Out of hours care

Contractually, the out of hours period is between 18.30 and 08.00 on weekdays, and from 18.30 Friday till 08.00 Monday including Bank and Public Holidays.

Clinical care provided for illnesses or injuries which require prompt attention but are typically not of such seriousness as to require the services of an emergency department.

Care that requires an immediate response to a time-critical health care need for those with serious or life-threatening symptoms.

Out of hours services are designed and resourced to focus on those patients who have care needs that are urgent, but no t an emergency. In reality, out of hours GPs are also seeing patients with non-urgent needs; this may be due to a range of issues including the difficulty patients experience with getting a GP appointment in-hours or a lack of understanding about the appropriate service to approach for different types of needs. This is a topic of debate which needs addressing to ensure out of hours services are sustainable.

• There is a growing need for training and career development in out of hours settings for GPs and other professional groups, to ensure GP skills are kept up to date in an increasingly challenging and complex environment. Separate from in-hours, providing care during out of hours periods requires keeping up to date with acute medical, surgical, and psychiatric knowledge, and specific approaches to governance due to the connections that exist between out of hours GPs, ambulance services and emergency departments. GPs will also be expected to offer advice and support to a wide range of professionals, often on an ad hoc basis, from the moment they are qualified; they must be fully trained and equipped to assume this role. There has been increasing demand for Advanced Nursing Practitioners (ANPs) and other members of multidisciplinary team members both in and out of hours. It is essential that primary care workforce planning recognises the need for multidisciplinary team members in out of hours settings as well as in hours, and the extent of training needed to address this growing need.
  The current three-year training programme for GPs does not provide sufficient opportunity for trainees to attain the necessary practical training in out of hours care settings, nor for the competencies and skills learned to integrate, further develop, and be assessed in context. GP trainees are often unable to take on late or overnight shifts due to the in-hours commitments they are also required to meet. This raises concerns about their level of exposure to out of hours training. To address this problem, some trainees and out of hours providers have highlighted the usefulness of specifying a minimum number of hours for trainees to spend in out of hours settings. In Scotland, for example, a minimum time spent in out of hours settings is mandated.
• In England, Wales and Northern Ireland, the cost of medical indemnity has risen significantly over the past few years, making out of hours GP care, along with various other areas of work, prohibitively expensive for GPs and other healthcare professionals. Prior to April 2019, GPs paid on average, £8,000 per year for indemnity, with, out of hours GPs paying a higher rate due to the increased risk involved.¹
  The English and Welsh Governments delivered state-backed GP indemnity schemes in April 2019, which cover GPs and their practice teams for indemnity costs associated with the delivery of primary medical services, including out of hours services. In Northern Ireland, the Department of Health announced in June 2018 an additional £1 million to support indemnity costs, however a long-term solution is still needed. In Scotland, indemnity costs are traditionally lower and all GPs (both salaried and sessional) in out of hours services are covered by the Clinical Negligence and Other Risks Indemnity Scheme (CNORIS).
• The capacity of GPs to meet the level and type of demand from patients is stretched. The number of GPs in active clinical work is decreasing across the UK while the population continues to expand and age. The total number of GP full-time equivalents (excluding registrars, retainers, and locums) has decreased by 0.6% from December 2017 to March 2018 in England², by 4.1% between 2016 and 2017 in Wales³, and by 4% between 2013 and 2017 in Scotland⁴. There is no equivalent data available for Northern Ireland. The publication of the Northern Ireland Regulation and Quality Improvement Authority (RQIA) report on the state of out of hours GP in Northern Ireland is awaited.

