Urgent and unscheduled care

This Topic Guide explores part of the RCGP curriculum, Being a General Practitioner. It will help you understand important issues relating to understand the care of people presenting in the urgent and unscheduled care context by illustrating the key learning points with a case scenario and questions. It also contains tips and advice for learning, assessment and continuing professional development, including guidance on the knowledge relevant to this area of general practice.

Each Topic Guide is intended to illustrate important aspects of everyday general practice, rather than provide a comprehensive overview of each clinical topic. It should therefore be considered in conjunction with other Topic Guides and educational resources.

The role of the GP in urgent and unscheduled care

As a GP, your role is to: 

  • Make the patient's safety a priority. Recognise patients with urgent needs and act promptly and effectively to ensure correct and timely treatment and reduce the risk of death or morbidity 
  • Meet the additional challenge of gathering information and communicating effectively, professionally and sensitively with patients, carers and family members in urgent and unscheduled care contexts. This includes accurately assessing a patient who may be acutely ill through phone, email and face-to-face consultations 
  • Co-ordinate care with other services and professionals (for example, ambulance service, community nurses and secondary care) and follow agreed protocols where appropriate, ensuring appropriate referral or follow up where necessary 
  • Maintain patients' autonomy in urgent situations where you may need to make decisions in their best interests. Consider the appropriateness of interventions according to the patient’s wishes, the severity of the illness, any co-morbid diseases and best evidence, while managing any differences of opinion with and between relatives and carers 
  • Offer patients and carers tailored advice on self-management and when and who to call for help if their problem worsens or does not follow the expected course of recovery (‘safety-netting’). 

Emerging issues in urgent and unscheduled care

The provision of urgent and unscheduled care is becoming increasingly diverse across the four UK nations and services in one area may differ substantially from another. It is therefore important that the experience attained during training is sufficient to enable the development of capabilities necessary to work in a variety of urgent and unscheduled care contexts.  

The models for delivering unscheduled care (including urgent care) in different communities and regions are changing, and it is important to stay up to date with your local arrangements. Within urgent and unscheduled care, there is increasing focus on the delivery of integrated multi-professional care delivered in the most appropriate setting, with more care being provided ‘closer to home’ or in the home itself. This requires a more flexible and team-based approach. 

Reviews of the Urgent and Emergency care (UEC) system 1 and subsequent reports have outlined five key elements to be developed in relation to urgent and unscheduled care:  

  1. Provide better support to self-care  
  2. Help people to get the right advice or treatment in the right place, first time 
  3. Provide a highly responsive urgent care service outside of hospital 
  4. Ensure that those people with more serious or life-threatening emergency needs receive treatment in centres with the right facilities and expertise 
  5. Connect the whole UEC system together through networks. 

Specifically, national priorities for Urgent and Emergency Care include focus on simplifying access for the public, improved mental health care, development of 111 / triage services and increasing patient access to primary care through online tools and Apps. Skills and capabilities required through training will increasingly need to be applied to these new contexts and may include calculation and interpretation of clinical prediction tools for severe illness (for example, early warning scores). 

Knowledge and skills guide

For each problem or disease, consider the following areas within the general context of primary care: 

  • The natural history of the untreated condition including whether acute or chronic 
  • The prevalence and incidence across all ages and any changes over time  
  • Typical and atypical presentations 
  • Recognition of normal variations throughout life 
  • Risk factors, including lifestyle, socio-economic and cultural factors 
  • Diagnostic features and differential diagnosis 
  • Recognition of deterioration, 'alarm' or 'red flag' features 
  • Appropriate and relevant investigations 
  • Interpretation of test results 
  • Management including self-care, initial, emergency and continuing care, chronic disease monitoring 
  • Patient information and education including self-care and 'safety-netting' (when and who to call for help if their problem worsens or does not follow the expected course of recovery) 
  • Prognosis 

