used with relatively few constraints.” http://www.rcgp.org.uk/patient_information/your_surgery/records_and_confidentiality. aspx

Full Policy Available on Hurley Shared Drive (Podio) Reasons for referral Tick relevant boxes

Child subject to Child Protection Plan/Child in need/ Looked After Child

Safety Issues – preventable accidents to a child under 5

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Fractures, burns, unexplained bruising to a child under 3

Any injury to a child with a disability/ learning need

Suspected or obvious NAI (non-accidental injury)

Serious or life threatening injuries/ illnesses

Child Death

Drug or Alcohol misuse/ mental health problems/ deliberate self- harm

Domestic Abuse or social issues (parental alcohol/drug misuse)

Bullying/ assault

Feeding problems in baby/crying baby

Developmental causes

Parental issues e.g young parents/ private fostering

An unacceptable or unexplained delay in seeking treatment

Frequent attendances

Child not registered with a GP/ not in an educational establishment

DNA/ not following treatment plan

Other (Please specify in comments section below

Sexual Health