• In England, the provision of extended GP access (pre-bookable and same-day appointments in the evenings and on weekends for routine care) has recently been rolled out nationally. This may impact both the use of out of hours services and the availability of GPs to staff these services.
• The increasing use of multidisciplinary teams within practices in-hours and successful task substitution from GPs to other professionals (with GP support), has led to GPs focusing more of their time on complex patients as well as stepping into leadership roles to advise and oversee wider teams. GPs working in out of hours settings should also benefit from working as part of multidisciplinary teams and be supported by other services from the community which provide out of hours care such as palliative care, community hospital cover and mental health services. People suffering from mental health problems tend to access GP urgent care services because appropriate crisis care services are not available.⁵ The availability of appropriate other care services during out of hours periods would enable GPs to focus on those urgent patient encounters which only they are best placed to manage.
• The variety of telephone triage solutions in operation across the UK are becoming increasingly sophisticated in improving access to primary care services, encouraging self-care and signposting patients to services within the wider health and social care system.
  • There were 16 million calls received by NHS 111 England in 2017-18 - the volume has increased by 67% over the last 3 years and 60% of these callers were successfully signposted back to a primary care setting (visit to an out-of-hours centre 34.1%, home visits 12.2% and self-care advice 10.2%).⁶ By March 2019, NHS 111 will adopt an enhanced triage system across integrated urgent care services.⁷.
  • In Wales, the latest figures show that 53.3% of calls to the NHS Direct were directed towards primary care, other healthcare professionals or to minor injury units.⁸ 111 Wales is in the process of a phased roll-out across Wales over the next three years, combining the existing NHS Direct and GP out-of-hours call handling services.
  • In a review of emergency and urgent care services care journeys that start in the out of hours period in Scotland, a substantial proportion of these involved out of hours primary care, and most commonly this would be initiated through NHS 24.

  The capacity and skills of primary care to adjust to technological developments such as telephone triaging and e-consultations, and cope with the increased flow of patients, remain important issues which need addressing.

• The potential widening of health inequalities is a key consideration when implementing new technologies, including those supporting out of hours care. For example, patients facing language barriers, or those without telephone or internet access, may not be able to use telephone or online services to access out of hours care. Patients using such avenues for accessing out of hours care should not be prioritised over those patients approaching out of hours services in person. Alternative access pathways may need to be developed for those with limited technological literacy.
• In light of the increasing number of people living with multiple long-term conditions and the increasing complexity of conditions, the need for integrated, locally distinctive, person-centred care is vital to ensure that patients receive the right care from the right healthcare professional, at the right time and in the right place. Out of hours settings provide GPs and other healthcare professionals with valuable learning experiences and rewarding opportunities to assess urgent patient needs and identify appropriate care pathways which link to other care services and health care professionals within the community.
• Urgent care is short and episodic, therefore is delivered most effectively when clinicians and patients have efficient access to medical records – at a minimum, some form of summary care record and Special Patient Notes (SPNs). SPNs enable in-hours GPs and other clinicians to clearly communicate additional specific information to out of hours GPs, to help support integrated, patient-centred care particularly for patients with long-term conditions and frequent 111 callers. SPNs have been successful in some areas with assisting out of hours services with closing calls and reducing the likelihood of referrals to A&E or ED. However, the process of populating information into these note templates must be further automated to ensure all clinicians can quickly and easily update information for out of hours GPs.⁹ Scotland’s Key Information Summary (KIS) is an example of a successful application of SPNs; it is created by a patient’s GP and can be seen by out of hours services, NHS24, ambulance services and secondary care services. It is also used to create Anticipatory Care Plans (ACPs) for vulnerable patients at risk of hospitalisation, to reduce unnecessary admissions.
  Advances in patient record sharing between out of hours services and A&E or ED have been made to varying extents across the UK, but barriers to efficient record sharing still exist, such as the incompatibility of IT infrastructure across various providers. In the digital era patient data must be integrated and transferrable at every critical point across the care continuum. This is necessary to ensure medical advice delivered out of hours and under time pressure is based upon the most accurate and timely patient data.
  • In England, 98% of the initial cohort of Urgent Treatment Centres (UTCs) and 96% of e-prescribing pharmacies now have access to primary care records through either summary care records or local record sharing portals. Over 2018-19, NHS England has pledged to increase the number of patients who have consented to share their additional information through the extended summary care record to 15% and improve the functionality of e-SCR by December 2018.¹⁰
  • Welsh out of hours services have had access to a summary GP record for many years. Its successor, the Welsh GP Record system was launched in Autumn 2016 and broadens access to doctors and nurses working in hospitals in addition to GP out of hours services across the country. While the system has been successful in sharing information between primary and secondary care, it is limited by its sole use of specific diagnostic code descriptors and lack of free text fields. In many cases (e.g. diabetes, asthma, palliative care cases such as organ failure), out of hours services need more information than just a diagnostic code. Home visiting clinicians are currently not granted access to the record system, although a secure solution to this is in the process of development. Community-based pharmacists, emergency services first responders and advanced paramedics will also soon have access to patient records via this system.
  • In Scotland, the Emergency Care Summary (ECS) is directly extracted from the patients’ GP record and provides of a list of medications which the GP prescribes (these may include recent acute medications and repeat medications). This information can be viewed by out of hours services, NHS24, ambulance services and the ED. Work is underway to enable community pharmacy to directly access this information as well. Scotland also uses the KIS as described above.
  • The Northern Ireland Electronic Care Record (NIECR) effectively stores and shares real-time patient information, including information on medicines and allergies. NIECR is accessible by any health and social care staff treating the patient (with their consent). When a patient is referred to a hospital by an out of hours GP, the hospital doctor can view and triage information about the patient in electronic form on NIECR; similarly, out of hours GPs are able to view letters from hospitals in electronic form once their patient has been admitted and treated.