Symptoms and signs

  • Symptoms and signs of acute illness in adults including patients with intellectual disabilities, dementia, communication problems 
  • Symptoms and signs of the acutely ill child (see RCGP Topic Guide on Children and Young People) 
  • Symptoms of acute illnesses that may indicate an acute exacerbation of a chronic disease 
  • Chronic or co-morbid diseases, risk factors and treatments that can influence the incidence and presentation of acute illnesses 
  • Important symptoms and signs that may indicate severe illness but which may be produced by other, less severe illnesses and strategies to avoid missing those severe illnesses when not obvious at initial presentation (for example, viral symptoms in a child should not exclude the recognition of sepsis) 
  • Factors that may alter the presentation of symptoms and signs of severe illness, particularly when there are limitations to immune competency (including those who are pregnant, very young or very elderly, on immunosuppressive drugs or who have other health conditions) 
  • Features of mental health emergencies including delusional states and self-neglect 
  • Factors suggestive of a high risk of harm to self or others 
  • Features of severe or life-threatening injuries 
  • Features of serious illnesses that require an immediate response. Examples include: 
    • Cardiovascular: chest pain, abnormal pulses (arrhythmias, bradycardia, tachycardia), hypertension, dyspnoea, oedema, hypotension, dizziness, syncope, vascular compromise haemorrhage 
    • Central nervous system: reduced conscious level, seizures, dizziness, confusion, loss of sensation or function, cerebellar and vestibular dysfunction, weakness, spasticity, paraesthesia, speech and language deficits, headache, visual problems including reduced acuity, diplopia, pupillary abnormalities, visual field defects, ophthalmoplegia 
    • Digestive: abdominal pain, dysphagia, melaena, bloody diarrhoea, haematemesis 
    • Endocrine: lethargy, polyuria, polydipsia, pain 
    • Kidney: dehydration, anuria / oliguria 
    • Respiratory: wheeze, dyspnoea, stridor, drooling, choking, respiratory distress and respiratory failure, cyanosis, hypoxia, tachypnoea, low oxygen saturations, low peak flow, chest pain, haemoptysis, swelling of face or tongue 
    • Sepsis: tachypnoea, hypotension, and altered mentation, fever, rashes and meningism

When providing urgent and unscheduled care, it is especially important to consider how acute illness and distress, and the emotional effect this has on patients, carers and healthcare professionals, can affect communication. 

Common and important conditions

  • 'Dangerous diagnoses' – these are conditions that always require urgent action if they are suspected. Some important examples include:
    • Acute psychosis/mania
    • Aneurysms
    • Appendicitis
    • Cancer (for example, hypercalcaemia, neutropenic sepsis, spinal cord compression, superior vena cava obstruction)
    • Intestinal obstruction or perforation
    • Limb ischaemia
    • Meningitis
    • Mental health including crisis
    • Myocardial infarction
    • Pregnancy related issues including ectopic
    • Pulmonary embolus
    • Sepsis
    • Stroke / CVA
    • Subarachnoid haemorrhage
  • Emergency conditions where the underlying diagnosis may not be known (for example, anaphylaxis, choking, loss of consciousness, cardio-respiratory arrest)
  • Emergencies that may occur in relation to certain healthcare activities (for example, anaphylaxis or allergic reaction after immunisation, local anaesthetic toxicity, vasovagal episodes)
  • Emergencies arising in patients receiving palliative or end-of-life care (see RCGP Topic Guide on People at the End-of-Life) 
  • Multi-factorial problems associated with patients who live alone and / or with multiple co-morbidities, particularly older adults, with an acute presentation may be frail and have both social and medical care needs 
  • Conditions associated with social, cultural and lifestyle factors that influence the incidence, severity and presentation of acute illnesses (for example, delayed presentation and increased mental distress in cultures in relation to certain illnesses that may be considered stigmatising; or acute illness relating to omitting medication during periods of religious fasting)
  • Death (both expected and unexpected) including the assessment, confirmation and the legal requirements.  

Examinations and procedures

  • Basic Life Support skills including performing cardio-pulmonary resuscitation (CPR), using Automated External Defibrillators and giving emergency drugs 
  • Examination of the relevant system or body part as appropriate 
  • Mental state examinations and risk assessments to ensure the safety of others 
  • Giving emergency or urgent medications in primary care, including oxygen, adrenaline, GTN, intramuscular or subcutaneous injections, inhalers and nebulisers

Investigations

  • ECG interpretation 
  • Recognise and differentiate between patients who require urgent investigation, patients who can wait longer for a routine investigation and those where time should be used as a diagnostic tool 
  • Near patient blood testing (for example, glucose, haemoglobin, CRP, d-dimer) 
  • Peak flow measurement and interpretation 
  • Urinalysis tests including pregnancy test 
  • Vital signs measurement including respiratory rate, blood pressure and oxygen saturation