• The in-hours period for general practice represents approximately 55 hours out of a total 168 hours each week; this leaves a significant amount of care to out of hours GP services. Any quality improvement initiatives, development plans and support schemes for general practice must acknowledge the out of hours component of primary care.
• The perceived fragmentation and overlap of services in the out of hours period, raises concerns about patients’ awareness and ability to navigate and access the most appropriate service. The current system tends to blur the boundaries between in-hours, extended hours, out of hours, emergency and urgent care, whereby patients are often confused about when they should access various urgent care services, and how (i.e. by walk-in or pre-booked appointment).¹¹
• To ensure a sustainable out of hours GP service, the need for investment in out of hours training, supervision and support must be clearly communicated to policymakers.
  • Over half of the respondents to the King’s Fund survey of GP trainees in 2018 reported that they wanted to undertake other clinical NHS work and responsibilities, alongside traditional general practice, with ‘portfolio’ careers becoming increasingly popular.¹² Younger GPs are increasingly seeking a more varied career, including working in out of hours and urgent care settings which can deepen their knowledge and skills, and the opportunity to develop special interests, broadening the clinical options they can offer to patients.
  • As such, GP trainees must be offered a sufficient amount of practical training and work experience opportunities in out of hours settings. Supervisors and mentors in out of hours must be sufficiently experienced in these settings and should be actively encouraging and motivating GP trainees towards working in this area.

While there is no ‘one size fits all’ model for the design and delivery of out of hours GP services, the RCGP believes that to ensure high quality care for patients, future models of out of hours care provision across the UK should be based on the following principles:

• Patients should be able to gain timely access to the skills of an expert medical generalist¹³ and a multidisciplinary team when they need it, including outside core surgery hours.
• Training programmes (at each stage of medical training and through ongoing professional development), guidance material and support services for GPs should incorporate a key focus on the competencies and skills required to deliver urgent care, including in out of hours settings.
• Out of hours services must be adequately resourced and balanced with the resourcing of in-hours services.
• Out of hours services must be developed from a patient, community, and local population perspective, delivering integrated, whole person care to individuals interacting with different parts of the health and social care system.
• Systems and processes must be in place to facilitate the appropriate sharing of patient information and ensure smooth and timely handover of patient information and urgent care needs between out of hours and in hours services.
• All out of hours service delivery models must ensure that working patterns are safe and sustainable.
• Technological developments which are currently aiding patient information sharing, the provision of remote consultations and triaging of patient needs, should be applied to out of hours services as well as to in hours ones. New digital platforms and tools must be applied in an equitable, balanced manner, which continues to recognise the importance of relationship-focused care.