Service issues

  • Knowledge of how to access the key services, organisations and professionals, both in the community and in secondary care, who provide unscheduled care for patients in- and out-of- hours, in order to organise effective care in the most appropriate location for the patient 
  • Familiarity with available prescribing options, medicines and equipment in the workplace, and car / bag and maintenance of appropriate equipment and drugs 
  • Local and national protocols and decision support systems for urgent care (for example, NICE / CKS and SIGN guidance) 
  • Options available to enable timely review of acutely ill patients to monitor their condition and determine changes to initial management plans 
  • Options available to maintain continuity of care for a patient undergoing an episode of acute illness, including appropriate communication between team members. This includes access to the patient's medical records and other relevant information about them 
  • The importance of providing appropriate documentation and records for each patient contact, which must be communicated to the next professional involved with that patient 
  • Appropriate use of emergency services, including the logistics of communicating with an ambulance/paramedic crew and the response time required 
  • Strategies for ensuring effective and appropriate communication and escalation of concern regarding deteriorating patients to ambulance services, the ED and acute service colleagues 
  • Clinical, administrative and pastoral support that a GP needs to provide at times of crisis or bereavement (including certification of illness or death) 
  • Approaches for managing patients who may make inappropriate or frequent demands on the health service (for example, because of a disorganised lifestyle or mental health disorder) 
  • The role of the GP in commissioning urgent and unscheduled care in your community  
  • The administrative and operating processes for the urgent care organisations you may be working in. These include: 
    • Information technology (IT) systems, including electronic patient records 
    • The process for recording and transmitting information about patients and the outcomes of any contact with them 
    • The communication systems used by the organisation, particularly regarding an urgent or deteriorating patient

Additional important content

  • Knowledge of how to access and use the processes and procedures in place to ensure patient safety in the urgent care setting (for example, clinical governance, quality control and health and safety) 
  • The medico-legal issues and indemnity requirements for the urgent and unscheduled care you provide 
  • The importance of positive, caring and respectful attitudes to the patients, carers and colleagues with whom you work in urgent care context, many of whom you may not have met before 
  • Processes for reporting and analysing significant and untoward events relating to acutely ill patients 
  • Procedures for giving effective feedback to the urgent care organisations and colleagues with whom you have worked and trained

Case discussion

You are working in an urgent care clinic. You take a phone call from a father who is worried about his 4-year-old daughter, Jana who has 'tummy pain'. He tells you they have recently moved to the UK from Russia and that he has already consulted another GP colleague earlier today who diagnosed an upper respiratory tract infection with mesenteric adenitis.  

The father has a thermometer at home and reports that Jana's temperature is now 39.6°C. He is worried because Jana has not recovered since her appointment earlier and he asks you to prescribe some antibiotics for him to collect from a nearby pharmacy, as he has no car and feels Jana is too unwell to bring down to the clinic in a taxi or on the bus.  

Questions

These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case discussion with your Educational Supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.

                         Core Competence                 
                           Questions                     
Fitness to practise
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients. 
Would my approach to the management of this child differ at different times of the day (for example, if the call was at lunchtime/midnight, or at the start of my shift/at the end of my shift)? Why and how might this affect my behaviour? 

If Jana's parent was a regular patient I knew well, how might my management be different? 

Would my approach to the management of this child differ if I had a previous experience of a significant event or complaint from a similar case? 
Maintaining an ethical approach
This addresses the importance of practising ethically, with integrity and a respect for diversity. 
Do I think that a doctor who is a parent would manage this situation differently from a doctor who has no children? What are my attitudes towards parents and families of a different social class or general educational achievement to my own? 

What experiences have I had of patients from a different ethnic background? How might my practice change as a result of this? 
Communication and consultation
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters.

What skills do I need to consult effectively on the telephone? How might this change with a potential language barrier? 

What questions would be reasonable to ask the parent to establish Jana's clinical condition? 

How might my consultation be different if there was very high parental anxiety or, alternatively, a lack of sufficient parental concern? 

How do I manage situations where the patient or their family are used to a healthcare system or culture that operates different to the NHS? 

Data gathering and interpretation  
This is about interpreting the patient's narrative, clinical record and biographical data including investigations
What other factors do I need to know about the child? What other information about the family would be useful? 

How do I assess the severity of this child's condition? 

What guidelines might help? 
Clinical Examination and Procedural Skills 
This is about the adoption of an appropriate and proficient approach to clinical examination and procedural skills. 
How do I accurately assess possible signs of sepsis in children? 

Are there circumstances where I might need to be able to obtain venous access and administer IV fluids or medication? If so, am I able to proficiently do this? 
Making decisions 
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice. 

What is my strategy for ensuring Jana's safety? 

How much should the anxiety of Jana's parent influence this? 

If I establish this is not urgent and does not require examining, how would I safety net? 

Clinical management
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches. 
What are the differential diagnoses? 

What would make me suggest bringing Jana in to examine as opposed to going straight to hospital? 

What advice would I give Jana's parent if I establish Jana needs immediate ambulance assistance? 
Managing medical complexity
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation. 
If I feel I need to examine the child but the parent is reluctant to bring Jana to see me, how would I deal with this? 

How would my management differ if Jana had a complex medical history? 

If this was a non-urgent case in-hours, what services are available that could offer support? 
Working with colleagues and in teams
This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development. 