• The training programme for GPs should include a sufficient number of hours in out of hours services/primary care based urgent/unscheduled care provision to enable GPs to be both competent and confident in any out of hours setting, and accustomed to dealing with urgent care in a general practice supported environment.
  Some parts of the UK have specified a minimum number of hours that they expect their trainees to fulfil. The RCGP believes that setting such an indicative benchmark sends a strong statement of intent to trainees and health and education systems and provides clarity and consistency on what is required from trainees to meet relevant competencies. However, there is also a risk that setting specific targets can lead to unintended consequences. The College calls for an independent formal evaluation of the duration of out of hours training to inform further discussion between educators, trainees, funders and out of hours service providers.
• The competencies assessed in out of hours settings must be clearly defined and reflective of the skills required for today’s urgent care needs and developments in care provision, including the ability to use new technologies and lead/manage multidisciplinary teams in time-critical environments.
  There should be an enhanced rigour around processes for evidencing out of hours competencies, including the sign-off process.
• Additional funding for resources to support the provision of out of hours training and supervision is required. Shared supervision between GPs and other professionals providing of out of hours services should be encouraged and facilitated where appropriate, whilst ensuring trainees are able to access advice and guidance from a lead GP providing medical support during trainee shifts.
• A requirement should be introduced for out of hours service providers to provide training sessions and supervision for GP trainees. This should be embedded into the commissioning process for out of hours services.
• Remote supervision (i.e. supervision provided by a trainer who is not physically present with the trainee but is available on the telephone or electronically) is sometimes necessary in certain practices and can also be used as a valuable way of stretching trainees towards the end of their training period. However, it should be recognised that face-to-face supervision is crucial for trainees in the early stages of their training, and in cases where remote supervision is necessary, clear guidance should be provided to optimise safety.

• Mental health services, social care, palliative care, prison cover, community health cover and other care services within the community should be readily available to support GPs in out of hours periods. This is particularly important where patient needs are more appropriately addressed by these services rather than by GPs.
• The governments of the four nations must set clear actions and deadlines to ensure interoperable IT infrastructure is established across all stakeholders, to enable efficient patient record sharing between all urgent and out of hours services, and other care services.
• The development of urgent and out of hours service arrangements must reflect the increasing number of practices moving towards ‘at scale’ working and collaborative network models. Considerations should include clarity of accountabilities, quality incentives, and the involvement of out of hours providers in the local health economy to ensure they are able to develop integrated care pathways with other parts of the system including A&E or ED and ambulance services.

• State-backed GP indemnity schemes currently being developed for England and Wales must ensure adequate and affordable cover is provided for GPs and wider practice team members working in out of hours settings. A similar scheme should also be developed and implemented in Northern Ireland and, if necessary, Scotland.
• The UK Government must ensure the financial rewards provided to GPs in out of hours services are sufficiently competitive, to incentivise GPs to work in out of hours, and balanced with rewards provided to GPs working in-hours.

• GPs working in urgent care and out of hours settings must be equipped with the technology (e.g., efficient internet access, interoperable IT systems, triaging tools, e consulting software), facilities and skills to efficiently attend to urgent patient needs.
• Only experienced and competent clinical professionals should be responsible for unsupervised frontline triaging in urgent and out of hours care.
• Services such as NHS 111 and NHS 111 Online in England, NHS Direct in Wales, and NHS 24 and NHS Inform in Scotland, must be applied equitably across patient populations and balanced with more traditional means of accessing consultations to ensure equitable access for all patients.

• The RCGP intends to work closely with government bodies to raise awareness and improve public understanding of out of hours care services and ensure that there is clarity about each of the services available for various health needs and their specific levels of urgency.
• The governments of the UK must recognise, and act upon, the pressures on out of hours GP services, and the critical need to invest funding and resources into this sector to ensure sustainable care for patients at all times of the day.
• The RCGP will engage with its members and future generations of GPs to actively promote the importance of the role of GPs in providing out of hours care, and to ensure that this is recognised as a valued part of what the profession does both now and in the future.