If I was concerned there was a safeguarding issue in this case, how would I manage this? Who else might be able to help me?  

What processes are important for continuity of care in the urgent care and out of hours setting? 

What documentation would be particularly helpful for Jana's GP? How might this differ if Jana needed referral to hospital? 

What conditions are notifiable and how would I do this? 

Improving performance, learning and teaching  
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, quality improvement and research activity. 
What do I know about the incidence of specific infections illnesses in the community? What are the routes and sources for getting that information for my locality and nationally? 

What is the evidence relating to temperature control in febrile illnesses? 

What areas could be explored further for potential improvement for colleagues managing similar cases? 
Organisational management and leadership
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills. 
What are the challenges with working with different care records in different parts of the health care system? 

What can my practice do to improve patient access to urgent appointments? 

If I had difficulties or if I noticed areas for organisational improvement, how would I feedback to the organisation? 
Practising holistically, safeguarding and promoting health 
This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers. 
How would I explore the health beliefs of the parent? What do I need to know about this family? 

How could I support Jana's parent with self-management? 

How might I react if I find out a parent refuses to have their child immunised against measles, mumps and rubella? 
Community orientation 
This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare. 
How do I include the parents in the management of this situation? What questions would I ask?  

What negative influences or barriers might exist in the community that could exacerbate problems for Jana and her family? 

What community services might be available to help Jana and her family?  

How to learn this area of practice

Work-based learning

As a GP specialty trainee, you must gain experience of managing patients presenting with urgent and unscheduled healthcare needs, which is an important feature of both 'in-hours' and 'out-of-hours' GP care. Because there are particular features of unscheduled care that require a specific educational focus, such as the increased risk of working in isolation, the 'high-stakes' nature of clinical decisions, the relative lack of supporting services and the frequent need to promote self-care, it is important that you spend sufficient time in these environments.

There are a number of organisations involved in the delivery of urgent and unscheduled primary care including, pharmacies, dentists, 111, GP Practices, Urgent Care Centres, Out-of-Hours providers, 7-day access services and Emergency Departments (EDs or A&Es). The model of service provided increasingly varies, but there will be a need for partnership and collaboration between all agencies at the local level. As part of your training programme, you need exposure to a variety of community-based emergency and out-of-hours models.

The hospital environment can be an ideal setting for you to see concentrated groups of acutely ill children and adults. All doctors entering general practice training programmes are expected to have acquired the competences in acute care set out in the Foundation Programme Curriculum. Many doctors will have acquired additional competences during their hospital training, before entering GP specialty training. Some GP training programmes will contain placements of varying length in acute medicine and Emergency Departments that are ideal environments for learning about acutely ill people and their management. While you will have learnt cardiopulmonary resuscitation skills in the Foundation Programme (or equivalent), it is important to maintain these skills once in practice through regular updates and practical training sessions. Hospital resuscitation departments usually have excellent learning resources for you to keep up to date with these skills.

All GP trainees and GPs should have access to BLS/cardiopulmonary resuscitation courses and learning resources during their primary care placements, to help them address their learning needs.

Learning with other healthcare professionals

Teamwork is essential for the effective management of acutely ill patients in primary and secondary care. It is vital that all members of the primary healthcare team (including receptionists) understand their roles in managing acutely ill patients and contribute to the development of practice guidelines.

Acute events are an important source of material for significant event analyses and team members should be encouraged to participate in these and learn from them at both the individual and team level. Working in the acute and urgent environment will help you team members to gain valuable experience of working and learning in multi-professional settings, which will include GPs, nurses, paramedics, Emergency Department staff, etc. Examples include observing nurse practitioners or emergency care practitioners triaging patients and attending home visits with paramedics.

Formal structured learning opportunities can include organisation induction programmes (for example, when starting to train or work in an out-of-hours GP centre), telephone consulting skills courses and e-Learning opportunities. You can find an e-Learning module(s) relevant to this topic guide at e-Learning for Healthcare

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT)

  • Recognition of less common presentations of CVA 
  • Symptoms and signs of sepsis 
  • Management of an epileptic seizure 

Clinical Skills Assessment (CSA)

  • Phone call: Paramedic asks for a routine visit to a middle-aged man who has a 4-hour history of paraesthesia in his arm. His provisional diagnosis is nerve entrapment 
  • House call: Young man with acute headache and vomiting. An examination is expected 
  • Young woman feels unwell and is sweating, lightheaded and has a rapid pulse. An examination is expected

Workplace-based Assessment (WPBA)

  • Take a history with a parent about their febrile child 
  • Case discussion about an elderly patient with pneumonia who has capacity and is refusing admission to hospital  
  • Clinical examination of an acute abdomen for possible appendicitis.

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